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Cause

Suggestive Findings

Diagnostic Approach

Cardiac

Coarctation of the aorta

Delayed or absent femoral pulses

Tachypnea

Cough

Diaphoresis

Poor feeding

Systolic ejection murmur, systolic click

Chest x-ray

ECG

Ultrasonography

Heart failure

Tachypnea

Cough

Diaphoresis

Poor feeding

Third heart sound (S3) gallop

Chest x-ray

ECG

Echocardiography

Supraventricular tachycardia

Tachypnea

Cough

Diaphoresis

Poor feeding

Heart rate > 180 beats/minute (usually 220–280 beats/minute in infants; 180–220 beats/minute in older children)

Chest x-ray

ECG

Gastrointestinal

Constipation

Anal tears or fissures

History of decreased stool frequency and hard pellet stools

Distended abdomen

Clinical evaluation

Gastroenteritis

Hyperactive bowel sounds

Loose, frequent stools

Clinical evaluation

Gastroesophageal reflux

History of spitting up, arching, or crying after feedings

Swallowing study

Esophageal pH or impedance probe study

Intussusception

Severe colicky abdominal pain alternating with calm, pain-free periods

Lethargy

Vomiting

Currant-jelly stools

Ultrasonography

Abdominal x-ray

Air enema

Cow's milk protein intolerance (milk protein allergy)

Vomiting

Diarrhea or constipation

Poor feeding

Failure to thrive

Stool heme test

Volvulus

Bilious vomiting

Tender, distended abdomen

Bloody stools

Absent bowel sounds

Abdominal x-ray

Barium enema

Incarcerated hernia

Tender, erythematous mass in groin

Clinical evaluation

Infection

Meningitis

Fever

Inconsolability, irritability

Lethargy

Bulging anterior fontanelle in infants (see Neonatal Bacterial Meningitis)

Nuchal rigidity (meningismus) in older children (see Bacterial Meningitis in Infants Over 3 Months of Age)

Lumbar puncture for cerebrospinal fluid testing

Otitis media

Fever

Pulling at ears or complaints of ear pain

Erythematous, opaque, bulging tympanic membrane

Clinical evaluation

Respiratory infection (bronchiolitis, pneumonia)

Fever

Sometimes cough

Tachypnea

Sometimes hypoxia

Sometimes wheezing, crackles, or decreased breath sounds on auscultation

Chest x-ray

Urinary tract infection (UTI)

Fever

Possible vomiting

Urinalysis and culture

Trauma

Corneal abrasion

Crying with no other symptoms

Fluorescein test

Fracture (eg, due to child abuse)

Area of swelling and/or ecchymoses

Favoring of a limb

Skeletal survey x-rays to check for current and old fractures

Hair tourniquet

Swollen tip of a toe, finger, or penis with hair wrapped around the appendage proximal to the swelling

Clinical evaluation

Head trauma with intracranial bleeding

Inconsolable, high-pitched cry

Localized swelling on skull with underlying deformity

Head CT

Abusive head trauma (shaken baby syndrome)

Inconsolable, high-pitched cry

Lethargy

Seizure activity

Head CT

Retinal examination

Skeletal survey

Other

Cold drugs

History of recent cold drug therapy

Clinical evaluation

Testicular torsion

Swollen erythematous asymmetric scrotum, absent cremasteric reflex

Doppler ultrasonography or nuclear scanning of the scrotum

Vaccine reaction

History of recent immunization

Clinical evaluation

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