The Crying Infant
Dr Clare Thomas - Paediatrician
Thelma McDougall – Social Worker
The Crying baby
Normal behavourial
crying
Colic
Bewitching hour
 The peak crying time is
between 3-11 pm
Crying out loud
 Red in the face
 Pull up their legs
 Pass wind
 Likely normal infant crying
and NOT pathological
History and examination
Fever
Bacterial meningitis: fever, paroxysmal irritability, lethargy
vomiting, full bulging fontanelle
Bronchiolitis: cough, fever, wheezing, tachypnoea, apnoea, poor
feeding
Otitis media: fever, ear discharge, erythematous/bulging
tympanic membrane
Pneumonia: cough, fever, tachypnoea, poor feeding, recent
URTI,
UTI: fever, odorous urine, vomiting, dysuria
Viral illness: fever, cough, rhinorrhoea, nasal congestion,
sneezing, vomiting, diarrhoea, shin rash, ill contact
Afebrile infant. Consider UTI
 UTI most common serious Dx (25%)
 Crying has been reported as the chief complaint in
afebrile children with UTI
 <1month old
 Culture may be positive despite negative pyuria
 Don’t rely on a negative urinalysis
GIT symptoms and signs
Constipation: hard, infreq stools, palpation of small pellets
Hernia: bulging in groin/umbilicus
Intussusception: sudden onset of severe intermittent crampy
abdo pain, drawing up of legs, well between episodes,
vomiting lethargy, haematochezia, currant jelly stools, pos
fecal occult blood, sausage shaped abdo mass
Could it be GOR?
 1/6 of infants with persistent crying had pathological
GOR on pH monitoring
 Only if baby vomits > 5 times per day
 “silent reflux” (ie reflux without vomiting) very unlikely
 In the absence of frequent vomiting, anti-reflux
medications are ineffective in reducing crying
Heine et al. JPCH 2006
Is it food allergy?
 Food allergy may play a causal role
 Cow’s milk protein and soy protein
 Symptoms vary:
 Immediate: vomiting, contact erythema, urticaria
 Delayed: vomiting, diarrhoea, constipation, FTT, blood or
mucus in stools
Is it Lactose intolerance?
 Symptoms of explosive diarrhoea
 May have perianal excoriation
 Test stool for faecal reducing substances
 Clinical response to lactose free diet confirms the
diagnosis
Hiscock, et al. MJA 2004
Could it be abuse?
 Inconsolable infant crying can provoke fatal abuse
 The median age of infants with shaken baby syndrome
(SBS) is 10 weeks.
 5-6% of parents will slap, smother, or shake their baby at
least once because it is crying
 In 28% of cases the stimulus for SBS is crying
Investigations
 Routine investigations in afebrile children with crying are
unwarranted as <1% of children received a diagnosis on
the basis of investigations alone
 Exception is urine m/c/s in infants < 1 month
 Investigations should be tailored to history and physical
examination findings
Freedman et al. Pediatrics 2009
Matt – 4 weeks old
1st presentation
 presented to DEM 11pm unsettled and off feeds
 Since 6pm inconsolable
 GP home visit to review “clicking noise”
 ?? Tender chest wall. Increase crying on certain handling
 Blocked nose and cough
 No temps
Matt – 4 weeks old
1st presentation
 Feeding history
 Breast fed until 2 weeks and now added cows milk formula
as irritable
 Windy ++
 3 vomits per week
 Today 1 vomit
 Passing urine 4 x day
 BO every 1-2 days
Matt – 4 weeks old
1st presentation
 PMHX
 Term, BW 3.66kg
 Issues with growth on discharge >10% weight loss
 Community child health nurse follow up
 3yo sibling
Matt – Examination
 Alert, unsettled, hydrated, afebrile
 RR 44 sats 97% no inc WOB
 No clicking heard with breathing
 Good AE to bases
 CVS, abdo, ENT normal
 Imp: unsettled ? Cause ? colic
Matt - Investigations
 CXR
 Urinalysis – negative
 NPA
 Bloods
 CRP - normal
 FBC - normal
CXR “30 day old, cough, unsettled”
Matt - Mx
 Observed in DEM
 Fed well, settled
 Discharged home
Matt – 6 weeks old
2nd presentation
 Sudden collapse/floppy pale episode
 BIB QAS unresponsive, seizure
 Immunisation yesterday
 afebrile
Matt – 6 weeks old
2nd presentation
 Feeding history
 GOR – recently commenced losec
 Generally unsettled baby
 1 week ago – loose stool and large vomit with altered blood.
