CPJXXX10.1177/0009922818798389Clinical PediatricsMatijasic and Premilovac 798389research-article2018

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Clinical 2019, Vol. 58(2) 133­–139 Inconsolable Crying in : © The Author(s) 2018 Article reuse guidelines: sagepub.com/journals-permissions Differential Diagnosis in the DOI:https://doi.org/10.1177/0009922818798389 10.1177/0009922818798389 Pediatric Emergency Department journals.sagepub.com/home/cpj

Nusa Matijasic, MD1 and Zdenka Plesa Premilovac, MD1

Introduction clothing fibers, causing strangulation, which may subse- quently lead to ischemic gangrene and amputation of the Crying is a part of the physiological neurodevelopment affected part. According to a review of 66 cases from the of an , ensuring survival and social interaction. medical literature, the most commonly affected sites are The crying period reaches its peak at 6 to 8 weeks of life, toes (43%), genitalia, and fingers.4 The diagnosis can be with an average duration of 2.6 hours per day, after delayed, as strands are more stretchable when moist, which it gradually decreases by the age of 3 to 4 months. but once they are dried they shrink and wind so tightly Episodes of inconsolable crying typically tend to cluster around the body part that they even cut through the during the evening, but may occur throughout the day, edematous skin. The surrounding skin may re-epithelial- causing anxiety, fatigue, and concern in the caregiver. ize, and the hair escapes detection. The median age of Therefore, it is not surprising that excessive crying is infants with toe involvement is 4 months, which coin- one of the most common symptoms in emergency cides with excessive hair loss in the postpartum period departments, leading to approximately 20% of pediatric 1,2 (telogen effluvium). The optimal therapeutic option is consultations of infants up to 3 months old. According wound exploration under general anesthesia, along with to studies, an organic cause is revealed in only 5% of a longitudinal incision on the dorsum, perpendicular to infants, with urinary tract infections being the most the constricting agent, which allows safe and complete prevalent (in more than 50% of cases), especially in decompression.4,5 newborns.2,3 Other underlying etiologies are numerous, varying from simple general causes such as hunger or tiredness to severe life-threatening conditions. In most Dermatitis cases, the diagnosis can be set after taking a detailed Diaper dermatitis is a location diagnosis that encom- medical history and performing a thorough clinical passes a group of dermatoses affecting body parts cov- examination of the child. ered by the diaper (perineum, buttocks, lower abdomen, and thighs). Primary irritant diaper dermatitis, the most Differential Diagnosis by Organic prevalent one, is a result of maceration of the skin in the System hot and humid, enclosed diaper environment. It is one of the most common skin diseases in the first months of Upon studying extensive literature concerning patholo- life. Characterized by confluent erythematous lesions in gies in infancy, we herein briefly discuss the most com- the form of the letter W, it usually spares body folds that mon organic causes leading to inconsolable crying in are not in direct contact with the diaper. The intensity of infants that should be taken into consideration by physi- skin affection ranges from mild to severe forms, includ- cians working in pediatric emergency departments. ing Jacquet dermatitis with vesiculo-erosive-ulcerative Throughout the following text, we point out alarming lesions, followed by permanent atrophy and hyperpig- accompanying requiring further mentation of the skin. As the skin’s natural pH is altered diagnosis or prompt therapeutic intervention. In order to and its barrier function reduced, secondary infections, simplify the text and make it easier for the reader, we have mainly fungal such as those caused by Candida yeasts, listed these conditions according to organic systems. occur. Typical findings of candidosis are erythematous

The Skin 1Children’s Hospital Zagreb, Zagreb, Croatia Hair Tourniquet Syndrome Corresponding Author: Nusa Matijasic, Children’s Hospital Zagreb, Klaićeva 16, Hair tourniquet syndrome is a circumferential constric- Zagreb 10000, Croatia. tion of body appendages by a strand or strands of hair or Email: [email protected] 134 Clinical Pediatrics 58(2) plaques that, unlike in primary irritant diaper dermatitis, diagnosed immediately at birth (25% to 40% of cases), affect the body folds, peripheral skin desquamation, and signs may be noticed at any time during the first few satellite pustules. The incidence has increased in recent months of life. Considering that it is an organic disorder years with the increased use of broad-spectrum oral anti- leading to blindness, with surgery being the only form of biotics and