Baby crying

Disclaimer These guidelines have been produced to guide clinical decision making for the medical, nursing and allied health staff of Perth Children’s Hospital. They are not strict protocols, and they do not replace the judgement of a senior clinician. Clinical common-sense should be applied at all times. These clinical guidelines should never be relied on as a substitute for proper assessment with respect to the particular circumstances of each case and the needs of each patient. Clinicians should also consider the local skill level available and their local area policies before following any guideline.  Read the full PCH Emergency Department disclaimer.

Aim

To guide staff with the assessment and management of crying babies.

Background

• Crying is normal. Young infants cry for an average of 2-3 hours per day.  
• Crying develops in the early weeks of life and peaks around 6-8 weeks.
• Parents present concerned, distressed, exhausted and confused, having often received conflicting advice from various health professionals and lay sources.
• Excessive crying is associated with higher rates of post-natal depression in both parents.
• Colic is an outdated term used to describe crying perceived as excessive.

Assessment

• A full history and examination should be carried out including birth history, feeding (volume, frequency, type of milk), weight gain, bowel frequency and social history.
• In young infants, ask about sleeping and awake times.
• The aim of the assessment is to exclude pathological causes for crying and identify physiological causes.

History

• Ask parents what they think the cause is and what they are concerned about.
• Take their concerns seriously and complete a full examination even if the baby is no longer crying.
• It takes a lot of effort to leave the house in the middle of the night with a small child and parents should be supported and feel their concerns are being heard.
• Crying infants are one of the most common stress factors associated with non-accidental injury and this presentation should not be taken lightly. Any concern regarding the cause of crying and parental ability to care should result in admission for observation and support.

Differential diagnoses

Pathological causes

• There is often a more acute history and associated clinical signs on examination.

Sepsis

• Babies may present febrile or hypothermic.
• May be constantly irritable
• Appear unwell or toxic (see Fever – Without Source, Serious Illness Assessment and Sepsis Management guidelines)
• Consult a senior clinician early.

Intracranial pathology

• Consider in all persistently irritable infants.

Gastrointestinal causes

Intussusception

• Acute onset
• Pale, floppy, drawing up of legs and blood in stool is a typical presentation but not always present.
• Consider diagnosis and exclude on clinical examination.

Cow’s milk intolerance

• This is a common cause.
• Consider if there is vomiting, evidence of colitis, family history of atopy, significant feeding problems worsening with time.

Gastro-Oesophageal Reflux

• Screaming during feed time with feed refusal after starting a feed is typical.
• Upright position during feeding, keeping upright after feeding, regular winding during feeds and feed thickeners can help.
• Proton pump inhibitors are often used but their benefit is uncertain.
• If the baby is not gaining weight or losing weight then a more detailed investigations should be performed by the General Paediatric Team.

Constipation

• Delayed gut transit is normal especially in the neonatal period.
• Colostrum is a stimulant laxative so initially breast fed babies open their bowels regularly but this slows down once the milk supply is established.
• Delayed meconium (>24hrs) is a concerning feature and these babies should be discussed with the Paediatric Surgical Team.
• Excessive screaming during defaecation and blood passed with the stool may indicate an anal fissure.

Oral Candida

• Crying with feeds and refusal to suck.
• Clinical examination of the mouth diagnoses the condition – swabs are not required unless ongoing symptoms despite treatment.

Incarcerated Hernia

• Clinical apparent on examination.
• Typically a history of a groin lump ‘that comes and goes’.
• Requires immediate referral and review by the Paediatric Surgical Team.

Testicular Torsion

• Very rare in the neonatal period but must be considered.
• Pain on palpation, swelling and erythema of testis or hemiscrotum. All features may not be present. 

Orthopaedic problems

• Fractures - all long bones should be examined.
  • Always suspect if bruising present in non-mobile infants.
  • Check the Moro Reflex –  asymmetry may be suggestive of clavicle fracture.
• Osteomyelitis / Septic Arthritis.
  • Pain on specific movement (e.g. cries with nappy change or lying flat).
  • Examine all joints.
• Hair Tourniquet
  • Examine all digits and the penis carefully to exclude a hair tourniquet.
  • If unable to be removed in the Emergency Department, requires immediate referral to the Paediatric Surgical or Orthopaedic Team for removal under anaesthesia

Ophthalmology

• Corneal abrasion / Foreign body
• Common in young infants
• Studies have shown inconclusive evidence of the relationship to crying episodes.
• All babies with consistent crying should undergo a basic eye examination including fluoroscein staining.
• By 6 weeks of age, babies should be able to fix and follow to 90º.
• Check the red reflex in all infants who present to the ED.

Clinical bottom line

• Sudden onset of irritability and crying must not be diagnosed as colic and another cause can usually be identified.
• Admission must be considered for observation, investigation and parental respite and reassurance.

Non-pathological causes

Hunger

• Most common cause of crying.
• Newborn babies feed every 2-4 hours.
• Cry is often loud and demanding and feeding instantaneously stops the cry.
• Poor milk supply may result in a baby that is sated but starts crying after detaching from the breast.  Ask the mother about breast engorgement pre-feeds, let down and check the baby for weight gain.

Tiredness

• Overtired babies cry and are irritable, fighting off sleep they desperately need.
• Average sleep requirements for a 24 hour period:
  • Newborn: 16 hours – awake time max 1.5 hours.
  • 3 months: 15 hours – awake time max 2 hours.

Discomfort

• Babies cry when their nappies are wet or soiled but also if they are too hot or too cold.
• Ask about sleeping arrangements.

Wind

• Crying post feeds or waking shortly after being put into the cot at night are often due to wind.
• Advise the parents to wind frequently during the feed and ensure bottle teats are full of milk to avoid increased air swallowing.

Colic

• Excessive crying (>3 hours /day) in an otherwise healthy infant is often termed colic.
• It is recurrent, typically in the afternoon and evening and usually resolves by 4 months of age.

Management

A medical cause must be excluded.

Advice and follow-up for non-pathological causes:

• Listen to the parents concern and give them your time.
• Explain normal sleep and crying patterns. 
• Advise use of a diary to:
  • See the pattern of crying
  • Work out how much sleep is needed and duration of awake time
  • Encourage parents to recognise the signs of tiredness.
• Discuss ways to comfort the crying baby
  •  The Period of PURPLE Crying website period provides settling strategies.
• Medication is not indicated.
• Allow the mother to discuss the stress related to having a baby that cries constantly – consider screening for postnatal depression.
• Follow-up with the child health nurse within the week.
• Inform the GP by letter of attendance and the information you have given the parents.

Bibliography

1. AMH Children's Dosing (2015) Australian Medicines Handbook Pty Ltd
2. Newborn 101 by Carole Arsenault
3. Nelson Textbook of Pediatrics: 20th Edition Robert M. Kliegman, Bonita M.D. Stanton, Joseph St. Geme, Nina F Schor Publisher: Elsevier 
   
   

Endorsed by:	Head of Department, Emergency Department	Date:	Aug 2021
		Review date:	Aug 2022

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