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A crying infant

Essentials

  • Even if crying is part of an infant’s normal development during the first three months of life, it is important to differentiate normal crying of infancy from crying caused by an illness (e.g. infection, cow’s milk allergy, acute surgical diseases).
  • Differential diagnostics are based on history and clinical examination.
  • An excessively crying baby may induce feelings of disappointment and helplessness in the parents and is always a burdensome problem for the family. The treating physician should show empathy and never underrate the effect of the crying on the family even if no underlying illness is diagnosed.

History

Crying as part of normal infant development, "three months' colic"

  • When did the excessive crying start and how much does the infant cry in a 24 hour cycle?
    • Crying increases at the age of 2–3 weeks and reaches its peak during the second month of life (in premature infants, the age is adjusted according to the prematurity), and the mean amount of crying will be about 2 hours in every 24 hours (the colic phase). The colicky crying declines by the age of 4 months.
    • The amount of crying shows great inter-individual variety, and an infant’s own crying pattern may also show daily variation. In clinical studies, ”colicky infants” are defined as infants who cry ”at least three hours a day for at least three days per week”. According to this definition, 5–15% of infants fall into this category.
  • What is the character of the crying?
    • The majority of the infant’s crying consists of discontented sounds with several intermissions (whining or fussing). Only a proportion of crying is incessant, and usually a small proportion is loud, attack-type ”sheer screaming” which is not soothed by taking the infant into one’s arms or by feeding and which is also called colicky cry.
    • Some amount of these intensive crying attacks is encountered in the majority of infants in the age of 1 to 3 months.
  • Does the infant cry at certain times of the day or is the crying continuous?
    • Crying often occurs at the same time of the day, usually in the evening, but may occur at any time of the day, and at other times the infant appears to be content.
    • The parents are particularly exhausted by infants whose crying occurs in the small hours.
  • What is the type of feeding? Is the infant growing normally?
    • Crying is as common in breast-fed infants as in those fed with milk formulas.
    • A colicky infant will gain weight normally.
  • What treatment approaches have the parents tried?

Crying as a symptom of hunger, pain or illness

  • Serious illnesses as causes of crying in a non-febrile infant can with great confidence be excluded by a carefully taken history and clinical examination, without the need of laboratory investigations (Acutely ill infant). In some cases, a monitoring period of 1–2 weeks is necessary in order to identify the cause of crying.
  • Does the infant have an acute infection?
    • Is there fever? General condition suggesting an illness? Breathing difficulty? Rhinitis, wheezy breathing?
    • Does the infant have an acute intestinal disorder requiring surgical treatment? Is there vomiting?
      • Causes of intestinal obstruction in an infant include e.g. pyloric stenosis (failure to thrive, projectile vomiting), intestinal stenosis/atresia/volvulus, incarcerated inguinal hernia, Hirschsprung's disease (constipation, distended abdomen).
  • Is the infant hungry?
    • If the reason for crying is lack of breast milk, complementary feeds will help the situation. Feeding will not help in colicky crying.
  • Are there problems with breastfeeding?
    • Assessment of the breastfeeding technique (e.g. latch-on, feeding position) and the feeding rhythm as well guidance in proper technique may reduce crying; see (Breastfeeding: advice and difficulties).
  • Crying during the first months of life is very seldom a symptom of reflux disease. A therapeutic trial with proton pump inhibitors is not recommended as their effect in the treatment of a crying infant is similar to placebo.
  • Is the infant allergic to cow’s milk?
    • Is the crying associated with the initiation of commercial infant formulas? It is rare to develop sensitivity via breast milk.
    • Does the child exhibit intestinal symptoms like vomiting, diarrhoea or poor weight gain? Does the child have atopic rash? Is there a family history of allergic diseases?
    • Cow’s milk allergy is a rare disease (2%) as compared to infant colic. Cow’s milk allergy should be suspected if the infant presents with intestinal or cutaneous symptoms, there is a relationship between the symptom onset and introduction of infant formulas as well as a positive family history of allergic diseases. These babies cry a lot throughout the 24-hour period, and the crying will show no normal, age-related reduction.
  • Does the infant have withdrawal symptoms?
    • The mother's medication during pregnancy and breast-feeding

Clinical examination

  • First of all, pay attention to findings suggesting an acute infectious disease.
    • Fever (> 38.0°C)
    • Poor general condition, the infant is tender to handling or languid
    • Difficulty breathing (muffled or wheezing breath sounds, respiration rate > 50/min)
  • An infant that has been brought to an appointment due to excessive crying is frequently well and contented during the appointment, which makes it easy to rule out any serious acute illnesses.
  • Weigh the child. Compare with the previous weight and calculate weight gain/week (> 150 g/week).
  • In the clinical examination, note especially
    • the child’s neurological development: eye contact, movements and muscle tone; palpate the fontanelle
    • auscultation findings of the heart and lungs, the size of the liver and the femoral pulses (aortic coarctation?)
    • abdomen (tender?) and groin (hernia?), genitals in a boy, anus
    • oral mucous membranes (thrush?)
    • skin (atopic eczema, nappy rash?)
    • tympanic membranes (otitis?)
    • extremities (fractures?)
    • the fundi of the eyes if there is a suspicion that the infant has been shaken (for retinal haemorrhage, see (Identification of child physical abuse)).

