The Crying Baby

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It’s midnight on a tuesday and a couple have presented to your hospital’s ED with 7 week old Jonny who will just not stop crying.

Bottom line:

  • Differentiate acute from chronic change in behaviour
  • Persistent crying is the commonest trigger for physical abuse
  • Enquire about maternal depressive symptoms and social support
  • Investigations in a thriving baby with a normal physical exam and no acute change in behaviour are usually not helpful
  • There are many ways to approach this problem and we would love to hear your thoughts in the comments section below

 

How much are babies supposed to cry?

This changes with age. Generally baby’s crying will increase to a peak at around 6-8 weeks of age and will gradually reduce over the weeks after that. Excessive crying is defined by Wessel’s criteria in infants under 3 months of age as

crying for more than 3 hours a day for more than 3 days a week for more than 3 weeks

This seems a bit arbitrary and I think a more useful definition is probably the amount of crying that the parents are distressed by.

What causes a rapid change in crying behaviour?

Young babies have very few communication strategies available to them so crying is non-specific but any acute change in behaviour should be viewed as a red flag and prompt a careful search for a cause.  Consider meningitis, non-accidental injury and intusussception. Collecting a urine sample is advocated in some paediatric texts and is prudent even though it tends to be a low yield activity. The “clean catch” is probably the most appropriate method of doing this in this circumstance but a debate on the pros and cons of urine collection methods is a topic for another post.

A few areas to pay special attention to include:

  • hernial orifices – inguinal hernias are particularly prone to incarceration
  • testicles – rates of testicular torsion have a peak in infancy
  • fingers/toes/penis – hair tourniquets can be difficult to spot and small babies will not localise the pain from them
  • eyes – it’s common to see babies with scratches on their faces from their own fingernails and they are very capable of giving themselves corneal abrasions which, while not requiring much in the way of treatment, will cause the baby to be upset. To stain a non-co-operative child/infants eye – lie the baby on its back and make a pool of fluoroscine (without lignocine) at the medial canthus. When the baby blinks the fluroscine will join the normal tear flow from medial to lateral

And when it is more chronic?

It is still worth a good history and exam, including a weight with comparison to previous weights, to rule out the causes described above but often (usually) no cause will be identified.  It is important to explore the social history and ask about how the parents, particularly the mother, are coping.

Are there any signs of post-natal depression? Is mum sleeping (as much as anyone with a small baby does)? Is she eating OK? Is she enjoying being a parent?

Try and explore her feelings in a non-judgemental way and reassure her that she is not alone in the feelings she may be experiencing. Formal tools like the Edinburgh depression scale can provide a good framework for discussing some of these issues. Ask about parental strategies for dealing with the crying and what they do when it all becomes too much.

I think it’s important to be open about the fact that sometimes people just feel really stressed and put their baby down too hard or give them a shake in a particularly difficult moment, and that if the parents ever feel like they are at risk of doing that then it’s ok to to just put the crying baby gently into their cot, leave the room and close the door.

Can we put it all down to colic?

Parents of crying babies are often looking for a reason why this is happening and as clinicians we like to provide diagnoses and explanations, or as Fleischer’s textbook puts it ”Numerous unproven theories abound about the etiology of colic”. Colic, reflux and even constipation often get the blame (they will all eventually get their own DFTB posts).

Rightly or wrongly these diagnoses are often made on clinical suspicion rather than objective evidence and the natural history of normal development means that if we put a baby on infacol or omeprazole or lactulose and continue it for a few months then most of those babies will experience a reduction in crying whether or not that medication is effective for that child.

What can we do about it?

There is no reliable, evidence based treatment for excessive crying. Some literature has shown impressive results from probiotics in small studies but these become hard to extrapolate due to the various types of probiotic supplement available. Larger reviews show no significant effect but probiotics are a fairly benign treatment option. Given the lack of proven efficacy of any one treatment it is particularly important to avoid treatments such as methylscopolamine, dicyclomine and chiropractic manipulation which can be harmful in infancy. Parental counselling has been shown to be more effective than dietary restriction in a small study.

I think ensuring the parents have access to a single health professional be that a GP or community child health nurse or other professional with whom they can discuss concerns on an ongoing basis is important, as many individual practitioners approach this problem differently and mixed messages can add to the stress felt by parents trying to do right by their child.

Though not usually required, if parental stress is severe, or if your shift’s most experienced nurse can’t settle the baby then admission to hospital with this presentation can be entirely appropriate.

 

References:

McKenzie SA. Arch Dis Child Educ Pract Ed 2013;98:209–211.

Wessel MA. Paroxysmal fussing in infancy, sometimes called “colic” Pediatrics 1975;14:421-435.

Taubman B. Parental counseling compared with elimination of cow’s milk or soy milk protein for the treatment of infant colic syndrome: a randomized trial. Pediatrics 1988;81:756-761.

Pawel B and Henretig F. Crying and colic in early infancy (ch16) in: Fleischer and Ludwig, Textbook of pediatric emergency medicine, 6th ed. 2010.

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About 

Paediatric emergency physician interested in education, retrieval medicine and simulation. Lives in Brisbane where he enjoys falling off his mountain bike and being outsmarted by his pre-teen children.

@paedsem | + Ben Lawton | Ben's DFTB posts

2 Responses to "The Crying Baby"

  1. Alyson Murray
    Alyson Murray 3 years ago .Reply

    Hello Ben
    Loved your article on crying babies. Just a note of caution. I hear that chiropractors are on the war path regarding comments that may be perceived as defamatory. FYI they took the American Medical Association to court and won and are seeking to do the same here. It may be best to not not comment on other professions in an inflammatory manner. It makes the lawyers rich!

    Alyson Murray
    Paediatric Nurse

  2. Ben Lawton
    Ben Lawton 3 years ago .Reply

    Hi Alyson, thanks for your comments and thanks for highlighting the sensitivities that can make objective discussion of many of the issues we deal with in paediatric practice difficult. My comments are intended not in an inflammatory manner but rather an expression of my understanding of evidence based practice in this area. I re-iterate I do not believe there is any therapeutic value in chiropractic manipulation of babies with colic. This paper referenced below forms a significant part of the basis for my opinion.

    Hunt K, Ernst E. the evidence-base for complementary medicine in children: a critical overview of systematic reviews. Archives of Disease in Childhood 2011, Aug 96(8) 769-76.

    The following is a direct quote from this article:
    “Three RCTs of chiropractic for colic were identified in two systematic reviews.(17) (31) Two of which were methodologically poor and the third, which was conducted more rigorously, did not suggest chiropractic is effective for that condition. None used validated outcome measures and relied upon parent self-report of colic symptoms despite the fact that parents were not blinded to group assignment.”

    These are the references referred to:
    17 – Ernst E. Chiropractic spinal manipulation for infant colic: a systematic review of randomised clinical trials. Int J Clin Pract 2009;63:1351–3
    31 – Gotlib A, Rupert R. Chiropractic manipulation in pediatric health conditions – an updated systematic review. Chiropr Osteopat 2008;16:11

    While admittedly at the case report level there is material in the medical literature demonstrating the potential for harm from this intervention e.g:
    Wilson et al. Posterior rib fractures in a young infant who received chiropractic care. Pediatrics 2012 (Nov)1359-62.

    All of my opinions and my practice are continually evolving as I learn more, and I welcome evidence-based discussion of this topic. We would be happy to publish any scientifically valid contribution on this topic at DFTB.

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