The crying baby

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    Cry-fuss behavior in an infant's first 3-4 months is a common problem. With many different disciplines providing advice on this problem, the result is often confusing and conflicting for parents. GPs are well positioned to offer cost-effective management for parents of persistent criers. This How to Treat aims to get GPs up to speed on managing crying babies.

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    Contents

    Background

    Prevalence and aetiology

    Assessment and diagnosis

    Management


    Background

    Cry-fuss behaviour in the first 3-4 months of life is a common and complex problem. Parents seek help from doctors, midwives, child health nurses, lactation consultants, psychologists, and other health professionals. The research in this field has been characterised by discipline-specific interpretations of the evidence, so families often receive conflicting advice from different health providers (figure 1). This results in costly duplication of services as parents resort to multiple service providers, including the ED. Popular discipline-specific interventions, such as behavioural interventions, or the diagnosis and treatment of gastro-oesophageal reflux disease or food allergy, commonly derive from an extrapolation of research on older infants back to the first few weeks and months of life. But in the highly neuroplastic post-birth period, cry-fuss and sleep problems emerge out of multiple interacting and dynamically coevolving variables in the complex system of the mother and baby. In complex systems, discipline-specific interventions that manipulate just one or two variables risk unintended outcomes. Effective and holistic management of the crying baby and his or her family demands a multifaceted clinical approach, arising from an interdisciplinary synthesis of evidence.1-5 The nomenclature concerning cryfuss and sleep problems is confused.6 Clinically, parents use “unsettled” as a non-specific term referring to their babies’ crying, fussing and frequent waking from sleep in this age group, and for that reason this article applies the terms unsettled behaviour, cryfuss behaviour, and excessive crying interchangeably. A baby is most usefully defined as being unsettled or crying excessively if the parents consider that to be the case.7 Hospital stays are shortening after birth, and families complain of difficulty accessing timely support in the early weeks and months. Because of their interdisciplinary and integrative clinical skills, gps are well positioned to offer cost-effective management for the complex and undifferentiated presentation of infant crying.


    Prevalence and aetiology

    Excessive crying is reported by one in five parents of infants at two months of age.8 many more cite unsettled behaviour as the reason for commencing formula or complementary feeds, with crying, fussing and frequent night waking perceived to signal inadequate breastmilk supply.9-12 Parents are more likely to complain of cryfuss problems in the first 12 weeks post-birth and sleep problems thereafter. Infants with problem crying and fussing in the first three months of life do not wake more than other babies on average.13 Clinically however, crying, feeding and sleep problems interact and co-evolve, particularly in the first few months, and have been generically defined as regulatory problems.4,14,15 A 2011 meta-analysis concludes that amounts of cry-fuss behaviours vary greatly between babies, with a stable average total daily crying duration of 110-118 minutes from birth to six weeks in healthy infants. This decreases to 72 minutes by 10-12 weeks, then tapers off.16 Bouts of crying tend to cluster at the end of the day. The condition previously known as “infantile colic” does not constitute a clinical entity, but an arbitrary upper limit of normal crying, and we do not recommend the use of this term.16 The average duration of infant crying in a 24-hour period varies according to the infant care practices of different societies even within western society, although the frequency of cry initiation remains constant across cultures.16,17


    The number of bouts of prolonged and unsoothable cryingis proportional to the overall amount of crying.18 An increased risk of problem crying has been linked with prenatal stress, family adversity, birth complications, the first child, and planned return to work by four months postbirth.19-21 These associations are not clinically useful when cry-fuss problems present, however. Cry-fuss behaviours in the first 3-4 months of life are a spectrum of infant neurobehavioural cues, caused by activation of the mygdala and hypothalamic–pituitary– adrenal (HPA) axis and sympathetic nervous system arousal. When an infant’s amygdala are activated by a perceived need or threat either internally or in the environment, HPA neuronal circuitry upregulates, triggering sympathetic nervous system activity and adrenaline release with associated cardiovascular, vocal, facial and other physiological changes along a gradient of crying. In a positive feedback loop evolved to ensure the infant’s survival in threatening circumstances, sympathetic nervous system arousal causes more release of cortisol from the HPA; adrenaline and cortisol further upregulate sympathetic nervous system activity.


