Ilana Levene & Mark Anthony
It’s 2am and you’re called to see a 3-week-old baby who won’t stop crying. The baby fell asleep in the car seat on the journey but the parents are both in tears. You can feel the desperation in the room and as you hear the story of hours of crying, interrupted sleep and all the things they’ve tried, it starts to make you feel desperate too – to find a solution for them.
The crying baby is a pretty common presentation to acute and primary care, but rarely has a serious cause (5% in one case series). However, the impact on families can’t be overestimated – in terms of parental mental health, effect on feeding choices, overdiagnosis of pathology, exposure to side effects of treatment and, in a small but important number, risk of non-accidental injury.
As doctors, we find these presentations particularly difficult because of the mismatch between parents’ desperation for a solution, and what we can offer in return – thus the proliferation in prescribing specialist formula and anti-reflux medications. This blog will go through how to assess the crying baby, which serious conditions to exclude, and how to help the family understand and manage the crying. Part 2 of this series will look at “The Big 3” (colic, cows’ milk protein allergy and reflux disease).
What is ‘normal’ crying?
On average, infants in the first 6 weeks of life cry for 2 hours a day, decreasing to 70 minutes a day by 12 weeks – that’s a lot of crying, so no wonder inexperienced parents get worried! 70% of this crying happens between noon and midnight, and there may be inconsolable bouts, where nothing the parents try will get the baby to stop crying.
Why do babies cry?
The commonest causes for crying are normal newborn behaviour and colic (‘excessive crying’; see part 2).
The rare but important causes to think about in your history and examination are serious bacterial infection (including urinary tract infection), acute surgical causes (incarcerated hernia the most likely in a baby, rarely torted testicle, intussusception or volvulus), supra-ventricular tachycardia and hair tourniquet. Many sources also mention corneal abrasion, but studies of normal babies show that corneal abrasions are common and not associated with the level of crying, so it is difficult to know how important abrasions are.
Finally, the commonly over-diagnosed conditions of cows’ milk protein allergy and gastro-oesophageal reflux disease must be carefully considered and a risk-benefit, family-centred approach used when thinking about treatment.
Box 1: causes of crying
Excluding serious causes
Box 2 outlines what to ask in your history. Red flags are presence of fever, and bilious or projectile vomiting. A sudden change in behaviour from settled baby to inconsolable crying may be a red flag.
Key areas to check in the examination are abdomen, groin, genitalia (you can get genital hair tourniquet) and all digits (take off those socks and scratch mitts!). And of course, at least one full set of vital signs.
If you have no concerns from the history and examination, no further investigations are needed. If you are concerned about any of the serious causes in box 1 then divert to those pathways of investigation. If you’re not sure which way to go, consider a period of observation. Send a clean catch urine for culture if the baby has a fever, abnormal vital signs, vomiting with faltering growth, frequent vomiting with marked distress or vomiting starting after 8 weeks of age.
Box 2: what to ask in the history
- What is the pattern of crying over 24 hours and over the last few weeks or months?
- If breastfeeding – how is it going? See here for how to assess if breastfeeding is going well
- If formula feeding – check that parents are making formula up correctly. What volumes is the baby taking? Are parents feeding responsively?
- Perinatal risk factors for sepsis
- Risk factors for hernia (male sex, preterm, low birth weight, family history)
- Potential allergic symptoms – rashes/eczema, vomiting, loose/bloody/mucousy stool, rhinitis, excessive sneezing (occasional sneezing is normal in newborns), wheeze, cough, angio-oedema
- Potential GORD symptoms – feed refusal, association of crying with flat position/vomiting (but remember fussy feeding is common, and most babies prefer to stay cuddled up to a parent after a feed rather than be laid flat in a Moses basket so it’s easy to overinterpret this)
- Ask to have a look at the red book (UK parent-held child record) or take a growth history if not available
- What do the parents think is the cause of the crying and what do they hope you can help them with?
- Have they sought help before? What has been advised/tried?
