Many babies are unsettled in the first few months of life and it is often difficult to determine what is a normal, or abnormal, amount of crying.
In early infancy, crying is practically the only way an infant can communicate its need for physical and emotional caring, or the presence of discomfort, hunger or pain. There are many ideas on what is an excessive amount of crying1, however, most authorities would define it as crying of greater than three hours per day, for three or more days per week in the preceding week, for at least three weeks.2 The degree of parental distress is most important, as this is the main determinant for seeking professional help.3
The term colic has been extensively used in the past to describe an unsettled baby with excessive crying. I feel it is better to avoid this term as there is no generally accepted working definition for colic.4 The use of the term implies a painful disturbance of the gastrointestinal tract5 and this further intimates that simple treatment or relief should be available when usually it is not.
During the first three months of life, excessive crying is reported by parents in around 20 per cent of infants6, with the highest prevalence being at one month of age.1 In well-looking, thriving babies with excessive crying only around five per cent will be found to have an organic cause.7 Most cases of persistent crying are thought to be multifactorial in origin. Douglas and Hiscock8 state that, ‘infant crying is commonly a normal state or a transient developmental problem that peaks at six weeks and resolves by three to four months of age’.8 They correctly point out that there is currently an over-diagnosis of ‘the big three’ as the presumed cause of excessive crying, that is: gastro-oesophageal reflux, food allergies and lactose intolerance.8
Concurrent with an increase in unsettled behaviour there is an increase in risk of maternal depression8,9, premature cessation of breastfeeding and child abuse.8 In fact, there is some evidence that prenatal exposure to maternal stress, such as depression or anxiety (as suggested by elevated maternal serum cortisol at 30–32 weeks gestation) is associated with a higher rate of negative infant temperament.10 In the general population, the prevalence of postnatal depression is estimated to be between ten and 15 per cent.11 With an unsettled, irritable baby at home, interactions between each parent and the child, as well as between the two parents, can be negatively affected.12 Frequent night waking usually leads to maternal sleep deprivation, resulting in adverse effects on mood, cognition and motor function.13
Any complete assessment of an excessively crying or a poorly sleeping baby therefore needs to take a wide-angled lens look at the infant, its family and environment. As well as a detailed conventional history of the infant’s symptoms, one should ask how this impacts on each family member individually as well as the family as a whole. Enquiry should be made into how the parents are currently coping and what amount of family support might be available from relatives, friends and health professionals. Even though an otherwise well baby with excessive crying may not appear a major issue under the traditional medical model, it certainly can have devastating effects on the overall family functioning.
Although organic causes represent only five per cent of cases of excessively crying babies who are well and thriving, ruling out these causes is important. One should have a higher index of suspicion where the baby is persistently irritable on a daily basis. Just about any medical condition could cause excessive irritability, however, a useful mnemonic to remember some of the more common causes of excessive irritability and crying is IT CRIES.14 This list is by no means exhaustive.
R reflux, reactions to medications, reactions to foods, raised intracranial pressure
I immunisations, insect bites
E eye and ear
S surgical and strangulation (hair or fibre tourniquet)
Most infections are associated with fever; however, in infancy, many infections (particularly urinary tract infections) may present as irritability alone. Osteomyelitis or septic arthritis may also present in this age group as irritability without fever. During examination it is therefore important to examine all the joints checking for any swelling or pain on movement, and any bony tenderness. It is worthwhile at least to collect urine for urinalysis and culture to rule out a urinary tract infection.
Traumatic injury may be accidental or non-accidental and one should examine the baby carefully for any bony tenderness or deformity (as may occur with bony fracture) and for bruising. Cardiac causes include periodic angina (for example, with anomalous coronary artery) and congestive heart failure. Irritability can be associated with certain medications (for instance, some anticonvulsants) and food sensitivities (such as cow’s milk protein intolerance or lactose intolerance).
Gastro-oesophageal reflux is frequently overdiagnosed. Signs such as back arching, aversive feeding behaviour, sleep difficulties and tense abdomen and limbs are not correlated with acid-peptic gastro-oesophageal reflux and are common behaviours.15 The diagnosis of reflux may be considered more where the child has increasing distress over several weeks with symptoms usually on a daily basis, where conventional behavioural methods of settling have been ineffective. Similarly the diagnosis of cow’s milk allergy may considered in the same setting, particularly if there is a family history of milk allergy. Cow’s milk allergy is present in two to three per cent of children and 0.5 per cent of exclusively breastfed infants.16 Where allergy to cow’s milk is suspected, a trial of partially hydrolysed (Pepti-Junior) or fully hydrolysed formula (Neocate or Elecare) may be justified to aid in the diagnosis. Likewise, a trial of a dairy-free diet in the exclusively breastfeeding mother may help an infant if they are allergic to cow’s milk.
Eye causes include corneal ulceration (think of brother or sister poking in the eye) and glaucoma. Ear infections can occasionally cause persistent pain over several weeks, especially when associated with middle ear effusion. Surgical causes include incarcerated inguinal hernia, volvulus and intussusception. These three causes are usually, but not always, accompanied by vomiting. Another cause that may easily be missed is strangulation by hair or fibre, which usually affects the digits. I have seen a three-month-old infant who had been crying excessively for over a week who had strangulation of his middle toe with circulation impairment from hairs. The offending hairs were not initially visible as they had cut through the skin. The message is to look very carefully at all the digits.