subsequent diarrhea.6 effective treatment, early diagnosis is of utmost importance.9 Atopic Dermatitis Ears and Oropharynx Infants affected by atopic dermatitis tend to have behav- ioral deviations in the form of irritability, fussiness, and Ear Infections increased crying, due to intense pruritus, discomfort, and sleep deprivation. Their caregivers, unable to cope and Various conditions involving the ears and oropharynx help their crying child, therefore often search for comfort result in excessive crying in infants. They are mainly and advice through numerous emergency department infections, especially otitis, which is one of the most fre- visits. It is interesting that excessive crying in infants quent diagnosis during childhood, with a reported inci- with a normal skin status can be a predictive symptom dence peak between the ages of 6 and 18 months. for development of atopic dermatitis later in childhood. Although the medical literature suggests that there is a serious problem concerning the overdiagnosing of acute A prospective study conducted on 116 healthy but high- 10 risk infants, with a positive family history, demonstrated otitis media in children, a large cohort Danish study that those who manifested atopic disease at 2 years had actually proved that the infection frequently remains shown significantly more fussing during the 7th week of undetected in young infants due to their lack of language life and excessive crying during the 12th week of life, skills and the small external ear canal. Therefore, many compared with those who remained healthy.7 of those examined for inconsolable crying leave the physician with a misdiagnosis of infantile colic. In order to prove the hypothesis, the study investigated whether Eyes infants with a diagnosis of infantile colic were more Corneal Abrasion likely to have reported subsequent ear problems during early childhood, compared with infants with normal cry- Corneal abrasion is a superficial lesion of the corneal ing patterns. A “dose-response” pattern was observed as epithelium, usually caused in infants by fingernail the highest risk of ear infections was in the group of scratching or foreign body trauma. Signs and symp- infants who spent the most hours crying and fussing.11 In toms include redness of the eye, excessive tearing, conclusion, to avoid these mentioned problems, it is blepharospasm, and photophobia. A study conducted essential to perform a precise otoscopic examination on 96 1- to 12-week-old, asymptomatic, healthy infants with adequate illumination, after cerumen removal and showed 49% of them had corneal abrasion, diagnosed with the emphasis on the position and mobility (not only by a fluorescein dye test. Although the study confirmed redness) of the tympanic membrane.10 a high incidence of corneal abrasions in infants, it also demonstrated that the mean crying times were not sig- Stomatitis nificantly different for children with and without abra- sions, pointing that pediatricians should be extremely Inflammatory conditions of the oral mucous membranes careful when attributing excessive crying to corneal are of great clinical importance in infants, as they often abrasions, potentially missing a more serious present with erosions and ulcers, which are painful and condition.8 can lead to decreased oral intake and dehydration. They may be related to relatively harmless conditions, such as Glaucoma acute Herplex simplex and Coxsackie virus infections or candidosis, but may also be associated with severe sys- Most cases of glaucoma in infants are primarily congen- temic diseases that need a prompt diagnostic and thera- ital, occurring as a result of an anomalous development peutic approach. A special entity found in infants is of the eye’s aqueous outflow system, leading to increased Bednar aphthae. These are infected wounds localized on intraocular pressure. Apart from the infant being irrita- the hard palate caused by chronic trauma due to an ble, it presents with photophobia, blepharospasm, epiph- incorrect feeding posture and feeding method. Although ora, and a strikingly enlarged eye (hydrophthalmus, Bednar aphthae do not require specific treatment since buphthalmos). The condition is more common in males they regress spontaneously in a few days after correct- and is usually bilateral. Although glaucoma is mainly ing the feeding position, if they remain undiagnosed Matijasic and Premilovac 135 they may worsen the nursing and cause feeding Paroxysmal Supraventricular Tachycardia 12 intolerance. (PSVT) PSVT is the most frequent form of symptomatic Infant Teething arrhythmia in children. Newborns may have a positive A variety of symptoms has long been strongly associ- history of fetal tachycardia, possibly with signs of ven- ated with infant teething by both and pediatri- tricular dysfunction due to tachycardia in fetal age. On cians. However, there is