Abstract
Persistent crying at the start of life is a common problem and has been reported by approximately 20% of parents. In most cases, no organic cause is found, and crying improves by around 3–4 months. This article will describe the causes and management of persistent crying, or ‘colic’, in the first 3 months of life.
The GP curriculum and infant crying
GPs have an important role in the care of children, indeed most care for children is delivered outside the hospital setting. The GP curriculum statement on
It also states that GPs should
Coordinate care with other primary care professionals, paediatricians and other appropriate specialists, leading to effective and appropriate care provision
Ensure that parents receive information, advice and support to enable them to manage minor illnesses themselves
Prescribe and advise appropriately about the use of medicines in children
Adopt a family-centred approach — this requires an understanding of the importance of supporting parents
Use a decision-making process determined by the prevalence and incidence of illness in the community and the specific circumstances of the patient and family
Have an understanding of neonatal problems, including feeding problems, breastfeeding and nutrition, as well as the normal growth and development of children. They should be able to manage conditions, which may present early and in an undifferentiated way, and be able to recognize a seriously ill child and intervene urgently when necessary.
Finally, GPs should have an awareness that consultations about children may be a presentation of a mother's post-natal depression and should also be aware of the effect that post-natal depression may have on her children.
Crying — when is it ‘abnormal’?
Crying is a normal part of infant life; however, it can be problematic in around 20% of babies. From an evolutionary perspective, crying is an attachment behaviour, which ensures the infant's primary caregiver is never far away. Babies vary in the amount that they cry and the ease with which they are soothed. Equally, parents vary in their capacity to withstand crying.
Normal crying behaviour usually starts in the first few weeks of life, and, on average, peaks at 6–8 weeks (with a duration of about 2.6 hours/day). It decreases around 3–4 months of age. Bouts of crying tend to occur in the evening — parents often report their baby going red in the face, pulling up their legs and passing wind during these episodes. Persistent and problematic crying, or ‘colic’, has been defined medically as that which lasts for at least 3 hours a day, for 3 days a week and for at least 3 weeks. However, many babies cry less than this but are still perceived by their parents to have a problem.
Although the frequency of crying episodes is similar among all cultures, practices such as breastfeeding on demand and carrying the baby result in a shorter duration of time spent crying. Also important are the mother—baby relationship dynamics — maternal anxiety and depression is known to be reflected in the baby's behaviour. Conversely, family breakdown can result from an irritable infant, and this should not be underestimated — crying has been causally linked to family stress, maternal depression and child abuse. Other complications of persistent crying include an earlier cessation of breastfeeding and earlier weaning on to solid foods — which may in turn have negative effects. Good management of the crying baby will help to avoid these repercussions.
Around 5% of ‘crying babies’ will have an organic cause for their crying, such as gastro-oesophageal reflux, lactose intolerance and cow and/or soya milk protein allergy. In most cases, however, the problem is an inability of the baby to self-soothe (often referred to as delayed neuromaturation). For example, the baby cries in response to tiredness, hunger, thirst, being hot or cold or in discomfort/pain — but an inability to self-soothe (even when the initial problem has been resolved) leads to a cycle of persistent crying.
Medical causes of persistent infant crying
Listen to any parent who presents with a baby that ‘cries all the time’. History and examination will usually be all that is necessary to rule out medical causes (Box 1).
Gastro-oesophageal reflux disease
Infantile gastro-oesophageal reflux disease (GORD) is caused by repeated exposure of the lower oesophagus to refluxing gastric contents. It is particularly common in preterm infants, any form of gastro-intestinalobstruction (e.g. pyloric stenosis) and infants with abnormal neurology (e.g. cerebral palsy.) It also appears to be more common in formula-fed infants.
Infant crying is commonly attributed to GORD — however, it is important to remember that normal infants, too, have a high prevalence of reflux symptoms (such as daily regurgitation, arching of the back and hiccups). Significant GORD is more likely when there are five or more episodes of vomiting a day, persistent crying and difficulty during feeds. More serious features include failure to thrive and apnoeic episodes. When giving the history, parents will describe vomiting shortly after a feed. Occasionally, there may be a history of aspiration pneumonia, recurrent wheeze or cough. During the examination, it is useful to watch the baby feeding if possible — infants with GORD may arch their back and turn their heads to one side (known as the Sandifer manoeuvre). Plot the baby's weight as failure to gain weight is one of the criteria for referral.
