Irritable infant

Question 1

What age does crying usually improve by?

Answer 1

usually improves by 3 - 4 months of age

Question 2

Define excessive crying

Answer 2

Excessive crying is defined as crying >3 hours/day for >3 days/week.

Question 3

How much should a 6-8 week old baby cry on average?

Answer 3

At 6 - 8 weeks age, a baby cries on average 2 - 3 per 24 hours.

Question 4

At what age does crying usually peak?

Answer 4

crying develops in the early weeks of life and peaks around 6-8 weeks of age

Question 5

What are some common, non-pathological causes of crying?

Answer 5

Excessive tiredness

• suspect if the infant’s total sleep duration per 24 hours falls more than an hour short of the “average” for their age
• average sleep requirements:
  
  • at birth: 16 hours
  • at 2 - 3 months: 15 hours
  • a 6 week-old baby generally becomes tired after being awake for 1.5 hours
  • a 3 month-old baby generally becomes tired after being awake for 2 hours

Hunger

• this is more likely if a mother reports her baby has frequent feeds (ie, < 3 hourly), poor weight gain and inadequate milk supply

Question 6

What are some differential diagnoses to consider?

Answer 6

1. Cow milk / soy protein allergy

• both can be found in human breast milk
• goat milk protein is as allergenic as cow milk protein
• usually a manifestation of delayed (non-IgE mediated) reactions
• suspect if there is vomiting, blood or mucus in diarrhoea, poor weight gain, family history in first degree relative or signs of atopy (eczema / wheezing), significant feeding problems (especially worsening with time)
• diagnosis is made clinically by a trial of eliminating cow milk by modifying the mother’s diet or changing to an extensively hydrolysed formula for a period of 2 weeks

2. Gastro-oesophageal reflux

• no causal relationship between gastro-oesophageal reflux and infant crying and irritability has been demonstrated
• “silent reflux” (reflux without vomiting) is an unlikely cause of infant crying
• gastro-oesophageal reflux disease may exist if there is frequent (ie 4 or more times per day) vomiting or if the baby has feeding difficulties
• the duration of daily crying is unlikely to reflect the severity of gastro-oesophageal reflux
• ranitidine and omeprazole have not been shown to be effective in reducing crying
• in the absence of frequent vomiting. Anti-reflux medication to manage persistent infant irritability is not recommended
• gastro-oesophageal reflux disease may be secondary to cow milk / soy protein intolerance

3. Lactose overload / malabsorption

• primary lactose intolerance is extremely rare
• suspect if there is frothy watery diarrhoea with perianal excoriation
• diagnosis is made by the presence of faecal reducing substances ≥0.5%% and pH < 5.0, and confirmed by clinical response to lactose-free formula
• in breastfed babies, may be functional lactose overload (high lactose content in foremilk in babies who frequently switch breastfeeding sides +/- feed frequently ie <3 hourly)
• in formula-fed babies, may be lactose malabsorption due to mucosal injury of the gastrointestinal tract secondary to cow milk / soy protein allergy
• if baby formula-fed, consider change to lactose-free or extensively hydrolysed formula
• if baby breastfed, advise to space feeds to 3 hourly or longer, empty breasts at each feed, and alternate sides for feeding. Consider referral to lactation consultant for feeding advice / trial of lactase-treated breast milk if no improve

Question 7

What differentials should be considered if cyring is acute in onset?

Answer 7

• Urinary tract infection
• Otitis media
• Raised intracranial pressure
• Hair tourniquet of fingers / toes
• Corneal foreign body / abrasion
• Incarcerated inguinal hernia

Question 8

Red flags in crying

Answer 8

1. Sudden onset of irritability and crying should not be diagnosed as colic; a specific cause is usually present
2. The maternal and family psychosocial state must be taken into account. Maternal post-natal depression may be a factor in presentation. Note that excessive crying is the most proximal risk factor for Shaken Baby Syndrome.
3. Suspect cow milk / soy protein allergy if
   
   1. vomiting / blood or mucus in diarrhoea / poor weight gain / family history in first degree relative / signs of atopy (eczema / wheezing) / significant feeding problems (especially worsening with time)
   2. gastro-oesophageal reflux is diagnosed
   3. lactose malabsorption is diagnosed in formula-fed babies

Question 9

Investigations for acute crying

Answer 9

Investigations

If the history is typical and examination normal, no investigations are required.

Consider (optional):

Stool examination for reducing substances and pH (if watery stools and perianal excoriation)

For acute crying:

Urine microscopy and culture (if acute crying and vomiting)

Fluoroscein staining of eyes (if history suggestive)

Question 10

Acute management of crying (flowchart)?

Answer 10

Question 11

Management of irritable infant?

Answer 11

Management

• Exclude medical cause
• Explanation and reassurance.

A) Engage in a partnership with the parents

B) Explain normal crying and sleep patterns

• Use a sleep / cry diary to explain the infant’s cry / sleep / feeding patterns
• Work out the amount of sleep over a 24 hour period using the Sleep / Crying Diary
• Encourage parents to recognize signs of tiredness (frowning, clenched hands, jerking arms or legs, crying, grizzling)

C) Assist parents to help their baby deal with discomfort and distress

• Establish pattern to feeding / settling / sleep
• Aim to settle the baby for daytime naps and night-time sleep in a predictable way (eg, quiet play, move to the bedroom, wrap the baby, give the baby a brief cuddle, then settle in the cot while still awake)
• Avoid excessive stimulation - noise, light, handling. Excessive quiet should also be avoided. Most babies find a low level of background noise soothing
• Darken the bedroom for daytime sleeps
• Carry baby in a papoose in front of the chest
• Baby massage / rocking / patting
• Gentle music
• Respond before baby is too worked up
• Give the mother permission to rest once a day without the need to carry out household chores. Have somebody else care for the baby for brief periods to give the parents a break.

D) Assess maternal and emotional state and mother-baby relationship

• Invite the mother to talk about how stressful it is to care for a baby who cries persistently
• Ascertain whether the mother is worried that she is depressed. Consider screening for postnatal depression using the Edinburgh Postnatal Depression Scale.

E) Provide printed information as parents are unlikely to remember much given their state of mind at the time

Question 12

Medication for irritable infant?

Answer 12

Medication is rarely indicated.

• Colic mixtures, gripe water etc are of no proven benefit.
• Anticholinergic medications are not recommended due to the risk of serious adverse events (apnoeas, seizures).
• Simethicone (Infacol Wind Drops / Degas Infant Drops) has no effect on infant crying when compared with placebo

Formula changes are usually not helpful unless there is proven cow milk allergy. Weaning from breast milk has no benefit.

Spinal manipulation is no more effective than placebo