aka Pediatric Perplexity 009
Baby Tim is 3 months-old and has been crying inconsolably. His exhausted mother has brought him into the emergency department at one in the morning desperate for help.
This post is dedicated to LITFL team member Paul Young in New Zealand and our emergency medicine blogging colleague Davíð Þórisson in Sweden. Congratulations to both of your newly enlarged families, and I wish you each immunity against the vicissitudes of sleep deprivation!
Q1. What is the normal pattern of crying in an infant?
There is wide variation in the ‘normal’ pattern of crying.
Crying is normal behaviour in young infants; it starts in the first few weeks of life and usually reaches a peak at about 6-8 weeks of age. Crying tends to improve by about 3-4 months of age (90% of colic improves by 4 months).
Crying is often worse in late afternoon or evening and may last several hours. The ‘colicky’ infant may seem to cry at all hours of the day. Drawing the legs up as if in pain can be a normal behaviour (but not always…)
Q2. What important and common conditions need to be excluded on clinical assessment in the infant with excessive crying?
The complete differential diagnosis of excessive crying in an infant is enormous. However you may find this modification of the IT CRIES mnemonic useful (IT CRIES is from Herman and Le, 2007):
T — Trauma (accidental and nonaccidental injuries) and bites (e.g. insects), tumours
I — Infections (otitis media, herpes stomatitis, urinary tract infection, meningitis, osteomyelitis, etc)
M — Maternal/ parental stress, anxiety or depression
S — Strangulation (hair/fiber tourniquet)
C — Cardiorespiratory disease
R — Reflux, reactions to medications, reactions to formulas, rectal (anal fissures)
I — Intracranial hypertension, immunizations, intolerance of lactose or cow’s milk allergy
E — Eye (corneal abrasions, ocular foreign bodies, glaucoma, retinal hemorrhages)
S — Surgical (volvulus, intussusception, inguinal hernia, testicular torsion)
Q3. Why is the pattern of onset of crying (i.e. acute versus chronic) important?
Be wary of diagnosing colic when the onset of crying and irritability is acute.
A chronic pattern of prolonged crying is more reassuring of acute irritability and excessive crying, even if the acute change does not even meet the criteria for ‘colic’ (i.e. <3 hours). Organic causes, such as the TIM’S CRIES diagnoses, need to be excluded.
Q4. What are the most important features to assess in the history?
History needs to include:
Temporal association of crying with feeds.
Variation of crying with contextual or environmental factors.
Parental response — in terms of emotional responses and actions.
The parents support system. Screen for depression. Consider the potential for non-accidental injury.
Growth and development — physical causes of chronic crying are rare if the child is thriving.
Associated symptoms — e.g. vomiting, diarrhoea, eczema.
Q5. When should you assess for corneal abrasions in the crying infant?
It often advised that fluorescein should be used to check for corneal abrasions in the persistently inconsolable infant. However, Shope et al (2010) recently found about half of infants aged 1 to 12 weeks had corneal abrasions, and this was not associated with differences in crying times or sleep. Shope and colleagues caution that attributing unexplained persistent crying to corneal abrasions could lead to other potentially serious causes being missed.
Nevertheless, if the baby stops crying after topical anesthesia is applied to an eye and a corneal abrasion is seen, you’ve probably found the answer.
You perform a thorough history and examination. No organic cause for Tim’s excessive crying has been identified thus far.
Q6. What is ‘colic’ and what features are typical?
The prevalence of excessive crying in infants is estimated to be between 1.5% and 40% (helpful, eh).
Colic is defined as excessive crying for >3 hours/day for >3 days/week for at least 3 weeks (the rule of three 3’s). However, parents may perceive lesser durations of crying as excessive, and management should be directed at the effects of the unsettled behaviour rather than whether or not it meets the criteria for ‘colic’.
Colic is probably a misnomer — the etiology is uncertain — and may be best viewed as a syndrome of similar symptoms rather than a specific disease entity.
Q7. What investigations should be performed?
No investigations are required if the history is typical of colic and no abnormalities are found on physical examination. Otherwise, start looking for a cause of TIM’S CRIES.
Q8. What is your approach to management?
No single approach is helpful in all infants.
- The infant is not unwell or in pain
- the crying and unsettled behaviour will improve with time.
- empathic acknowledgment of anxiety and stress
- constructive options for ongoing support from within and outside the family.
- Printed information with management advice and support contacts
Suggest the following behavioural measures:
- establish a regular routines (e.g feeding and settling)
- avoid excessive stimulation (such as noise, light, handling, temperature), but avoid excessive quiet too. A low level of background noise is soothing to most babies.
- Carrying the baby in a sling in front of the chest
- baby massage, rocking or patting
- Gentle music tapes
- Respond before baby is too worked up
- have somebody else care for the baby for brief periods to provide some parental respite
Unfortunately there is little evidence supporting the effectiveness of these commonly used behavioural measures.
Q9. What are the potential consequences of excessive crying in an infant?
Excessive crying in infants is a significant health problem. Consequences include:
- Common reason for seeking medical attention
(costs the UK’s NHS US$108 million annually for the first 3 months of life)
- Maternal anxiety, stress and depression
- Contributes to discontinuation of breast feeding
- Harms relationships within families, e.g. between parents
- Contributes to non-accidental injury
Q10. What follow up is necessary?
Early referral for ongoing support is always a priority. Disposition will depend on the effects of excessive crying on the infant’s family, and the family’s ability to cope.
The options include:
- Maternal/ child health nurse
- General practitioner
- General paediatrics
- Inpatient admission — for severe cases or if there is risk of parental exhaustion or non-accidental injury to the infant.
Q11. What medications or feeding measures help to improve ‘colic’?
Many medications and feeding formulations have been suggested for colic. The current evidence-base, taking into account the varying methodological qualities of the various studies, suggests that the following measures are all ineffective:
- Medications, such as simethicone, anti-spasmodics and sedatives.
- Colic mixtures, gripe water etc
- Addition of lactase enzymes to milk
- Formula changes unless there is proven cow’s milk allergy or lactose intolerance.
- Weaning from breast milk
Interestingly, a recent double-blind trial (Savino et al, 2010), as yet unvalidated, strongly suggests that probiotics may help improve colic. Hopefully this finding will be borne out in future studies.
- Herman M, Le A. The crying infant. Emerg Med Clin North Am. 2007 Nov;25(4):1137-59, vii. PMID: 17950139.
- Royal Children’s Hospital Melbourne. Paediatric Handbook (8th edition), Wiley-Blackwell 2010. [website]
- Royal Children’s Hospital Melbourne. RCH Clinical Practice Guidelines — Crying baby – Infant distress.
- Savino F, Cordisco L, Tarasco V, Palumeri E, Calabrese R, Oggero R, Roos S, Matteuzzi D. Lactobacillus reuteri DSM 17938 in infantile colic: a randomized, double-blind, placebo-controlled trial. Pediatrics. 2010 Sep;126(3):e526-33. Epub 2010 Aug 16. PMID: 20713478.
- Sharieff, G. The Inconsolable Baby — Free Emergency Medicine Talks, 2010.
- Shope TR, Rieg TS, Kathiria NN. Corneal abrasions in young infants. Pediatrics. 2010 Mar;125(3):e565-9. Epub 2010 Feb 8. PMID: 20142290.