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.
- 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
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.
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
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.
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.
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.
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.