If GORD is suspected, offer parents practical tips as a first measure. Posturing is important — after feeds, advise parents to hold the infant upright for about 10 minutes over the shoulder. When laid down to sleep, advise parents to raise the cot by 30 degrees (e.g. by placing books under the head legs of the cot). It is also important to ensure the baby is not being overfed.
If further intervention is needed, begin with a food thickener — this is often a sufficient measure in reducing symptoms. Refer for advice from a dietician so that the thickeners of the feed can be changed according to the infant's response. Examples of thickeners include Instant Carobel and Thixo-D. Alternatively, a pre-thickened feed, such as Enfamil AR or SMA Staydown, can be given. Advise breastfeeding mothers to administer a gel of thickener in water on a sterilized plastic teaspoon prior to feeds.
Although frequently prescribed, Infant Gaviscon has never been tested in randomized controlled trials; however, it may well offer symptomatic relief. Parents can be advised to give one to two sachets before each feed. Gaviscon should not be given to infants due to its high sodium content.
Ruling out medical causes of crying in small babies
As a GP, management of the crying baby always begins with taking a good parental history. Elicit
Parents' views — what do they think the problem might be and what are their concerns? What are their fears? How experienced are they? Do they appreciate that duration and frequency of crying varies in infants and at different times in the same infant? How are they coping? What sources of support do they have at home, among their circle of friends and family? Do they need extra help?
The nature of the crying — when does the baby cry? Can it be consoled? What alleviates the crying? What's been tried?
Associated symptoms — a blocked nose may contribute to difficulty in feeding, vomiting may indicate a gastro-intestinal cause [distinguish between vomiting (forceful ejection of stomach contents) and ‘possetting’ small amounts of food effortlessly, which is normal], excessive straining may be due to constipation and eczema suggests discomfort from itching. Diarrhoea may suggest lactose intolerance.
A sleep and feeding history — this will help reveal an underlying cause such as overfeeding or underfeeding or premature weaning. The baby may inadvertently be swallowing air, especially at the end of a bottle-feed.
Assess the home environment — the family dynamics and atmosphere at home may well impact on the baby. Views of the father and other family members may also be useful. Also ask about sleep arrangements at home. Family stress should be considered — post-natal depression may be a reason why the crying cannot be tolerated.
Parental well-being — ask about the pregnancy, birth experience and mother's pre-existing physical and mental health
Thoroughly examine the baby from head to toe, while explaining to the parent what you are examining for
Exclude causes of discomfort, such as nappy rash and eczema
Examine the baby's orifices: look for a tight phimosis, anal fissures, evidence of oral thrush or teething and signs of otitis media
The baby should be weighed and growth plotted along the centile line. Check if the baby is gaining weight adequately.
Reassure parents that possetting and vomiting decrease with time, especially once solids have been introduced. However, referral to a hospital paediatrician should be made when
Simple measures such as posturing and thickeners have failed
Diagnosis is uncertain
GORD is complicated by failure to thrive or apnoeic episodes
GORD is on a background of an underlying condition, e.g. cerebral palsy
Further parental reassurance is required
Prokinetic drugs (such as domperidone) as well as antireflux medications (such as ranitidine and omeprazole) can also be used; however, there is no evidence that these drugs are better than placebo, and they should be initiated in secondary care.
Lactose intolerance
The role of lactose intolerance in persistent infant crying is controversial — the theory is that some babies have transiently low levels of lactase, causing lactose levels to build up in the gut. Gut bacteria break this down to lactic acid and hydrogen, and the resulting acidic faeces may cause watery, frothy stools and peri-anal excoriation. Diagnosis includes testing for faecal reducing substances and detecting an acidic faecal pH — however, this is not required in the primary care setting.
Management includes a 1 week trial of lactase drops. Parents should note the response of the child in a behaviour diary (see Fig. 1). In breastfed babies, advise the mother to express a tablespoon of milk into a sterile container, to which four drops of lactase (Colief 50000 U/g infant drops) should be added. The baby should be breastfed as usual and then given the foremilk with the lactase at the end of the feed, using a sterilized plastic teaspoon. In the case of a bottle-fed baby, advise parents to warm the feed, add four drops of lactase, wait half an hour, shake the bottle gently and then feed the baby. Low-lactose formula is not recommended.
Illustration of a behaviour diary.
Trial of lactase drops should be abandoned after a week if no benefit is seen. If there is a response to treatment, treatment should be continued until about 3 months of age (and by 6 months of age at the latest), when it can be gradually weaned off over the period of a week.