little evidence to support these the other hand, infants with no known history of fetal beliefs. Although studies have found that symptoms, tachycardia present with episodes including crying, irri- such as inconsolable crying and irritability, along with tability, poor feeding, pallor, tachycardia, and diaphore- increased biting, sucking, sleep disturbances, facial sis. Their heart rate is typically in excess of 220 beats rash, decreased appetite for solid foods, and mild tem- per minute, unresponsive to calming measures and fluid perature elevation, were all statistically associated with resuscitation. Most of them have structurally normal teething, they did not confirm the expected strong con- hearts. Only 15% of infant PSVT cases are associated nection. A prospective study conducted on 125 healthy with heart disease, drug administration, or febrile ill- infants showed that none of the above-mentioned symp- nesses. It is crucial to identify the condition as it causes toms was sensitive enough for teething or could reliably progressive left ventricular dysfunction, especially if predict the emergence of a tooth, as no symptom the heart rate is higher than 250 beats per minute, which 18 occurred in >35% of teething infants and no symptom leads to heart failure. occurred >20% more often in teething than in non- teething infants. Therefore, the strong idea that teething Myocarditis causes excessive discomfort may delay the diagnosis of a more serious underlying pathologic process in a cry- The main pathophysiological process in myocarditis is ing infant.13 the development of myocardial necrosis and interstitial edema, with the consequent impairment in the contrac- tile function of the myocardium. This leads to inade- Cardiovascular System quate cardiac output that worsens in the presence of comorbidities, such as fever and anemia. In addition, Congenital Cardiovascular Anomalies acute life-threatening arrhythmias may occur. As com- In 2009, a large Norwegian case-cohort study was the pensatory mechanisms are depleted, the heart fails. first to reveal increased emotional reactivity (irritability, Newborns and infants are more severely affected intense crying, and difficulty soothing) in infants with because of their limited adaptive possibilities. The com- moderate to severe congenital heart disorders.14 These mon complaints in infants are dyspnea with feeding, congenital disorders affect about 1% of all live born vomiting, and irritability, usually with a positive history children with a wide spectrum of severity. Neonates of flu-like symptoms. Physical examination reveals with critical congenital anomalies requiring prompt tachypnea, gallop rhythm, tachycardia, hypotension, intervention usually present during their birth hospital- pallor, delayed peripheral capillary refill, hepatomeg- ization with serious and life-threatening manifestations, aly, and generalized edema. Cardiomegaly on chest including shock, cyanosis, tachypnea, and/or symptoms X-ray and small voltages on electrocardiogram are also of pulmonary edema. However, some infants with con- typical findings.19,20 Myocarditis in children is mainly genital cardiovascular defects may be asymptomatic at caused by cardiotropic viruses, with infants having a birth and develop symptoms after discharge.15,16 higher rate of blood viral positivity compared with Examples are congenital coronary artery anomalies, older children.21 such as the abnormal origin of the left coronary artery from the pulmonary artery (ALCAPA) syndrome, known also as the Bland-White-Garland syndrome. Gastrointestinal System ALCAPA is characterized by episodes of crying, along Acute Abdomen with pallor, increased sweating, and feeding difficulties. The newborn is discharged as healthy, but as the pulmo- Acute gastroenteritis, constipation, gastroesophageal nary vascular resistance decreases so does the perfusion reflux (GER), nutritive allergies, lactose intolerance, through the anomalous left coronary artery, causing anal fissures, hernia, appendicitis, and gastrointestinal myocardial , pain, heart failure, and even sud- obstruction are only some of the various gastrointestinal den death.17 causes of discomfort and crying in young children. A 136 Clinical Pediatrics 58(2)