Stools now normal
 Breast feeding with CMF top ups
Matt - Examination
A.
Patent
B.
RR 40, sats 100% RA, no inc WOB
C.
HR 147, CR <2secs
D.
No spontaneous movements, Responds to pain, floppy.
Pinpoint pupils. Bulging fontanelle
E.
Afebrile
5cm linear bruise R arm
faint bruise L cheek
Matt - Urgent CT
CXR
Matt 4 weeks old
Matt 6 weeks old
Lessons from the case
 History and Examination most important aspect in
determining the correct diagnosis
 Examination didn’t follow through with important points
obtained in history.
 Investigations should be tailored to the history and
examination
 Unhelpful investigations
 Missed Dx because of misinterpretation of investigation
 Communication between health care professionals
Parents with unsettled infants can
experience
 Diminished parental confidence and feelings of
helplessness
 Poorer mother-infant and father-infant relationships
 Compromised maternal mental and physical health
 Severe maternal exhaustion
Parents with unsettled infants can
experience
 Paternal feelings of depression, frustration, anger
 Marital dissatisfaction and tension
 Poorer quality infant care-giving
 Most serious adverse consequence , infant abuse.
Assessment
 Family history: relationships, conflict, coping strategies,
interpersonal communication
 Obstetric history including:
 Precious pregnancies/deliveries/ and physical wellbeing
during the pregnancy; expectations and experience of
delivery, postnatal depression, reproductive losses: misscarriage, stillbirth, infertility, abortion
Assessment
 Societal factors: support network: partner, family, social
networks
 Marital relationship; financial situation and
accommodation and other life stresses
 Infant factors: including the health, development and
temperament of the infant and other children
Assessment
 Loss and grief issues (especially if unresolved)
 death of a sibling,
 death of a baby
 childhood abuse of any kind,
 adoption
 of the mother,
 of other children,
 recent bereavement
Assessment
 Personal adaptation to motherhood

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

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parenting skills;
emotional demands of the responsibility for the baby,
lack of time to spend on her own needs
loss of personal identity and independence,
loss of a job and social isolation
 Past or present violence
 rape,
 childhood abuse, childhood sexual abuse,
 domestic violence
Professional Advice
 Understanding unsettled infant behaviour
 enhance strong parent-infant emotional bonds,
 sensitivity and responsively to infant cues,
 pleasurable interactions and confident care- giving
Professional Advice
 Its normal and healthy for newborns to wake at night
 Most babies will need their parents during the night for
feeding and help with settling in the first six months of life
 Babies do not cry to annoy or upset their parents
Professional Advice
 Most babies who cry inconsolably are not sick, but
important to exclude a physical cause
 Appropriate wrapping can help settle a distressed baby
(from birth to 4 months)
 Sleep problems reduce and eventually disappear with
time,
 but waiting for spontaneous resolution can take years and
have adverse effects on parental wellbeing.
Responding to unsettled infant
behaviour
 A calm and safe family environment is beneficial for
infants
 If parents feel they are becoming irritable, the baby
should be placed in a safe place and time should be
taken to become calmer before resuming infant care
 Baby should never be shaken
Services for parents
 Tertiary Health Services:
 Hospital emergency
 Specialist out-patient clinics
Services for parents
 Secondary health Services:
 Early parenting service: home visiting, day stay, residential
 Medical specialists, eg pediatricians
 Infant and adult mental health practitioners
 Complementary/ allied health
Services for parents
 Primary health care
 General practitioners
 Maternal, child and family health nurses
 Telephone help lines: government and professional
 Private practitioners, eg lactation consultants; home visiting
Services for parents
 Self help resources and peer support
 Websites
 Books
 DVDs
 Family, peers
 Mother to mother supports eg Australian Breastfeeding
association
Summary
 5% of infants with problem crying have an identifiable
organic cause
 Hx and Ex remains most important aspect in evaluating
the crying infant and determines choice Ix
 Afebrile infants <4weeks old should have urine culture
 Parents complaints of excessive crying of their infants is a
signal the parents need to be carefully counselled
 Empathic listening and validating the women’s experience