Cow and/or soya milk protein allergy
Transient intolerance to cow's milk protein occurs when large molecules (such as cow's milk protein) pass through the infant's permeable gastro-intestinal tract and are absorbed rather than broken down. As the gastro-intestinal tract matures, fewer whole proteins get through and symptoms resolve.
This problem can affect both bottle- and breastfed babies, as both cow's milk protein and soya protein can be found in human breast milk. Around 50% of babies allergic to cow's milk protein will also be allergic to soya milk protein. Reactions can be immediate or delayed for up to 48 hours post-ingestion and usually include persistent crying, along with one or more of the following:
Vomiting after most feeds
Diarrhoea with blood or mucus
Poor weight gain
Atopia, e.g. eczema and wheezing
Family history of cow's milk protein allergy
The presence of these symptoms is not diagnostic of food allergy, though, and the best diagnostic test remains a trial of diet modification. For breastfed babies, advise mothers to exclude all dairy products from their diet (including casein and whey). To avoid malnutrition, advise mothers to use soya milk products and take a calcium supplement instead. The baby's response should be charted in a behaviour diary, and if no improvement is made within 1 week, a normal diet should resume. If multiple food allergies (e.g. to wheat, eggs or nuts) are suspected, more restricted diets can be advised with input from a dietician. The latter is crucial to avoid malnutrition of both mother and infant. Of note, goat's milk is as allergenic as cow's milk.
Babies who are formula-fed should be given a trial of hypoallergenic infant milk formula from hydrolysed cow's milk protein or from other sources of protein such as soya. Examples of these include Nutramigen 1, Pregestimil (both of which are casein hydrolysates) and Pepti-Junior (whey hydrolysate). Once again, response should be noted in a behaviour diary. A positive response can be expected within a week. As with lactose intolerance, if there is a response to treatment, it should be continued until about 3 months of age (and 6 months of age at the latest). At that time, treatment can be weaned off gradually over the period of a week.
Non-medical causes of persistent infant crying
The tired baby
Overtiredness is a common cause of infant crying and should be suspected when an infant's total sleep duration per 24 hours is more than an hour less than the average for the child's age (see Box 2). Parents are often concerned as to whether or not their baby is sleeping enough — on the whole they can be advised that if their baby is awake and happy, then the baby has had adequate sleep. If the baby is awake and crying, however, he or she may well be tired. Often, tiredness is misinterpreted as hunger or boredom, and so the cycle escalates. Signs of a tired baby include frowning, clenching fists, jerking limbs, and later, crying and yawning.
Average sleep patterns in babies
Birth — 16 hours
2–3 months — 14 hours
6 weeks — 1.5 hours
3 months — 2 hours
Give parents information on good sleep hygiene for babies. Advise them to allocate the baby a consistent ‘sleeping place’, regardless of the time of the day and lay the baby down there when settled but still awake. In this way, babies learn how to drop off to sleep independently, so that when they wake after the first sleep cycle, they are more likely to self-settle. If babies start to cry, advise parents to soothe them by stroking and patting, but not to pick them up. If necessary, they should repeat this every few minutes until the baby has learnt to settle. Playing background ‘white noise’ (such as that of a vacuum cleaner, hairdryer, running water, washing machine or commercially available white noise CDs) may also help. For the first few months of the baby's life, swaddling may be useful, but beware of overheating.
Occasionally, parents may become somewhat obsessive about getting their baby to settle, and indeed after a 2 week trial, they find that their baby is still not settling. In such a case, parents should be advised to ‘go with the flow’ of the baby, for example by allowing him or her to play if not showing signs of tiredness.
The hungry baby
Parents will report a baby who feeds more than every 3 hours, yet still does not settle after feeds and has poor weight gain. If breastfeeding, the mother may complain of having a poor milk supply. If offered top-up feeds, these babies will accept willingly. Breastfeeding counsellors and health visitors may be able to advise on how to improve breast milk supply. Many mothers find that topping up with formula in the evening can help to satisfy the baby. Contrary to popular belief, there is no evidence that early weaning lessens infant crying.