proper physical examination of the abdomen is always patients. A randomized, double-blind, placebo-con- challenging in infants, but crucial, as one should never trolled crossover trial showed that, compared with a pla- miss possibly lethal acute conditions, such as bowel cebo, omeprazole significantly reduced esophageal acid obstruction, primarily as a result of volvulus or intus- exposure, but not irritability or crying.27 susception. If this is the case, the infant presents with periodic fierce attacks of inconsolable crying, perfuse Genitourinary Tract vomiting, distension, fever, and signs of shock. Intestinal malrotation is a congenital abnormality resulting in Besides urinary tract infections, which are the leading shortening of the mesenteric root that is predisposed to organic cause of excessive crying in infants and the rea- midgut volvulus. Its incidence is estimated as 1 in 500 son why crying infants should undergo urinalysis, espe- live births.19,22 A review performed on 37 cases of intes- cially when febrile, other genitourinary conditions are tinal malrotation showed that the most common symp- discussed below which may cause discomfort, pain, and tom was bilious vomiting (97%), followed by inconsolable crying in babies. constipation. Therefore, neonates and infants with per- sistent bilious vomiting should always be highly suspect Ovarian Torsion for malrotation and preferably undergo ultrasound as the first diagnostic step.22 However, 95% of patients appear Pediatric ovarian torsion is a rare finding, especially in to be well on initial examination, including a large num- infants. It is a result of the rotation of the ovary and its ber of those with an already developed volvulus.23 On vasculature along its axis, leading to the obstruction of the other hand, intussusception, which remains the num- venous outflow, infarction, necrosis, and even peritonitis. ber one cause of intestinal obstruction in infants and Most cases are reported in ovaries containing benign young children, is characterized by a classical symptom masses, predominantly cysts, but if torsion occurs a malign triad consisting of abdominal pain, vomiting, and cur- neoplasm should also be suspected. Torsions are more rant-jelly stools. Still, this well-known triad is present in common on the right side, which is probably either due to less than a quarter of patients, and currant-jelly stools the hypermobile caecum on the right or the sigmoid colon are especially rare in the early stages, as they are a mani- on the left, which restricts the movements of the ovary. festation of an already significantly ischemic gut.19,24 Sterile pyuria is documented in a substantial proportion of patients, although no single laboratory finding is consis- Gastroesophageal Reflux tently suggestive of torsion. The most useful initial diag- nostic modality is ultrasound. Infants usually present with GER is the retrograde passage of the gastric contents excessive crying and a painful abdomen, but due to its rar- into the esophagus. When associated with esophagitis ity and nonspecific signs and symptoms, which mimic and persistent symptoms such as excessive vomiting, other acute abdominal conditions, the entity frequently regurgitation, , or respiratory disorders, goes unrecognized and surgical intervention is unfortu- the condition is referred to as gastroesophageal reflux nately often delayed. In a study of 13 pediatric patients disease (GERD). GER is a physiological phenomenon with ovarian torsions, only one was a 7-month-old infant. in infancy with most infants having complete resolution Although in her case she underwent prompt surgical inter- by the end of the first year of life. In a study of 948 vention, the ovary was found to be necrotic, which raised healthy infants, 50% of those aged 0 to 3 months, 67% the question whether the disease process is accelerated in of those 4 months old, and 21% of those aged 6 to 7 infants, or the more severe findings are due to torsions months regurgitated at least once a day, while the inci- being initially asymptomatic in that age group.28 dence declined to only 5% in those 10 to 12 old.25 Although there is a widespread opinion that children Acute Scrotum who cry excessively have GER more often, a study of 151 babies with persistent crying who were admitted to Acute scrotum is a pediatric emergency defined by scro- hospital for 24-hour pH monitoring and cry/sleep pat- tal pain, swelling, and redness, of acute onset. The dif- tern recording demonstrated that crying was related nei- ferential diagnosis encompasses torsion of the appendix ther to the duration of reflux nor to the number of reflux of the testis, testicular torsion, acute orchitis and/or epi- episodes.26 In addition, the use of proton pump inhibi- didymitis, trauma, incarcerated inguinal hernia, tumor, tors in the management of infants with excessive crying, or idiopathic scrotal edema.29 Testicular torsion accounts based on the presumptive diagnosis of GERD, remains a for about one quarter of all acute scrotum cases in chil- common practice, despite the fact that there is a lack of dren, with a much higher incidence in those younger any evidence-based treatment efficacy or utility in these than 1 year of life, and it is usually supravaginal. It is a Matijasic and Premilovac 137 sudden rotation of the testis around its axis, resulting in disease of prematurity and osteogenesis imperfecta. The blocked venous drainage, reduced arterial perfusion, first one, also referred to as osteopenia of