    This feedback loop explains bouts of unsoothable crying, so that an initial signal of discomfort or distress becomes a temporarily stable behavioural state. Some infants, whether due to temperament, genetics or environmental factors, become sensitised and quickly bypass pre-cry cues, moving straight into high levels of sympathetic nervous system arousal and unsoothable crying.22 Although problem crying usually resolves without long-term sequelae, it is not as benign as previously believed. Excessive crying increases the risk of premature breastfeeding cessation, child abuse and postnatal depression.22-24 It is also linked with increased risk of behavioural and feeding problems later in childhood, particularly in the 5% of babies who continue to have cryfuss problems at five months of age, and if the family have psychosocial risk factors.15,25,26 For all families with an unsettled baby, intervention as early as possible to identify and manage treatable problems is important.2-4


    Assessment and diagnosis

    A thorough history and examination are required to identify the myriad medical and surgical problems that may present with excessive infant crying.


    History

     

    Inquire into the antenatal, birth and postpartum histories. A detailed feeding and elimination history is essential (see box). Ask for details of the mother’s medical and surgical history as this may impact directly on her health postnatally. Previous breast surgery, thyroid problems, diabetes and polycystic ovary syndrome are examples of conditions that may affect lactation. Inquire into parental allergy history including food allergies. If any red flags turn up during history-taking (eg, blood in the baby’s stool or vomit; projectile vomiting or fever in the baby; excessive vaginal blood loss, abdominal pain, or fever in the mother) then appropriate investigation and management is the first priority. Ask about the pattern of infant crying, its timing and duration, precipitating factors and strategies already tried by the parents. Ask what the parents understand about normal infant crying. Is the baby pulling away, back arching, or resisting touch or movement? If these signs occur while feeding, they most commonly indicate a feeding problem, but occasionally point to a sensory processing or vestibular problem.


    Enquire about where the baby sleeps and use this as a prompt to discuss safe sleep, according to the sids and kids guidelines (see box). It is also important to delve into psychosocial factors. Do the parents have extended family support? Do they have supportive social networks? Is the caregiver engaged in supportive activities outside the home (eg, parent groups or mother– baby exercise classes)? Are there siblings and if so, how is the new baby impacting on these children? What were the parents’ experiences with their previous babies? Are both parents working or planning to return to work soon? Administer the edinburgh postnatal depression scale, remembering that this scale is only a marker of risk and should not override clinical judgment (see online resources). It may also be appropriate to ask if the parents ever feel at risk of harming the baby or harming themselves.

     

     

     

    Examination

    Note general appearance of the infant, including an assessment of hydration, jaundice, and subcutaneous fat stores. Check that the baby is gaining at least an average of 125g a week in the first three months of life. Assess vital signs. Perform a thorough physical examination to exclude any systems abnormalities (see Stanford Newborn Nursery website, online resources). Check for tongue-tie (figure 2) and other oral abnormalities such as cleft palate. Note if the baby cries in response to movement or touch. Poor eye contact and lack of interest in caregivers may be developmental red flags, and should be carefully monitored. History may lead to a focused examination of the mother. If the baby is breastfeeding, examine the mother’s breasts and nipples.


    Investigations

    Abnormal findings in the history and examination guide choice of investigation, management and referral pathway for both mother and baby. But in an otherwise healthy afebrile infant with cryfuss problems, routine investigation is not warranted.26


    Management

    Synthesis of the heterogeneous evidence concerning cry-fuss and sleep problems in the first 3-4 months of life translates into a systematic clinical approach, which we call the “possums approach.” In our approach, five domains are considered: baby’s health, mother’s health, feeds, sensation, and sleep (figure 3).1-5,32 Our framework is applied flexibly to fit the unique needs and values of any individual mother–baby pair, and to accommodate the different time frames that a GP has available.

    Baby’s health

     

    Table 1 lists rare causes of infant crying in the first few months that should not be missed. About 5% of crying babies have an underlying illness, most commonly uti.31 However, in the absence of signs suggestive of infection, excessive crying should not in itself prompt routine urinalysis in an afebrile crying infant under 3-4 months of age.33 Feeding and nutrition is fundamental to a baby’s health, and many babies who cry excessively in the first few months of life have an underlying feeding problem, dealt with in the third domain of the possums approach, that is, feeds. Gastro-oesophageal reflux disease (GORD) is often diagnosed in crying babies in the first few months of life, and treated with proton-pump inhibitors or other anti-secretory medications. But randomised controlled trials, systematic reviews and two international consensus statements by paediatric gastroenterologists show that acidpeptic or allergic GORD is very rarely a cause of cry-fuss problems in this population, and PPIS are no better than placebo.34-40 Gastric acid is buffered for two hours after feeds of either breastmilk or formula, and buffered refluxate is not irritative of oesophageal mucosa.41-44


