The crying infant

Published on 23/06/2015 by admin

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1.2 The crying infant

Barbara King

Essentials

1 Define if this presentation is part of a recurrent stereotypical pattern in an otherwise well infant, or a single acute episode.

2 A careful history and examination will often lead to an appropriate diagnosis.

3 Screening tests, with the exception of urine culture, have little utility.

4 Review carefully carer’s coping and supports.

5 Organise appropriate follow up.

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 stereotypical ³ 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

Anticolic medications should be avoided, as they have been shown to at best have no effect (simeticone) or risk serious adverse effects (anticholinergics).⁴

Behavioural interventions, including advice to reduce stimulation in combination with permission to leave the infant when the crying was no longer tolerable was effective when compared to a non-specific empathic interview.⁴^,⁷ Reduction of stimulation advice includes avoiding excessive patting, winding, lifting, vigorous jiggling and loud noises or toys. Carers were advised not to intervene in the early part of sleep when the infant may appear restless and also given an assurance that a certain amount of crying is normal.⁴^,⁷ It is important to remember that even if behavioural interventions do not change the infant’s temperament, they may well alter the impact colic has on the carer and on carer–infant interactions.⁸

Carers very reasonably assume that there must be something wrong either with the child or their parenting for an infant to cry frequently and excessively. Much reassurance that the child is healthy can be gained from witnessing the conduct of a complete history and thorough examination. Similarly, an explanation that this is a common problem that does not reflect on their parenting, that some babies may be assisted by some simple behavioural techniques and that the carers will be supported by appropriate referral will also reduce anxiety considerably.

Acute crying

The causes of a single episode of excessive crying in an infant are vast. In an afebrile infant without a cause apparent to the carer, a careful history has been shown to provide clues to the final diagnosis in 20% of cases. Physical examination was revealing in more than 50% and a period of follow up often useful in patients where the diagnosis was still in question.²

Assessment

History includes the timing and amount of crying, duration of behaviour, measures taken to resolve the situation, specific carer concerns, the carer’s response to crying, expectations and experience, specific social difficulties (including substance abuse), contact with child health nurse or other medical supports. A thoughtful review of the carer’s supports and coping is essential.⁹

Also important are details of pregnancy, labour and neonatal difficulties, feeding activities including volumes of feed (considerations include under and overfeeding), dietary changes, past medical history, vomiting (gastrointestinal reflux, gastroenteritis, sepsis, meningitis). Consider changes in stools (constipation, gastroenteritis, bleeding anal fissure, intussusception), type of feeding (breast or bottle), type of milk, drug exposure, recent immunisation, fever, respiratory symptoms, rash, contacts with infectious illness and growth history.

Examination

A complete set of vital signs is essential, including oxygen saturation (tachypnoea with pneumonia, sepsis or metabolic acidosis, tachycardia with supraventricular tachycardia, sepsis or dehydration, desaturation with pneumonia or bronchiolitis). Examination should include tone and activity, alertness/conscious state (meningitis, encephalitis, sepsis, metabolic crisis, hypoglycaemia, electrolyte disturbance), perfusion, hydration, fontanelle (bulging with infection or trauma, sunken in poor feeding and dehydration), assessment of chest for respiratory distress, (pneumonia, bronchiolitis, metabolic acidosis, cardiac failure). An abdominal examination (herniae, testicular torsion, evidence of surgical abdomen), cardiovascular examination (murmurs, femoral pulses, cardiac ischaemia due to aberrant coronary vessels is a reported but extremely rare cause), ears (otitis media), oropharynx (herpes stomatitis, tonsillitis, upper respiratory tract infection).

Several additional manoeuvres may also assist:²

• fluorescein staining of cornea (corneal abrasion);

• palpation of long bones (fractures, osteomyelitis);

• inspection of skin beneath clothing (bruising);

• retinal examination (shaken baby syndrome);

• close attention to digits and genitalia (hair tourniquet).

Investigations

Investigations should be guided by initial clinical assessment. Screening investigations, with the exception of urine analysis and culture, have little utility.²

Disposition

The diagnosis of serious medical conditions during the initial clinical assessment will clearly indicate admission. Admission should also be considered in those cases where the clinical assessment is normal but the child continues to cry excessively in the ED beyond the time of the initial assessment. Persistent crying in these circumstances may be an indicator of serious illness.²

Occasionally it may be necessary to admit an infant with colic or minor medical problem to allow recovery of a sleep-deprived or poorly supported carer.⁹ The involvement of social work services is appropriate under circumstances where the family or child is considered at risk. Serious injury to children by non-accidental shaking injury is preceded by other episodes of abuse or neglect in over 70% of cases.¹⁰ Admission and social work assessment is always warranted if non-accidental injury or neglect is suspected.

Ensure appropriate follow up is organised for infants discharged from the ED – particularly where the diagnosis is not yet clear or where excessive crying is likely to be recurrent.

References

1 Brazelton T.B. Crying in infancy. Pediatrics. 1962;April:579-588.

2 Poole S.R. The infant with acute, unexplained, excessive crying. Pediatrics. 1991;88(3):450-455.

3 Illingworth R.S. Three month’s colic. Arch Dis Child. 1954:165-174.

4 Lucassen P.L.B.J., Assendelft W.J.J., Gubbels J.W., et al. Effectiveness of treatments for infantile colic: systemic review. BMJ. 1998;316:1563-1569.

5 Forsyth B.W.C. Colic and the effect of changing formulas: a double blind, multiple-crossover study. J Pediatr. 1989;115:521-526.

6 Heine R.G., Jordan B., Lubitz L., et al. Clinical predictors of pathological gastro-oesophageal reflux in infants with persistent distress. J Paediatr Child Health. 2006;42:134-139.

7 McKenzie S. Troublesome crying in infants: effect of advice to reduce stimulation. Arch Dis Child. 1991;66:1416-1420.

8 Carey W.B. The effectiveness of parent counselling in managing colic. Pediatrics. 1994;94(3):333-334.

9 Singer J.I., Rosenberg N.M. A fatal case of colic. Pediatr Emerg Care. 1992;8(3):171-172.

10 Alexander R., Crabbe L., Sato Y., et al. Serial abuse in children who are shaken. AJDC. 1990;144:58-60.