prematurity and hemorrhagic infarction of the parenchyma. The and preterm rickets, is caused by a reduction in bone diagnosis needs to be set rapidly since testicular isch- mineral content due to deprivation of a period of intra- emia may lead to infertility later in life.30 Special ana- uterine minerals supply, inadequate postnatal intake of tomical variants predispose to torsion, such as the vitamin D, calcium, and phosphorus, an extended period bell-clapper anomaly, in which the gubernaculum, testis, of total parenteral nutrition, lengthy duration of immobi- and epididymis are not anchored as they normally are, lization, and the use of diuretics and corticosteroids. It is attached to tunica vaginalis.31 seen mainly in infants born at <28 weeks of gestation, who had necrotizing enterocolitis, late (>30 days) Neurological System establishment of full enteral feeds, conjugated hyperbili- rubinemia, and chronic lung disease. Fractures usually Meningitis occur at the age of at least 10 weeks and stop before the age of 6 months.35,36 Meningitis in young children has a nonspecific clinical Another important thing to consider is the possibility presentation. Infants are often initially examined in of physical abuse, which is the underlying etiology of emergency departments due to minor variations in their 12% to 20% of fractures in infants and toddlers. The behavior noticed by caregivers. Bacterial meningitis is a presence of multiple fractures or other injuries (coexist- medical emergency, requiring prompt recognition and ing bruises, injuries of the internal organs or central ner- urgent antibacterial therapy. While overall mortality has vous system), fractures of different stages of healing, declined over the past several decades, morbidity associ- and a delay in obtaining medical treatment are all warn- ated with meningitis remains practically unchanged, ing signs of possible .37 especially in the neonatal group. Early signs and symp- toms are subtle. Positive meningitic signs are usually late findings associated with a poor outcome. According to Septic Arthritis Mercier, there are 2 distinct clinical forms observed in Septic arthritis in infants is a rare and challenging diag- infants. The first is characterized by irritability, abnormal nosis. It usually involves the knees, hips, and shoulders. crying, bulging fontanel, unusual generalized seizures, The most common causative microorganisms are Group fever usually greater than 39°C, and poorly specific gas- B Streptococcus, methicillin-sensitive Staphylococcus trointestinal signs, such as anorexia and/or vomiting. The aureus, Haemophilus influenzae, Streptococcus pneu- second comes in the form of severe sepsis with tachycar- moniae, Salmonella enterica, and Candida albicans. In dia, cold and/or mottled limbs, skin hemorrhage, and 32,33 a study conducted on 14 infants aged up to 3 months, the suggests a meningococcal disease. Viral central ner- leading findings on physical examination were decreased vous system infections frequently occur as a complica- range of motion (100%), tenderness (100%), and swell- tion of systemic viral infections, and may be as severe as ing (71.4%). Their mean temperature was 38.5°C. White bacterial. Over 100 viruses are implicated as causative blood cell count, erythrocyte sedimentation rate, and agents, including Herpes simplex virus type I, which is C-reactive protein levels were likely to be slightly ele- the most common and neurologically devastating, caus- vated, but nonspecific, and the diagnosis was made only ing death or permanent disability in 90% of infants in combination with physical status and imaging affected. Performing lumbar puncture to collect cerebro- studies.38 spinal fluid is necessary to confirm the diagnosis, deter- Table 1 summarizes some of the most common causes mine the causative pathogen, and adjust antimicrobial 19,34 of inconsolable crying in infants, listed by organic therapy. systems. Musculoskeletal System Conclusion Bone Fractures Inconsolable crying in infants is one of the most com- Symptoms and signs suggesting bone fractures in chil- mon diagnosis in pediatric emergency departments. dren younger than 12 months of age include reduced Underlying etiologies are numerous and it is practi- movement of the affected body part, localized swelling, cally impossible to list them all; they may be anything crepitus, screaming and withdrawal on palpation of the from simple general causes, such as hunger or tired- fractured limb bone, or an asymmetrical Moro reflex. ness, to severe life-threatening conditions. However, a The two most frequently recognized underlying diseases thorough medical history and a detailed physical causing bone fragility in infancy are metabolic bone examination of an undressed child are usually 138 Clinical Pediatrics 58(2)

Table 1. Causes of Inconsolable Crying in Infants by Organic Systems.