The baby who will not settle
There are some babies who simply ‘will not settle’ — despite attempts to ensure they are well rested and fed. It is proposed that these babies have delayed neuromaturation and that once crying starts — as an understandable response to bowel gas or a loud bang — they simply cannot stop. By about 3–4 months of age, they usually develop the ability to self-soothe. However, in the meantime, there are several practical things parents can try to distract the baby, including
Carrying the baby in a sling during crying episodes
Minimising separation between parent and infant
Going for a walk in the pram or pushing the pram over an uneven surface in the house (e.g. kitchen tiles or over a doorway where the carpet joins the floorboards)
Giving the baby a warm bath
Playing white noise
Often parents are concerned that their babies might become ‘spoilt’. It is important to emphasize that these measures are only a preliminary management plan and that once the baby matures at around 3–4 months of age and is able to self-soothe, he or she should no longer require these techniques. It is important not to label babies as having a ‘difficult temperament’ because doing so can make parents feel hopeless and implies that any attempt at improving the situation will be futile.
Deterioration in maternal and family psychosocial state
The infant—parent relationship, social and cultural beliefs of the family, as well as the parents' level of emotional responsivity and ability to deal with a dependent infant all impact hugely on the infant's behaviour. Likewise, these factors also affect the parents' response to a crying baby. For example, parents who have had a difficult pregnancy, or previous miscarriages, may well have become emotionally blunted in terms of their reaction to the foetus during gestation. Upon arrival, therefore, they may be totally unprepared for the reality of looking after a baby. They may also be anxious that there is an underlying abnormality with their crying child, despite reassurance from healthcare professionals. Post-natal depression may also alter a mother's emotional response, and she may find it extremely difficult to care for her baby and react to its behavioural cues. This may result in over-exaggeration of the baby's irritability, or in her being unable to soothe the baby and establish a bond. Symptoms of depression are common in mothers of irritable babies, and indeed this may act as a trigger for post-natal depression.
How to manage persistent crying in primary care
Since most infantile crying has no organic cause, once medical causes are excluded, it is important for the GP to explain normal sleep and feeding patterns to parents (Box 3) and help them to deal with their baby's distress (Box 4).
Explaining normal crying and sleeping patterns
Reassure parents that crying is normal among all babies, that it is worst at 6 weeks and that excessive crying usually resolves around 3–4 months of age
Inform parents about normal sleep patterns, but emphasize that sleep requirements differ according to the child
Educate parents about the signs of tiredness, such as frowning, clenched hands, jerking limbs, crying and moaning. Advise them that, taking this into account, if they think that their baby is tired, they should attempt to put him or her to sleep.
Talk about the baby's need for interaction and play — sometimes parents develop a ‘campaign’ to avoid crying and may direct all their energy against ‘overstimulation’. Promote the concept of letting the baby ‘go with the flow’ — for example, allow the baby to play if he or she does not seem tired and take the baby for a walk if he or she appears tired but will not settle after 20 minutes or so. Alternatively, the parents could give the baby a warm bath and then attempt to put him or her to sleep again.
Treatment and support for persistent crying of all causes
Regardless of the cause of problematic crying, support and follow-up should be routine for all parents. Advise them to use a daily diary to record their babies' behaviour, which helps them, together with healthcare professionals, decipher the baby's crying and sleeping patterns, as well as the response to settling techniques. Often, by keeping a diary, parents are reassured to see that actually their baby is crying an average amount. A diary may also help to locate the cause of the problem — for example, parents may find that their baby sleeps better if awake for longer periods between day-time naps.
Helping parents to deal with their baby's distress
When appropriate, reassure parents, explaining clearly why they should not worry about an underlying medical problem. It is difficult for a baby to be consoled by a parent who is frantic with worry.
Explain to parents that some babies find it difficult to cope with normal bodily functions, such as digestion, defaecation, normal reflux, tiredness and hunger. When this happens they become overwhelmed and irritable, culminating in persistent crying.
Help parents to ‘read’ their baby's behaviour as a marker of his or her emotional state
Be ‘baby-centred’ — consider means of dealing with the baby's distress. If the baby seems easily startled and cannot self-soothe, perhaps a quiet and gentle approach is best. If the baby seems to be looking around the room frantically, he or she may be soothed by being held in such a way so as to be ‘locked into’ the mother's face. Once soothed, the baby could then be tempted into looking at other items in the room.
Advise parents to establish a consistent routine, including regular evening bedtimes. A bedtime routine could comprise quiet play, moving to the bedroom, wrapping the baby, giving it a brief cuddle and then laying him or her down to sleep while still awake. Parents should be advised to allow the baby to sleep when tired — not just after a set amount of wakefullness.