How should one deal with a baby that cries persistently? The most important thing is to listen actively to what the parents or caregivers are saying and to speak to them in a positive reassuring manner. When talking to the parents, it is worthwhile asking what they believe could be the cause of the problem and any particular concerns or fears they may have. After taking an extensive history of the problem, and evaluating the family and the family dynamics, a full examination of the infant should take place. If the baby
is thriving and looks well then initially a urine culture should be sufficient initial investigation.
Asking the parents what works best for them to help settle their baby is useful. If their method is reasonable they should be encouraged to continue those methods so as to give them a sense of some control. It is worthwhile telling the parents that they may not be able to stop the baby crying every time, but even if they can’t, they are still giving the baby comfort and teaching the baby to better cope with its distress.
A suggestion that works for many babies is the provision of a ‘quiet time’, where the baby is given a few minutes to self settle in a dark room if possible. Swaddling or wrapping firmly in a muslin cloth is helpful for a lot of babies.17 Other babies respond to soothing sounds such as a soft voice, singing or music. White noise in the background has also proven to help some unsettled babies.18 For some the pacifier or dummy can be helpful. Baby massage, bathing and distracting the baby with play may also help settle on occasions. Medication is rarely indicated and colic mixtures, gripe water, analgesics and sedatives19 are of no proven benefit.
Parents and caregivers should be followed up regularly by their medical caregiver and should be given details on who or what service to get in contact with if the problem escalates and is getting unbearable. Encouragement should be given for the parents to take turns in settling their crying baby and they should also be encouraged to schedule quality time together away from the baby (in other words, arrange trusted relatives or trusted friends to babysit). The family should ideally have an early childhood nurse as a support person as well as a local general practitioner. Occasionally, referral to a general paediatrician may be warranted. In a crisis, admission to hospital may help diffuse a stressful situation, especially if there is parental exhaustion or a chance of harm to the baby.
Most of the major children’s hospitals have helplines and websites where parents and health professionals can get further information and advice. As well as information sheets, sleep/crying diaries can be downloaded that are useful to keep an objective record of sleeping and crying patterns. Parenting Units exist in some States that offer telephone support, day sessions or residential sessions for several days. In New South Wales, Tresillian and Karitane offer such a service. Their helpline numbers are 1800-637357 and 1800-677961, respectively.
- Reijneveld S, Brugman E, Hirasing R. Excessive Infant Crying: The Impact of Varying Definitions. Pediatrics; 2001: Vol 108 No.4: 893–897.
- Wessell M, Cobb J, Jackson E, Harris G, Detwiller A. Paroxysmal fussing in infancy, sometimes called colic. Pediatrics.1954; 14: 421–434.
- Barr R. Crying in the first year of life: good news in the midst of distress. Child care Health Dev; 1998:24:425–439.
- Miller A, Barr R. Infantile Colic-Is it a gut issue. Pediatric Clinics of North America; 1991:38:6:1407–1423.
- Illingworth R. Infantile colic revisited. Arch Dis Child;1985:60:981. Wake M, Morton-Allen E, Poulakis Z. Prevalence, stability, and outcomes of cry-fuss and sleep problems in the first 2 years of life: prospective community based study. Pediatrics; 2006;117:836–842. Freedman S, Al Harthy
- N, Thull-Freedman J. The crying infant: diagnostic testing and frequency of serious underlying disease.
- Douglas P, Hiscock H. The unsettled baby: crying out for an integrated, multidisciplinary primary care approach. MJA; 2010193:533–536. Oberklaid F. Persistent crying in infancy: a persistent clinical conundrum. J Paed Child Health; 2000: 36: 4:297–298.
- Davis E, Glynn L, Schetter C, Hobel C, Chicz-Demet A, Sandman C. Prenatal Exposure to Maternal Depression and Cortisol Influences Infant Temperament. J Am Acad Child Adolesc Psychiatry; 2007: 737–746.
- Boyce P, Stubbs J. The importance of postnatal depression. MJA ;1994:161:471–472.
- Raiha H, Lehtenon L, Huhtala V et al. Excessively crying infant in the family: mother-infant,father-infant and mother-father interaction. Child Care Health Dev; 2002:28:5419–429.
- Herman M, Nelson R. Crying infants: what to do when babies wail. Critical Decisions In Emergency Medicine; 2006: 20 :5:2–10.
- Sherman P, Hassall E, Fagundes-Neto U,et al. A global, evidence based consensus on the definition of gastro-oesophageal reflux disease in the paediatric population. Am J Gastroenterol; 2009:123:1278–1295.
- Hest A. Frequency of cow’s milk allergy in childhood. Ann Allergy Asthma Immunol; 2002:89;33–37.
- VanSleuwen B, L’Hoir M, Engelberts A et al.Comparison of behaviour modification with/ without swaddling as interventions for excessive cry. J Pediatr; 2006:149:512–516.
- Spencer J. Arch Dis Child; 1990:65:1:135–137.
- Merenstein D, Diener-West M, Halbower A, Krist A, Rubin H. The trial of infant response to diphenhydramine: the TIRED study. Arch. Pediatr. Adoles. Med.; 2006:707–712.