Treatment

  • Septicaemia, urinary tract infection and other diseases requiring immediate treatment must be excluded in a hospital setting if the infant
    • has fever (> 38.0°C)
    • has a sickly general condition: does not eat or eats poorly, is sleepy or tender to handling
    • has an increased respiration rate or has difficulty breathing
    • vomits or has diarrhoea
    • otherwise gives an impression of acute illness.
  • The majority of children less than 3 months of age brought to a physician due to crying prove out to be normal, i.e. their crying is a part of normal infancy. The parents must be made aware that
    • even a very well cared for infant will always cry at some point
    • crying will not harm the child and all colicky infants grow and develop normally
    • dimethicone drops or herbal products have not been shown to have an effect on the crying infant
    • increased carrying of the infant, baby massage or other alternative treatment methods, such as acupuncture or chiropractic treatment, have not been proven to be effective in the treatment of colicky crying.
  • If cow’s milk allergy is suspected, a 1–2 weeks' dietary trial with hydrolysed infant formula should be attempted. The trial should be used only after careful consideration and it should be withdrawn if no definite response is achieved. In any case, the final diagnosis of cow’s milk allergy is based on the reintroduction of cow’s milk (Cow's milk allergy).
  • The composition of the intestinal microbial flora in infants with colic has been shown to differ from that of healthy infants.
  • Daily administration of a probiotic supplement containing Lactobacillus reuteri has been shown to decrease the crying time in breastfed colicky infants, but the effect has not been demonstrated in formula-fed infants.
  • Make sure that the infant is given the recommended vitamin D supplementation (which the parents may erroneously consider as the cause of the crying because its onset usually coincides with the start of the vitamin D supplementation).
  • It is important that the parents share the care of the infant in order to avoid exhaustion. Relatives/friends/child care facilities etc. should also be utilised wherever possible.
  • The amount of colicky crying will decrease as the child develops regardless of the approach the parents choose for the care of their infant.
    • In the ”natural” approach, the infant is kept most of the time in skin-to-skin contact with the carer and all the infant’s demands are responded to immediately. This approach decreases the total duration of crying but not the proportion of intensive crying attacks during the first months of the infant’s life. On the other hand, nightly awakenings at the age of 3 and 10 months are more common. The strain to the mother caused by carrying of the child should also be taken into account.
    • In the rhythmic approach, the aim is to establish a regular rhythm for feeding and sleeping and the child is kept in his/her own bed when sleeping. In this way, there is on the average more crying and whimpering in the initial phase but later on the number of nightly awakenings is decreased as the child has learnt ways of self-control.
    • For the parents it is important to know that all the different care approaches have their pros and cons and that there is no single ”right” way to care for the child. The parents will thus not cause any harm to the child whether they keep him/her a lot in the arms, if they let the child sleep beside them or if, on the other hand, they leave the child occasionally crying.
  • The parents may try any other soothing interventions (steady calming stimulation, such as holding, cuddling,and continuous whirring sounds or, alternatively, reduced stimulation by putting the infant back into the cot), but the parents, and anyone else looking after the infant, must be fully aware that shaking the infant is life-threatening .
  • In order to monitor the crying pattern, a follow-up contact should be arranged with the family (appointment or phone call).
    • If new symptoms emerge or crying shows no sign of age-related reduction, the possibility of an underlying physical cause should be reassessed. The parents need repeatedly support and reassurance that the infant is in good health.
    • Despite the parents' suspicions colicky infants do not suffer from sleep deprivation. The good prognosis encourages the parents and will help them to cope through the colic phase.
    • The mother should be asked about her coping and, if necessary, postnatal depression should be addressed. Mothers to infants who cry a lot are at an increased risk of depression.
    • Peer support groups should be available for parents of young infants at the local child health clinics.

Evidence Summaries

References

1. Freedman SB, Al-Harthy N, Thull-Freedman J. The crying infant: diagnostic testing and frequency of serious underlying disease. Pediatrics 2009 Mar;123(3):841-8.  [PMID:19255012]

2. Sung V, D'Amico F, Cabana MD ym. Lactobacillus reuteri to Treat Infant Colic: A Meta-analysis. Pediatrics 2018;141(1);:e20171811.  [PMID:29279326]

3. Harb T, Matsuyama M, David M et al. Infant colic - what works: a systematic review of interventions for breastfed infants. J Pediatr Gastroenterol Nutr 2015;():.  [PMID:26655941]


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Citation

"a Crying Infant." Evidence-Based Medicine Guidelines, Duodecim Medical Publications Limited, 2019. Evidence Central, evidence.unboundmedicine.com/evidence/view/EBMG/454355/all/A_crying_infant.
A crying infant. Evidence-Based Medicine Guidelines. Duodecim Medical Publications Limited; 2019. https://evidence.unboundmedicine.com/evidence/view/EBMG/454355/all/A_crying_infant. Accessed August 21, 2019.
A crying infant. (2019). In Evidence-Based Medicine Guidelines. Available from https://evidence.unboundmedicine.com/evidence/view/EBMG/454355/all/A_crying_infant
A Crying Infant [Internet]. In: Evidence-Based Medicine Guidelines. Duodecim Medical Publications Limited; 2019. [cited 2019 August 21]. Available from: https://evidence.unboundmedicine.com/evidence/view/EBMG/454355/all/A_crying_infant.
* Article titles in AMA citation format should be in sentence-case
TY - ELEC T1 - A crying infant ID - 454355 BT - Evidence-Based Medicine Guidelines UR - https://evidence.unboundmedicine.com/evidence/view/EBMG/454355/all/A_crying_infant PB - Duodecim Medical Publications Limited DB - Evidence Central DP - Unbound Medicine ER -