Crying Or Fussing Child: MCCQE1 Preparation Guide

The “crying or fussing child” is a quintessential presentation in General Pediatrics and a high-yield topic for the MCCQE1. It requires a structured approach to differentiate between the benign (but stressful) phenomenon of infantile colic and serious, life-threatening pathology.

As a future Canadian physician, you must demonstrate the ability to rule out organic causes, manage parental anxiety, and apply CanMEDS roles—specifically Medical Expert, Communicator, and Health Advocate (prevention of non-accidental trauma).

MCCQE1 Objectives & CanMEDS Framework

For the MCCQE1, the candidate should be able to:

1. Differentiate between normal crying patterns (PURPLE crying), colic, and organic pathology.
2. Identify “Red Flags” suggesting infection, trauma, or surgical emergencies.
3. Manage the infant and support the family, including counseling on the prevention of Shaken Baby Syndrome.

Definitions and Epidemiology

Infantile Colic

Historically defined by Wessel’s Criteria (“Rule of 3s”), though modern definitions (Rome IV) focus more on the distress and lack of organic cause.

The “Normal” Crying Curve

Crying typically increases from 2 weeks of age, peaks around 6-8 weeks, and decreases significantly by 3-4 months. Understanding this trajectory is crucial for parental reassurance.

Differential Diagnosis: The “IT CRIES” Mnemonic

When approaching a fussing child on the MCCQE1, use the mnemonic IT CRIES to systematically rule out organic pathology.

I - Infection (UTI, Meningitis, Otitis Media, Osteomyelitis)
T - Trauma (Non-accidental trauma, Corneal abrasion, Fracture)
C - Cardiac (SVT, Heart failure) / Colic (Diagnosis of exclusion)
R - Reflux (GERD) / Reaction to formula (Cow's Milk Protein Allergy)
I - Intussusception / Incarcerated Hernia / Immunization reaction
E - Eye (Corneal abrasion, Glaucoma, Foreign body)
S - Surgical (Volvulus, Torsion of testis/ovary) / Strangulation (Hair tourniquet)

Clinical Approach

Follow these steps to maximize your score on MCCQE1 Clinical Decision Making (CDM) cases.

Red Flags (Referral/Admission Criteria)

• Fever in infant <3 months (Requires septic workup).
• Bilious vomiting (Green = Surgical emergency until proven otherwise).
• Failure to thrive (Crossing percentiles downwards).
• Abdominal mass or distension.
• Bloody stool.
• Signs of trauma (Bruising on ears, neck, torso, or in non-mobile child).
• Bulging fontanelle.

Management Strategies

1. Acute Management of Pathology

Treat the underlying cause identified in the “IT CRIES” differential (e.g., antibiotics for UTI, air enema for intussusception).

2. Management of Infantile Colic

Once organic causes are ruled out, management shifts to parental support and education.

• Reassurance: Explain the natural history (resolves by 3-4 months).
• Feeding Techniques: Ensure proper latch, burping, upright positioning.
• Dietary Changes:
  • Breastfed: Trial of maternal elimination diet (dairy/soy) for 2 weeks.
  • Formula: Trial of extensive hydrolysate formula if CMPA suspected.
• Soothing Techniques: Swaddling, white noise, gentle rocking (The “5 S’s”).
• Probiotics: Lactobacillus reuteri has shown some benefit in breastfed infants (Canadian Paediatric Society notes emerging evidence).

3. What NOT to do (Choosing Wisely Canada)

• Do not prescribe dicyclomine (safety concerns).
• Do not prescribe proton pump inhibitors (PPIs) for uncomplicated crying/regurgitation without pathologic GERD signs.
• Do not recommend chiropractic spinal manipulation for colic (lack of evidence/safety risk).

Canadian Guidelines

Canadian Paediatric Society (CPS)

• Colic: Emphasizes that colic is a benign, self-limiting condition. Recommends ruling out organic causes and supporting parents.
• Probiotics: CPS acknowledges L. reuteri may reduce crying in breastfed infants with colic, but evidence is insufficient to recommend it routinely for all.
• Pain Assessment: Utilize age-appropriate tools (e.g., FLACC scale) if pain is suspected.

Sample Question

Scenario

A 6-week-old female infant is brought to the Emergency Department by her parents due to episodes of inconsolable crying that began 12 hours ago. The crying occurs intermittently; between episodes, the infant appears lethargic and pale. The parents report she vomited green fluid twice. She has had no fever or upper respiratory symptoms. Physical examination reveals a distended abdomen and a palpable sausage-shaped mass in the right upper quadrant. Rectal examination reveals mucus mixed with blood.

Question

Which one of the following is the most appropriate initial diagnostic and therapeutic intervention?

• A. Abdominal X-ray (flat and upright)
• B. Pyloromyotomy
• C. Air contrast enema
• D. Upper GI series with barium
• E. Oral rehydration therapy and observation

Explanation

The correct answer is:

• C. Air contrast enema

Detailed Analysis:

• Diagnosis: The clinical presentation is classic for Intussusception: intermittent severe pain (colicky crying), lethargy between episodes, bilious vomiting (green), and “currant jelly” stool (mucus and blood). The palpable sausage-shaped mass supports this.
• Intervention: An air contrast enema (or liquid contrast enema) is both diagnostic (visualizes the telescoping bowel) and therapeutic (pressure reduces the intussusception) in the majority of cases.
• Why other options are incorrect:
  • A. Abdominal X-ray: May show signs of obstruction but is less specific than enema or ultrasound and is not therapeutic.
  • B. Pyloromyotomy: This is the treatment for pyloric stenosis, which presents with non-bilious projectile vomiting and an “olive” mass, usually in slightly younger infants (3-5 weeks).
  • D. Upper GI series: Used for malrotation/volvulus. While bilious vomiting is present, the mass and bloody stool point strongly to intussusception.
  • E. Observation: This is a surgical emergency; observation could lead to bowel necrosis and perforation.

Key Points to Remember for MCCQE1

1. Vital Signs: Always check temperature. Fever in an infant <3 months is a full septic workup until proven otherwise.
2. The Exam: You must undress the infant. Don’t miss a hair tourniquet or incarcerated hernia.
3. Bilious Vomiting: In a neonate/infant, this is volvulus until proven otherwise—an immediate surgical emergency.
4. Colic: Is a diagnosis of exclusion. Ensure the infant is gaining weight and has a normal physical exam.
5. Safety: Always counsel on Shaken Baby Syndrome prevention. This is a key “Health Advocate” mark.
6. Fluorescein: If an infant is crying and you can’t find a cause, stain the eyes to look for a corneal abrasion.

References

1. Canadian Paediatric Society. (2018). Infantile Colic: Is there a role for probiotics? [CPS Position Statement].
2. Barr, R. G. (2014). The Period of PURPLE Crying. National Center on Shaken Baby Syndrome.
3. Medical Council of Canada. (2023). MCCQE Part I Clinical Decision-Making and Multiple-Choice Question Objectives.
4. UpToDate. (2024). Evaluation and management of colic.
5. Choosing Wisely Canada. (2023). Paediatrics: Five Things Physicians and Patients Should Question.