    Treatments such as keeping babies upright after feeds, sleeping babies on wedges, or thickened feeds are not indicated. Back arching (Figure 4) is a neurobehavioural cue of protest, not oesophagitis regardless of feeding method. In breastfed infants, back arching and pulling away from the breast occur when positional instability or latch problems disrupt the infant’s reflex feeding sequence. Back arching may similarly signal feeding difficulties in bottle-fed babies.30,45 Screaming with a red face, flexed hips and knees, and flailing fists occur with the neurohormonal feedback loops of sympathetic nervous system hyperarousal but do not necessarily — or even usually — signal pain.46 Frequent vomiting is normal once serious conditions, such as pyloric stenosis and food protein induced enteropathy syndrome, have been excluded, the latter being very rare in exclusively breastfed babies.47 Vomiting occurs in 40% of babies, peaks at four months of age, and occurs more frequently with the high levels of sympathetic nervous system arousal associated with excessive crying.47-50 PPIS place infants at increased risk of infection and later development of a paediatric food allergy.40,51,52 Since PPIS are no better than placebo for cry-fuss problems, exposing the unsettled infant to even a modest risk of medication side effect is inappropriate. 37,38 When it is presumed an infant has gord, many cry-fuss behaviours and related problems are attributed to the GORD. As a result, other treatable factors relating to excessive crying in the first few months of life, including feeding problems, can be overlooked.1,3,53,54

     


    Cows milk allergy has only weak links with excessive crying in the first months of life.55,56 Cows milk allergy in infants most commonly presents as skin rashes (urticaria, eczema), and occasionally as blood in the stool (allergic proctocolitis). If cry-fuss behaviour persists after other issues with feeding have been assessed and managed, it is reasonable to ask breastfeeding mothers to trial a dairy-free diet for two weeks. If formula feeding, infant crying may improve with an extensively hydrolysed formula.57-59 Maternal diets that eliminate multiple food proteins other than cows milk protein are not indicated.60 Studies cited to support the efficacy of low-allergenic maternal elimination diets do not control for cows milk allergy, although cows milk allergy alone would explain their findings.61-63 Complicated maternal elimination diets are burdensome, risk heightening maternal anxiety, and may paradoxically increase the risk of later paediatric food allergy by denying early opportunity to develop immune tolerance.64-66 Lactose intolerance is another condition often misdiagnosed in this patient group. Lactose intolerance, if acquired, occurs from about 3-5 years of age in 75% of the world’s populations and congenital lactase deficiency is rare, so neither of these types are likely to be clinically relevant in crying babies. A transient secondary lactose intolerance may occur following damage to the intestinal villi, although the primary symptom of such lactose intolerance is diarrhoea, not excessive crying in the first few months of life.


    Secondary lactose intolerance is caused either by gastroenteritis or cows milk allergy. If the baby is formula fed, lactose intolerance secondary to gastroenteritis improves with a lactose-free formula. If the lactose intolerance is secondary to cows milk allergy, cows milk protein in any formula will perpetuate the intolerance. If the baby is breastfed, weaning is not indicated, although elimination of dairy products from the maternal diet should help if the underlying insult is cows milk allergy. The only lactose-related condition that causes cry-fuss problems is functional lactose overload, a common breastfeeding management problem. Functional lactose overload is diagnosed clinically from the signs of tympanic abdomen, copious flatus, frequent feeding and waking, frothy explosive stools, and crying.67,68 The initial part of a breastfeed is high in volume and proportionately low in lipid content. Further into a feed the suckling infant takes smaller volumes of more lipid-rich milk. This lipid-rich fraction triggers the release of cholecystokinin in the infant, signalling satiety, and modulates intestinal contractility by slowing down gut transit. The transfer of low volume, lipid-rich milk is compromised by a range of breastfeeding problems and also by the inaccurate advice that mothers should limit the duration of feeds (rather than letting the infant decide when a feed is finished) and feed from both sides with every feed in the first weeks. A consistently inadequate lipid fraction results in rapid intestinal transit of the normal lactose load so that the lactase in the small intestine doesn’t have time to properly digest it. Undigested lactose then reaches the colon and ferments.

