Pain in children is often under-recognised and under-treated. This is the screencast of my talk at the recent Emergency Registrars Regional Conference held at Sunshine Hospital in Melbourne.
It’s midnight on a Tuesday, and a couple have presented to your hospital’s ED with 7-week-old Jonny, who will not stop crying.
How much are babies supposed to cry?
This changes with age. Generally, a baby’s crying will peak at around 6-8 weeks of age and gradually reduce over the weeks after that. Excessive crying is defined by Wessel’s criteria in infants under three months of age as
crying for more than 3 hours a day for more than three days a week for more than three weeks
This seems a bit arbitrary, and a more useful definition is probably the amount of crying the parents are distressed by.
What causes a rapid change in crying behaviour?
Young babies have very few communication strategies, so crying is non-specific. However, 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 intussusception. 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 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 fingernails, and they can give themselves corneal abrasions, which, while not requiring much treatment, will cause the baby to be upset. To stain a non-co-operative child/infant’s eye – lie the baby on its back and make a pool of fluoroscein (without lignocaine) at the medial canthus. The fluorescein will join the normal tear flow from medial to lateral when the baby blinks.
What about when crying becomes chronic?
It is still worth a good history and exam, including a weight compared to previous weights, to rule out the causes described above, but often (usually) no cause will be identified. Explore the social history and ask how the parents, particularly the mother, cope.
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?
Explore her feelings non-judgementally 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 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 feel 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 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 often look 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 aetiology of colic”. Colic, reflux and even constipation often get blamed (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 excessive crying?
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 probiotic supplements available. Larger reviews show no significant effect, but probiotics are a 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 is 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. Mixed messages can add to the stress parents feel trying to do right by their child.
Though not usually required, if parental stress is severe or your shift’s most experienced nurse can’t settle the baby, admission to the hospital with this presentation can be entirely appropriate.
Bottom line
– Persistent crying is the most common trigger for physical abuse
– Differentiate acute from chronic change in behaviour
– 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
References
McKenzie SA. Arch Dis Child Educ Pract Ed 2013;98:209–211.
Pawel B and Henretig F. Crying and colic in early infancy (ch16) in: Fleischer and Ludwig, Textbook of pediatric emergency medicine, 6th ed. 2010.
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.
Wessel MA. Paroxysmal fussing in infancy, sometimes called “colic” Pediatrics 1975;14:421-435.