- Parents’ feelings. Have they ever felt like they might hurt the baby or are at the end of their tether? Are they worried about their own mood? Do they have a support network? An example questionnaire is here (behind paywall but NHS OpenAthens or RCPCH membership will get through)
If you are not concerned about an underlying cause, your management will cover two general topics – firstly the nature of normal crying and secondly simple management options.
You need to thoroughly reassure the parents about what normal newborn crying is like. Tackle the commonly held feeling that it must be abdominal discomfort – there is no specific evidence for this. Reassure them that they are doing the best they can, there’s nothing wrong with them or the baby, sometimes you can’t make a baby stop crying, but THIS WILL PASS!
For management, think simple needs, feeding, and the 5 Ss:
Simple needs means looking for a simple cause of the crying – wet or dirty nappy? Is the baby too cold or too hot? A good room temperature at home is between 16 and 20 degrees and a baby should normally be wearing one more layer than an adult is wearing. Most parents will have thought of these things already, but some may not. Folk wisdom says that frequent and effective winding is important for a baby’s comfort, but the single RCT of asking parents to burp babies versus no burping showed no change in the rate of excessive crying, and a significant increase in regurgitation with burping.
Feeding is often interlinked with crying. If you have identified breastfeeding difficulties, tell parents to access face to face expert breastfeeding support and reinforce how to assess that breastfeeding is going fine (growth, wet and dirty nappies, rather than focusing on the baby’s behaviour). See here for more details on how to assess feeding.
With formula or mixed fed babies it’s worth exploring the technicalities as making up formula incorrectly is prevalent – for example in a Scottish national survey, 9% of parents were putting powder in the bottle first and then adding water, which can result in an overconcentrated feed, particularly with larger volumes. Families in poverty may dilute feeds to make the formula go further – which could cause crying due to hunger.
Be a Baby Whisperer…
The 5 S’s are the baby whisperer secrets. The unifying idea is to create an environment as similar to the womb as possible.
Spending a significant part of the day carrying the baby, for example using a Sling, is associated with 50% less crying than ‘standard UK parenting’ that involves less physical contact – in fact an RCT of trying to carry babies for at least 3 hours a day (in addition to when feeding) reduced peak crying by an hour. Sucking is an important soother – which can be either through breastfeeding or a pacifier. Reassure mums that they can’t ‘spoil’ a baby by offering the breast for comfort, this is natural responsive feeding. Pacifiers should be avoided in breastfed babies until breastfeeding is established, around 4-6 weeks.
Swaddling mimics the confinement of the womb. Safe swaddling leaves the hips free to move and is not excessively tight across the chest. Babies must be put on their backs when swaddled, and it needs to be stopped when the baby can roll over. Shushing and singing provide the noisy environment prominent in the womb – white noise provides a similar function. The final S is Swinging, which can be jiggling, rocking or gentle motion, again mimicking the movement the foetus experienced as their mother walked around. A Cochrane review also reports some evidence that regular infant massage is associated with reduced crying.
Hopefully this blog has made you feel more comfortable about diagnosing normality, and giving evidence-based non drug advice. This is the most important stuff to remember, but sadly you are unlikely to see a baby who hasn’t already got a label or some treatment for one of the “Big 3” (colic, reflux disease and CMPA), which may or may not be helpful. Read part 2 to find out more.
Although crying babies can be a heart sink presentation for doctors, with confidence in the natural history and the rare potential underlying conditions we can have a big impact on parents’ understanding and acceptance of crying. Validate the parents’ distress and use your desire to help them to spend time on explaining, reassuring and signposting to community support, rather than knee jerk prescribing.
Key Learning Points
Normal babies can cry a lot
If you are not worried about a serious pathology after history and examination, no investigations are needed
Always check the tummy, groin, genitalia and digits and get a full set of observations
Have low threshold to direct a mother to expert face to face breastfeeding support
Be a baby whisperer: sling – sucking – swaddling – shushing – swinging
Resources for parents
Cry-sis telephone helpline 0845 122 8669