     

     

    Functional lactose overload is often, but not always, associated with a high supply of milk. It may be managed by offering the baby the same breast each time they cue to feed over a 2-3-hour period. However, caution must be exercised, as side effects of inappropriate management of functional lactose overload include mastitis and lactation failure. Referral to an international board certified lactation consultant should be considered. Once functional lactose overload has been properly managed, a baby cannot be overfed at the breast: high weight gains of more than 35g daily on average and protection against obesity are to be expected in breastfed babies in this age group.69,70 Complementary medicines, pharmaceuticals, and colic preparations do not reduce crying in infants.61,71 Administration of the probiotic lactobacillus reuteri dsm 17938 has been shown to decrease crying in breastfeeding infants.72-74 However, these studies do not control for underlying feeding problems, including functional lactose overload, which will alter gut microbiota, contractility and permeability. Chronically high levels of sympathetic nervous system arousal also alter gut microbiota, contractility, and permeability. The interactions between the gut and the nervous system are complex.75-77 Each of the five domains of the possums approach should be addressed before treatment with lactobacillus reuteri is considered.

     


    Maternal health

    Mothers and their partners are often better able to manage their baby’s cry-fuss problems once they are reassured that the baby is healthy, and that the crying usually resolves by 16 weeks without causing long-term effects. Parents with a crying baby are often stressed and exhausted, and it is important to avoid unnecessary pathologising of normal responses to a stressful life event. However, because mothers with crying babies are at increased risk of postnatal depression, it is essential to identify, monitor and manage the situation appropriately, utilising psychologists and local perinatal mental health services for symptoms of anxiety and depression.23 Randomised controlled trials show that the risk of child abuse can be reduced by instructing caregivers to place a crying baby in a safe place and to walk away if they feel they are at risk of harming the baby, returning when they feel back in control.78,79


    Feeds

    The link between cry-fuss problems and feeding difficulties, regardless of feeding method, is strongly established.2,14,15,67,68,80,81 The neurobehaviours of back arching, feeding refusal and frequent night waking have been widely misinterpreted to signal oesophagitis, but are signs of a feeding problem.30,45,54 Crying babies are more likely to have oral motor dysfunctions and lower levels of plasma cholecystokinin, the hormone of satiety.81,82 Breastfed crying babies are more likely to have functional lactose overload.67,68 Findings of more irritable behaviours in babies who are breastfed rather than formula fed can be explained by widespread unidentified and unmanaged breastfeeding problems, linked with significant gaps in health professional training.83,86 Feeding problems in the first days and weeks rapidly entrench disrupted and anxious maternal–infant relations, increasing the risk of premature weaning and persistent behavioural and feeding problems in later childhood.15,87-90 Very early identification and management of feeding problems is imperative, regardless of feeding method.


    An unsettled breastfeeding baby who appears to have a good latch or who is gaining about 125g a week or more may nevertheless cry and fuss, and feed and wake frequently, because of poor milk transfer and subsequent poor satiety. Most infants in the first weeks and months of life need 8-12 breastfeeds a day, with at least one breastfeed between midnight and 6am. Normal cluster feeding occurs commonly in the evening when healthy babies often cue to breastfeed every 30-60 minutes. The best way to ensure breastfeeding homeostasis, satiety, and settled infant behaviour is to encourage cue-based care – that is, responsiveness to the baby’s communications and desire to feed, rather than delaying feeds according to the clock. Limiting the duration and frequency of breastfeeding may undermine milk supply and fails to address the problems that cause excessive feeding and waking, including poor latch, positional instability, oral motor dysfunctions and anatomic problems such as tongue-tie.91-94 Breastfeeding mothers should be advised to respond to an unsettled baby’s pre-cry cue with an offer of a feed before the baby becomes difficult to soothe. The widespread concern about overfeeding in breastfed babies is unfounded if underlying feeding problems are properly identified and managed.


