Downloaded from www.paediatricpearls.co.uk for FAQ: My baby cries all night. What’s wrong with her? educational or clinical reasons only

Dr Vicky Agunloye, paediatric registrar, January 2015

Excessive crying, is the cause of 10% - 20% of all early medical presentations of aged 2 weeks-3 months. Although usually benign and self-limiting, excessive crying is associated with parental exhaustion and stress. An underlying organic cause is found in <5%. In the majority of cases, treatment consists not in "curing the colic," but in helping to manage the expectations and concerns of the .

Colic can be defined as episodes of inconsolable crying in an otherwise healthy (<3months). The crying can range from once a week to daily, lasting for several weeks. It is normally in the evening and it usually starts at the same time, “the witching hour”, lasting for up to 3hrs.

When these present it is vital we take them seriously and give them time. (These parents are likely to need several follow up appointments). By doing this we can reduce inappropriate attendance at A&E, maternal depression, NAI, long term behavioural problems in these children and increase the duration of exclusive .

1. Questions that need to be considered when 4. Is this maternal anxiety or depression?: faced with an excessively crying infant: 2. Is there an underlying medical cause? It is important to explore a ‟s expectation 1. Is there a medical cause? (see box 2) of her baby and its crying. You may well find that mother‟s expectations are unrealistic which 2. Is it a feeding issue? (see box 3) Is it GORD? Studies show that GORD is NOT a cause of excessive crying in infants in the first few is why she repeatedly seeks medical advice. months of life (most of all if the infant is not 3. Is there excessive maternal anxiety or postnatal vomiting or regurgitating). We must continue to reinforce to that depression at ? (see box 4) crying can be normal, but balance this with It is important to remind parents that it is normal for babies to bring up milk/posset (GOR), reported empathy and listen to her concerns. in up to 70% of healthy infants. It only becomes GORD when it effects the infants growth, or there is presence of persistently troublesome Mothers of otherwise healthy infants should be symptoms. reassured and told that their baby may be predisposed to excessive crying as a result of 3. Is there a feeding issue? It is also important to remember before temperament, neurodevelopment, or other considering PPIs, that what the baby is bringing unknown factors; and that they are not to up is milk, which has a neutral pH for up to 2 The key to getting this diagnosis or excluding it is by hours post feed so should not cause . blame. taking a thorough feeding history:  What should I start doing? Trials have shown that instructing parents to  What should I start doing?  Manage GOR conservatively with place a crying baby in a safe place and walk  Take a detailed feeding history. See parental education and give advice box 3a for questions. regarding positioning during and away if they feel at risk of harming the baby  Weigh the baby: healthy babies should post feeds. and to return when they feel in control again be putting on an average of 125g per  Consider the use of feed thickening reduces the risk of NAI. week in the first 3 months of life. agents.  Check for tongue tie  Rule out other non-GORD causes  See NICE pathway on infant feeding that may mimic the symptoms of  What I should start doing? and maternal nutrition GORD. (Namely cow‟s milk protein  Make a follow up appointment with allergy (CMPA), see below)  Regard warning signs, particularly these mothers, at least 15mins long if weight loss and faltering growth as a possible. „red flag‟ in infants and children with  Risk stratify them using the Edinburgh Box 3a: Feeding history questions: suspected GORD. (Box 2a) Postnatal Depression Scale. (http://www.fresno.ucsf.edu/pediatrics/d The following may indicate poor milk intake in the first weeks of life: <  What should I stop doing? six wet cloth nappies or 4 heavily wet disposable nappies daily, strong  Avoid the empirical trialling of acid ownloads/edinburghscale.pdf) smelling dark coloured urine, <3 -4 yellow curdy stools suppression therapy as a diagnostic  Look for signs of poor attachment or test for GORD in infants and young bonding. children. If the mother is breast feeding, ask her the following: Do you have  Do not routinely treat paediatric  Consider referring them to postnatal breast or nipple problems? Do you have any trouble attaching the baby to mental health teams. Click here for the breast? Does the baby feed fewer than 8 or more than 12 times in 24 patients with GORD with prokinetic hours?, Does the baby regularly fall asleep or slip off the breast in the first medications. NELFT service (PPIMHS). 10 mins of feeding?, Does the baby regularly take longer than 30-40 mins  Actively encourage increased physical of active feeding (not including fussing, interacting, dozing)?, Is there a See NICE‟s key priorities for implementation contact between mother and baby, clicking sound when the baby feeds? within guideline on GORD in children and young studies have shown this can reduce people, publ Jan 2015 infant crying and fussing by 50%. (If the Regardless of whether the mother is breast feeding or formula feeding, mother has a baby carrier, she can ask the following questions: Does the baby have increased breathing Is it cow’s milk protein intolerance or allergy?: effort during or after feeds? Are there no audible swallowing sounds?,Does Cow‟s milk allergy is the most common paediatric wear it at home whilst doing her daily the baby have difficulty sucking or wet or gurgly vocalisations during food allergy and may be a contributory factor in activities, (baby wearing)) feeding? Does the baby refuse feeds? excessive infant crying. It can mimic the symptoms of GOR. Other symptoms that you may