Organic Systems Disease Skin Hair tourniquet syndrome, diaper dermatitis, atopic dermatitis, rash, insect bites, and cellulitis Eyes Corneal abrasion, glaucoma, conjunctivitis, and foreign body Ears and oropharynx Acute otitis media or externa, stomatitis, Bednar aphthae, pharyngitis, and infant teething Cardiovascular system Congenital cardiovascular anomalies, paroxysmal supraventricular tachycardia, and myocarditis Respiratory system Nasal obstruction, bronchiolitis, laryngitis, bronchitis/asthma, pneumonia, and pneumothorax Gastrointestinal system Volvulus, intussusception, appendicitis, hernia, gastroesophageal reflux, food allergy, acute gastroenteritis, lactose intolerance, constipation, and anal fissures Genitourinary system Urinary tract infections, ovarian torsion, acute scrotum, meatal ulcer, and balanoposthitis Neurological system Meningitis, encephalitis, head trauma, and increased intracranial pressure Musculoskeletal system Bone fracture, septic arthritis, osteomyelitis, and developmental hip dysplasia sufficient to set the preliminary diagnosis. If the child 2. Hiscock H. The crying baby. Aust Fam Physician. is in a good general condition, with stable vital signs, 2006;35:680-684. afebrile, and with unremarkable somatic and neuro- 3. Freedman SB, Al-Harthy N, Thull-Freedman J. The cry- logical findings, no further laboratory or imaging stud- ing infant: diagnostic testing and frequency of serious ies are recommended. The exception is urinalysis, as underlying disease. Pediatrics. 2009;123:841-848. 4. Barton DJ, Sloan GM, Nichter LS, Reinisch JF. Hair- urinary tract infections are the most common organic thread tourniquet syndrome. Pediatrics. 1988;82:925-928. cause of inconsolable crying. Once all the organic 5. Lohana P, Vashishta GN, Price N. Toe-tourniquet syn- causes have been excluded, and the crying continues, drome: a diagnostic dilemma! Ann R Coll Surg Engl. the pediatrician should consider the diagnosis of infan- 2006;88:W6-W8. tile colic, defined as episodes of unexplained fussiness, 6. Fernandes JD, Machado MC, Oliveira ZN. Clinical pre- fulfilling Wessel’s criteria.39 sentation and treatment of diaper dermatitis—part II [in Portuguese]. An Bras Dermatol. 2009;84:47-54. Author Contributions 7. Kalliomäki M, Laippala P, Korvenranta H, Kero P, Isolauri E. Extent of fussing and colic type crying preced- NM: designed the work, made acquisition, analysis and inter- ing atopic disease. Arch Dis Child. 2001;84:349-350. pretation of data for the work, and made final approval of the 8. Shope TR, Rieg TS, Kathiria NN. Corneal abrasions in version to be published. ZPP: made conception of the work, young infants. Pediatrics. 2010;125:e565-e569. revised it critically for important intellectual content and made 9. Sefić M. Congenital glaucoma [in Danish]. Paediatr final approval of the version to be published. Croat. 2004;48(suppl 1):231-235. http://hpps.kbsplit.hr/ hpps-2004/37.pdf. Declaration of Conflicting Interests 10. Pichichero ME. Acute otitis media: part I. Improving The author(s) declared no potential conflicts of interest with diagnostic accuracy. Am Fam Physician. 2000;61:2051- respect to the research, authorship, and/or publication of this 2056. article. 11. Hestbaek L, Sannes MM, Lous J. Large cohort study finds a statistically significant association between excessive Funding crying in early infancy and subsequent ear symptoms. Acta Paediatr. 2014;103:e206-e211. The author(s) received no financial support for the research, 12. Tricarico A, Molteni G, Mattioli F, et al. Nipple trauma in authorship, and/or publication of this article. infants? Bednar aphthae. Am J Otolaryngol. 2012;33:756- 757. ORCID iD 13. Macknin ML, Piedmonte M, Jacobs J, Skibinski C. Nusa Matijasic https://orcid.org/0000-0002-1568-5095 Symptoms associated with infant teething: a prospective study. Pediatrics. 2000;105(4 pt 1):747-752. References 14. Stene-Larsen K, Brandlistuen RE, Holmstrøm H, Landolt MA, Eskedal LT, Vollrath ME. Emotional reactivity in 1. St James-Roberts I, Halil T. patterns in the infants with congenital heart defects: findings from a large first year: normal community and clinical findings. J case-cohort study in Norway. Acta Paediatr. 2010;99: Child Psychol Psychiatry. 1991;32:951-968. 52-55. Matijasic and Premilovac 139