    If the baby is formula fed, parents should still offer feeds according to infant cues in the neuro developmentally sensitive first 3-4 months. In this age group, we recommend paced bottle feeding to avoid overfeeding, by offering age and size-appropriate volumes over 20 minutes, watching for satiety cues (see paced bottle feeding in online resources).95 Cue-based feeding of a formula-fed unsettled baby in the first weeks and months enhances mother–infant bonding, and may be supplemented by pacifier use. If breastfeeding parents wish to use a pacifier, this should occur only after any underlying feeding problems have been identified and managed, and used judiciously to preserve lactation homeostasis.96


    Sensation

    Sensory integration is the complex neurological process by which the human body organises sensation from both within the body and from the environment, in order to operate effectively within that environment. Babies are highly dependent on their caregivers to facilitate the development of sensory integration. Neuroimaging studies show that babies need rich sensory nourishment in the first months of life to optimise longterm development of brain architecture. 97 Caregivers can be advised to provide their baby with a diverse range of sensory stimuli by having the infant in proximity as they pursue their own enjoyable daily activities outside the home, either outdoors or in physically or socially active contexts, and they may find a list of baby-friendly social activities in the local area useful. In a society such as denmark, where sensible cue-based care is practised from birth, combined with an average 10 hours of physical contact (whether awake, feeding, or sleeping) in a 24-hour period, there is 50% less crying or fussing in the first few months of life.13,16,98


    Reassuringly, the effect of sensible and moderate amounts of physical contact is the same as the effect of more extreme “attachment parenting” approaches. If a baby has moved to a full blown and unsoothable cry, the caregiver can be advised to wait calmly, holding the baby. Stepping outside may help. Skin-to-skin contact (ie, baby in nappy with or without a singlet, lying against the bare adult chest in a warm place) helps soothe the neonate until he or she is quietened enough to feed.99 A small minority of infants respond irritably to touch, and may have a sensory processing problem. Referral to a paediatric occupational therapist is warranted. 100 occasionally vestibular dysfunction causes cry-fuss behaviours in babies who startle and cry as they are picked up and put down, and these babies may benefit from the intervention of a paediatric physiotherapist.3 A new cochrane review of osteopathic and chiropractic interventions for cry-fuss problems does not conclusively demonstrate decreased crying.101


    Sleep

    The evidence linking behavioural regulation of infant sleep with positive effects on maternal and infant health applies only to babies over six months of age.61,102,103 In the first 3-4 months of life, londoners, who are more likely to use behavioural interventions to space feeds and entrain the biological characteristics of infant sleep, have twice the amount of infant crying as the danes (figure 5).17 In addition, two randomised controlled trials have demonstrated that introduction of behavioural regulation of infant sleep in the first few months does not decrease crying.104,105 ‘Sleep algorithms’ are not evidence based, since variability is the most prominent feature of infant sleep. The amount of sleep needed can vary by up to 10 hours a day among normal infants in the first months of life, and also varies markedly within the same baby from day to day.106-108


    Giving parents lists of ‘tired cues’ undermines their capacity to learn to make sense of their baby’s cues, which occurs through the process of experimentation, familiarity with context, and pattern recognition. Cues commonly attributed to tiredness also signal other needs such as hunger or the need for a change of environment. Instituting “feed–play–sleep” cycles disrupts the powerful biological cue of postprandial somnolence, undermining breastfeeding and the parents’ capacity to read their infants’ cues, and is associated with more unsettled behaviour in the first few months of life.17,103 These and other behavioural interventions, applied either preventively or as an intervention for unsettled infants, are not indicated in the first six months of life.61,109 If the previous four domains have been addressed, problems that commonly contribute to overly frequent waking will have been identified and managed. If the baby is satiated and receiving adequate sensory stimulation during the day, they can be trusted to take the daytime sleep needed without the effort that proves so burdensome to many families. In the first 3-4 months, normal babies wake on average three times a night; only 37% of healthy three-monthold infants regularly sleep eight hours at night without disturbing their parents; and parents can be reassured that unsettled babies do not wake more at nights, on average, than other babies in the first 3-4 months of life.110

     

    Online resources

    Safe sleeping guidelines

    www.sidsandkids.org/safesleeping/health-professionals


    Edinburgh postnatal depression scale

    www.blackdoginstitute.org.au/docs/cliniciansdownloadableedinburgh.pdf


    International board certified lactation consultants

    www.lcanz.org/find-a-consultant.htm


    The stanford newborn nursery

    Newborns.stanford.edu


    Paced bottle feeding

    www.youtube.com/watch?v=uh4t70oszgs


    Zero to three: national center for infants, toddlers, and families

    www.zerotothree.org


    Mothers matter

    www.mothersmatter.co.nz


    Breastfeeding inc

    www.breastfeedinginc.ca/content.php?pagename=videos

     

    Author

    Dr pamela douglas

    Gp, ceo, possums for mothers and babies, brisbane, queensland; senior lecturer, discipline of general practice, university of queensland.


    Dr beth shirley

    Gp, possums for mothers and babies, brisbane, queensland.

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