If the answer is yes to any of these questions, refer for assessment by note are loose stools or , blood in a feeding expert. stools, abdominal bloating and rash.

Click here for a troubleshooting breastfeeding guide written by a  What shall I start doing? breastfeeding counsellor and paediatric doctor especially for  In a breastfed infant: advise a Paediatric Pearls. maternal cow‟s milk protein free diet for 2 weeks. Box 2a: Warning signs requiring further  In a formula fed infant: give a 4 week investigations in infants and children with 5. Practical suggestions on how to soothe the crying baby trial of extensively hydrolysed formula, if still no change in regurgitation or vomiting. symptoms return back to standard  warm bath with plenty of eye contact and singing/talking formula or consider an amino acid  dance with the baby to music formula if you are convinced  Consistently forceful non-bilious vomiting suggestive  carry him/her around against your body in a sling clinically that this is allergy. of pyloric stenosis or raised  rock him/her gently patting his/her bottom rhythmically  Click here for direct link to 2013  turn the lights down and massage the baby‟s legs and arms with a  Gastrointestinal bleeding MAP algorithm on how to manage little warmed olive oil – many don‟t like their tummies being massaged CMPA in primary care.  Haematemesis  put the baby in the car and go for a drive or in the buggy for a walk  Faltering growth around the block (both these help the parent too) Is it ?: Infection should always be  Persistent diarrhoea Useful resources for parents considered whenever seeing an unsettled infant.  Fever Studies have shown UTIs to be the most common  Lethargy cause of infection in infants seen with afebrile  www.reflux.org has a fantastically practical and reassuring page on crying  Hepatosplenomegaly babies. The site seems to be closing but try clicking here for the time being. inconsolable crying in A&E. However, in the  Babies! by Dr Christopher Green is a humorous, sensible parents‟ guide to absence of any other symptom (tachycardia,  Bulging anterior fontanelle the first year and has a helpful chapter on how to hold crying babies lethargy, poor weight gain) routine urine dips are  Macrocephaly not recommended. (according to their temperament – it‟s not a “one-size fits all” game)  Seizures  http://www.cry-sis.org.uk/ offers support for families with excessively crying, sleepless and/or demanding babies  Abdominal tenderness or distension  http://www.nhs.uk/Conditions/pregnancy-and-baby/Pages/soothing-crying-  Unexplained pallor baby.aspx#close has some basic tips for parents on handling crying babies  Cyclical vomiting syndrome  http://www.nice.org.uk/guidance/ng1/ifp/chapter/what-is-meant-by-reflux-  Acidosis in a child with persistent vomiting may regurgitation-and-heartburn is NICE‟s hot-off-the-press parents‟ guide to reflux suggest a metabolic disorder