15. Tennant PW, Pearce MS, Bythell M, Rankin J. 20-year 27. Moore DJ, Tao BS, Lines DR, Hirte C, Heddle ML, survival of children born with congenital anomalies: a Davidson GP. Double-blind placebo-controlled trial of population-based study. Lancet. 2010;375:649-656. omeprazole in irritable infants with gastroesophageal 16. Khoshnood B, Lelong N, Houyel L, et al; EPICARD reflux. J Pediatr. 2003;143:219-223. Study Group. Prevalence, timing of diagnosis and mortal- 28. Poonai N, Poonai C, Lim R, Lynch T. Pediatric ovarian ity of newborns with congenital heart defects: a popula- torsion: case series and review of the literature. Can J tion-based study. Heart. 2012;98:1667-1673. Surg. 2013;56:103-108. 17. Sunilkumar MN. Bland-White-Garland syndrome in a 29. Günther P, Rübben I. The acute scrotum in childhood and neonate with review of literature. J Res Med Den Sci. adolescence. Dtsch Arztebl Int. 2012;109:449-457. 2015;3:94-97. 30. Campobasso P, Donadio P, Spata E, Salano F, Belloli 18. Kantoch MJ. Supraventricular tachycardia in children. G. Acute scrotum in pediatric age: analysis of 265 con- Indian J Pediatr. 2005;72:609-619. secutive case [in Italian]. Pediatr Med Chir. 1996;18(5 19. Hicks MP. An evidence-based systematic approach to suppl):15-20. acute, explained, excessive crying in infants. Pediatr 31. Khan F, Muoka O, Watson GM. Bell clapper testis, Emerg Med Pract. 2005;2:1-47. torsion, and detorsion: a case report. Case Rep Urol. 20. Dancea AB. Myocarditis in infants and children: a review 2011;2011:631970. for the paediatrician. Paediatr Child Health. 2001;6: 32. Ku LC, Boggess KA, Cohen-Wolkowiez M. Bacterial 543-545. meningitis in infants. Clin Perinatol. 2015;42:29-45. 21. Simpson KE, Storch GA, Lee CK, et al. High frequency 33. Mercier JC. Clinical signs suggestive of bacterial men- of detection by PCR of viral nucleic acid in the blood ingitis in infants [in French]. Med Mal Infect. 2009;39: of infants presenting with clinical myocarditis. Pediatr 452-461. Cardiol. 2016;37:399-404. 34. Téllez de Meneses M, Vila MT, Barbero Aguirre P, 22. Hamidi H, Obaidy Y, Maroof S. Intestinal malrotation Montoya JF. Viral encephalitis in children [in Spanish]. and midgut volvulus. Radiol Case Rep. 2016;11:271-274. Medicina (B Aires). 2013;73(suppl 1):83-92. 23. Bonadio WA, Clarkson T, Naus J. The clinical features of 35. Bishop N, Sprigg A, Dalton A. Unexplained fractures children with malrotation of the intestine. Pediatr Emerg in infancy: looking for fragile bones. Arch Dis Child. Care. 1991;7:348-349. 2007;92:251-256. 24. Fotso Kamdem A, Vidal C, Pazart L, et al. Incidence of acute 36. Rehman MU, Narchi H. Metabolic bone disease in the intussusception among infants in eastern France: results of preterm infant: current state and future directions. World the EPI study trial. Eur J Pediatr. 2017;176:301-309. J Methodol. 2015;5:115-121. 25. Nelson SP, Chen EH, Syniar GM, Christoffel KK. 37. Flaherty EG, Perez-Rossello JM, Levine MA, et al. Prevalence of symptoms of gastroesophageal reflux dur- Evaluating children with fractures for child physical ing infancy. A pediatric practice-based survey. Pediatric abuse. Pediatrics. 2014;133:e477-e489. Practice Research Group. Arch Pediatr Adolesc Med. 38. Bono KT, Samora JB, Klingele KE. Septic arthritis in 1997;151:569-572. infants younger than 3 months: a retrospective review. 26. Heine RG, Jordan B, Lubitz L, Meehan M, Catto-Smith Orthopedics. 2015;38:e787-e793. AG. Clinical predictors of pathological gastro-oesopha- 39. Wessel MA, Cobb JC, Jackson EB, Harris GS Jr, Detwiler geal reflux in infants with persistent distress. J Paediatr AC. Paroxysmal fussing in infancy, sometimes called Child Health. 2006;42:134-139. colic. Pediatrics. 1954;14:421-424.