Clinical assessment and risk stratification


  • Definition:
    • Unexplained episodes of irritability, fussing or crying that last ≥3 hours per day on ≥3 days per week for ≥1 week38
  • Hence, it is a diagnosis of exclusion.
  • The typical symptoms are non-specific:
    • Inconsolable crying (typically, high-pitched and occurring frequently in the afternoon or evening)
    • Redness of the face
    • Drawing up of the knees
    • Flatus
    • In-between episodes the infant remains well and thriving

Differential diagnosis

  • In the acutely distressed infant consider:
    • Physical discomfort (i.e. cold, wet, hungry)
    • Medical:
      • Sepsis
      • Severe nappy rash
    • Surgical:
      • Intussusception (especially if facial pallor instead of redness)
      • Volvulus (especially if billious vomiting)
      • Strangulated hernia
      • Testicular torsion
    • Injuries:
      • Corneal abrasion
      • Non-accidental injury
      • Hair tourniquets (digits, penis)

Image caption: USS image of an intussusception showing the classical target sign

  • If symptom are severe and recurrent consider:
    • GORD (only if associated with regurgitation)
    • Constipation or dyschezia
    • Cow’s milk protein intolerance (CMPI)
    • Parental distress will also exaggerate symptoms (consider maternal postnatal depression, inadequate support or ineffective parenting skills)
    • NB: Remember isolated distressed behaviour is not a sufficient reason to investigate or treat for reflux as per the NICE guidelines2.