Crying Baby - Infant Distress

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Introduction
Assessment
Investigations
Management
Disposition

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Introduction

Crying is normal physiological behaviour in young infants. The average baby of 6-8 weeks cries/fusses for up to 3 out of 24 hours. Excessive crying (colic) is defined as >3 hours/day for >3 days/week. However many babies present with lesser amounts of crying, as the parents perceive it as excessive.

Infants with "colic" are well and thriving. There is usually no identifiable medical problem. The parents are often distressed, exhausted, and confused, having received conflicting advice from various health professionals and lay sources.

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Assessment

Clinical Characteristics

• crying develops in the early weeks of life and peaks around 6-8 weeks of age usually worse in late afternoon or evening
• may last several hours
• infant may draw up legs as if in pain, but there is no evidence that colic is attributable to an intestinal problem or wind
• usually improves by 3 - 4 months of age. A thorough history and examination must be conducted to exclude any significant illness.
• Diagnoses to consider include:
  • Reflux oesophagitis
  • Urinary tract infection
  • Otitis media
  • Cow’s milk protein or lactose intolerance
  • Raised intracranial pressure

Notes:

1. More acute onset of irritability and crying should not be diagnosed as colic; a specific cause is usually present (eg. intercurrent illness, corneal foreign body/abrasion, hair tourniquet of fingers or toes, incarcerated inguinal hernia).
2. Maternal post-natal depression may be a factor in presentation.

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Investigations

If the history is typical and examination negative no investigations are required, consider:

• Urine M&C
• Stool exam for reducing substances (if watery)
• Fluoroscein staining of eyes

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Management

The parents require careful explanation and reassurance that their infant is not unwell or in pain, and that the unsettled behaviour will improve with time. At the same time they need empathic acknowledgement of their anxiety and stress, and ongoing support from within and outside the family. Suggestions that may be helpful include:

• Establish pattern to feeding/settling
• Avoid excessive stimulation - noise, light, handling. Excessive quiet should also be avoided. Most babies find a low level of background noise soothing.
• Carry baby in a papoose in front of the chest.
• Baby massage / rocking / patting
• Gentle music tapes
• Respond before baby is too worked up
• Have somebody else care for the baby for brief periods to give the parents a break

Medication is rarely indicated. Colic mixtures, gripe water, etc are of no proven benefit. Formula changes are usually not helpful unless there is proven cow’s milk allergy or lactose intolerance. Weaning from breast milk has no benefit. Provide printed information if possible, as parents are unlikely to remember much given their state of mind at the time.

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Disposition

Referral for early (within days) ongoing support is essential. Options include:

• Maternal and child health nurse
• Family doctor
• General paediatrician - hospital out-patients or private
• Mother-baby day unit or inpatient unit - for severe cases
• Admission to hospital - if child considered at risk of non-accidental injury or parental exhaustion

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Content by Dr Ronán O' Sullivan 20/05/2006. Next review 20/05/2007. Sleep Cry Diary

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