1.2 The crying infant
Introduction
Crying is an important method of communication for infants.1 Carers are usually able to identify and manage the cause (e.g. hunger, discomfort) and console the infant. Medical advice is sought if the crying is felt to be unusually intense or persistent or the infant is unable to be consoled by the usual methods.2 ‘Normal crying’ was defined in Brazelton’s 1962 study of 80 infants of American families selected to have minimal psychological stressors. There was a peak of crying to a median of 2¾ hours per day by 6 weeks, with a wide variation, and a decrease thereafter.1 The classification of crying as normal or excessive is highly subjective and will vary according to infant, carer and situational factors. All three areas need to be assessed in this type of presentation.
Either a single episode of or recurrence of a pattern of excessive crying may precipitate emergency department (ED) presentation.2
Recurrent crying
Colic
Recurrent excessive crying in an otherwise healthy infant is often termed colic. This diagnosis can only be made if the pattern is recurrent and stereotypical3 and a careful history, examination and period of follow up have ruled out important causes. The definition of colic varies but is frequently arbitrarily defined as a total of more than 3 hours per day of irritability, fussing and crying on at least 3 days a week for at least 3 weeks.4 This pattern typically occurs in the afternoon or evening, ceasing by 3 to 4 months of age.3
Management
Current specific dietary, drug and behavioural strategies meet with limited success; however, cows’ milk protein intolerance may have a role in a small proportion of infants.4,5 The positive effects of changing from cows’ milk based formula to casein hydrolysate formula have been noted to diminish with time, suggesting that colic is not related to allergy.5 A trial of hydrolysate (e.g. Pepti-Junior, Alfare) may be appropriate in a formula-fed baby but its long-term use is likely to be unnecessary. It is notable that soy protein formulas may have similar adverse effects to those of cows’ milk formulas.5 Mothers of breastfed babies can exclude all dairy products (but ensure calcium supplementation) for 2 weeks as a trial.
Gastro-oesophageal reflux (GOR) is frequently cited as a possible cause of infant crying. Feeding difficulties and frequency of regurgitation (> five times daily) are associated with pathological GOR as defined on oesophageal pH monitoring – there is a place for an empirical trial of proton pump inhibitors in this group.6
