The Crying Baby- Do we
actually do harm?
“She just won’t settle. Something is seriously wrong and we’re just not getting anywhere!”
It is not uncommon for these words to be heard as a general paediatrician, sat across from the pale tear stained face of an exhausted new mother. My heart sinks as the usual tale of events unfolds: they’ve tried Gaviscon, Carobel and Ranitidine, the milk has been changed several times and someone’s thrown in some Lactulose for good measure in case this is constipation. There’s usually a grandmother on the scene who ‘knows’ babies and is fully in agreement that this child is sick and we are doing nothing about it.
The disconnect between the picture painted by the family and the bouncing smiling baby in front of you can seem enormous but naturally always leads
I was pleasantly surprised to hear that in Melbourne, they run a specific unsettled babies clinic for those under 6 months, giving recognition to the fact that this is a common and important problem. I am not aware of any such service in the UK but would love to hear if there was. They also have a guideline for the management of these babies when they present to primary care or paediatric services, taking the focus away from gastrointestinal causes of crying in the absence of positive symptoms (vomiting, diarrhoea, eczema, failure to thrive) and denouncing the term ‘silent reflux’. The focus is on supporting the parents in dealing with the infant’s distress and the recognition of maternal mental health difficulties.
us to think: What am I missing? Is is it fair to put this apparently well baby through further invasive investigations based on the families concerns?
We have to be careful certainly so as not to miss the 1 in 300 000 babies with the rare congenital heart condition ALCAPA (anomalous left coronary artery) and more commonly to ensure we don’t miss those with urinary tract infections or meningitis. However often the solution lies right back at the beginning when we offered Gaviscon instead of support and understanding.
Everybody knows babies cry. Most new mothers do not need reminding of that fact. But what’s normal? Crying is a normal physiological phenomenon often increasing from 2 weeks of age and peaking around 6-8 weeks before improving after 3-4 months. It is recognised that it can last several hours and is often worse in late afternoon or evening. Excessive crying is defined as crying for >3 hours p/day for >3 days p/week.
The perception of excessive crying by parents is more multifactorial and influenced by anxiety, sleep deprivation, knowledge and the opinions of others. It’s difficult to unpick and often a period of observation by experienced paediatric nurses is vital in determining the scale of the problem. It is also worth acknowledging that excessive crying is the most recognised risk factor for shaken baby syndrome and that regardless of a physical cause for crying or indeed professional recognition of excessive crying, these families should not be left unsupported.
The term 'colic’ is often used to describe episodes of excessive crying (although this does seem to imply a gastrointestinal cause) and the NICE website has some helpful advice for management of infantile ‘colic’ including parenting techniques such as gentle motion, and the use of ‘white noise’. It even introduces the concept of ‘time out’ when things are becoming intolerable for parents. There are also several support organisations for parents of crying infants including the Cry-Sis website (For crying, sleepless and demanding babies) and the Purple Crying website (see below)
Acute onset of excessive crying or irritability in an infant warrants more serious investigation to exclude infection or non-accidental injury but I think early recognition and reassurance of normal infant crying in well babies presenting to paediatric services is key to reducing parental anxiety and avoiding unnecessary harmful interventions. Placing value on infant crying as an important problem for parents and the provision of follow up support services is vital for the long term wellbeing of both child and parent.