Work in a partnership with parents and be proactive in arranging follow-up consultations or phone calls
Organizations providing parent information and support
There are several organizations (Box 5) that provide support and/or information about behavioural techniques used to manage excessive crying to parents. The major organization supporting parents with excessively crying, sleepless and demanding children is CRY-SIS. They produce a regularly updated checklist that is useful for parents and healthcare professionals alike. Valuable information can be accessed via their website or over the phone — lines are open 7 days a week between 9 am and 10 pm.
Parents of crying babies will often be tired and stressed. Provide reassurance and support, and advise them to seek help from family and friends. A further valuable resource is the health visitor, who can offer support and practical advice to parents. Parents should be encouraged to rest when they can, prepare ahead for the baby's most difficult time of the day (e.g. by preparing dinner in advance) and given permission to let household tasks wait. Assess all new mothers for post-natal depression if it is suspected and routinely at 4–6 weeks and 3–4 months post-partum (Box 6).
Assessing maternal well-being and mother—baby relationship
Use open questioning to investigate how stressful it is looking after the baby. Ask the mother if she gets any enjoyment from her child — if she does not, she may well be depressed.
Establish whether the mother is depressed or feels at risk of becoming so. Post-natally (usually at 4–6 weeks and 3–4 months), healthcare professionals (including midwives, obstetricians, health visitors and GPs) should ask two questions to identify possible depression:
During the past month, have you often been bothered by feeling down, depressed or hopeless?
During the past month, have you often been bothered by having little interest or pleasure in doing things?
A third question should be considered if the woman answers ‘yes’ to either of the initial questions
Is this something you feel you need or want help with?
As part of a subsequent assessment or for routine monitoring of outcomes, consider using self-report measures such as the Edinburgh Postnatal Depression Scale, Hospital Anxiety and Depression Scale or Patient Health Questionnaire 9.
Source of depression screening questions: NICE Antenatal and post-natal mental health (2007) www.nice.org.uk/nicemedia/pdf/CG45fullguideline.pdf
Occasionally, parents may request prescription of medication to allay crying in babies with no organic cause. Although anticholinergic medication, such as dicyclomine, has been shown to reduce crying, its adverse effects (including apnoea and seizures) make it unsuitable for use. Simethicone (Infacol) has been compared to placebo in randomized controlled trials and has been shown to be ineffective; however, it is easily available, licensed for colic and cheap. Therefore, if parents feel unable to cope despite advice and reassurance, it is reasonable to offer a 1 week trial of one dropperful (0.5 ml) of Simethicone 40 mg/ml oral suspension before each feed. The dose can be increased to two dropperfuls before feeds if necessary. It has no reported adverse effects and the simple act of being able to give their baby treatment may help parents deal with the crying. Secondary options for management include a 1 week trial of diet modification to exclude cow's milk protein allergy and a 1 week trial of lactase drops to exclude lactose intolerance as described previously.
When to refer
It is important to seek advice from a paediatrician when
Parents are not coping, despite advice, reassurance and primary care interventions
Diagnosis is uncertain — e.g. failure to thrive, apnoeic episodes, crying which is not improving or worsening at 4 months of age, pyloric stenosis or significant GORD is suspected
Unable to wean off treatment by 6 months of age
The mother should be referred to the specialist perinatal mental health service if
She seems to lack empathy with or expresses intent to harm her baby
She does not feel ‘bonded’ with the baby or there is concern about the mother—baby relationship
She continues to express feelings of anger, anxiety or depression when her baby's symptoms have settled
Outcome
Almost all babies with colic will ‘grow out’ of it by the age of 3–4 months and by 6 months at the latest. However, these babies are more likely to develop behavioural and sleep problems going into their toddler and early childhood years. There is also conflicting evidence on whether or not infantile colic is related to a later development of allergies. Parents of irritable babies are less likely to have further children than their counterparts who have non-irritable babies.
This article has only considered the diagnosis and management of crying in babies up to the age of 3–4 months. Of course, beyond this age, crying can continue to be problematic and may be a reflection of other problems, including teething and separation anxiety.
Key points
Persistent crying at the start of life is common and reported by 20% of parents
Typically, bouts of crying occur in the evening, babies go red in the face and pull up their legs during these episodes
History and examination forms the mainstay of diagnosis, and behaviour diaries can be invaluable as a diagnostic and management tool
Important medical causes to exclude are GORD, lactose intolerance and cow and/or soya milk protein allergy
Once medical causes have been ruled out, parents should be reassured that there is no serious underlying cause and problematic crying improves by 3–4 months and offered practical support and information — the value of empathy and appropriate advice should not be underestimated
It is vital to screen for post-natal depression, given the increased prevalence in this group