Closer look at topical conditions How to treat You can earn 1 credit by completing the ELearning assessment for this article 1 CR at nzdoctor.co.nz The irritable baby This article, by Anne Tait, looks into the paediatrics conundrum of the crying baby, a common situation that can drive primary care practitioners and paediatricians to despair, and parents even more so. The aim is to provide a systematic approach to the crying baby aged less than six months he conundrum of the crying baby is that the baby depression and premature cessation of breastfeeding.2 Colic, Anne Tait appears otherwise well except for their prolonged for example, can thus affect babies and their caregivers, al- Do you need to read this article? is a general crying. They are feeding, growing and developing paediatrician though it is difficult to say if this impact is direct, indirect T well and have no other significant medical symptoms. at Starship or a temporal association. But from the parent’s perspective, the baby is clearly “not Children’s This article aims to provide a systematic approach to Try this quiz right”; the baby cries for long periods with minimal respite. Hospital, the crying baby – recognising that babies cry for many rea- 1. A feature of colic is that it can begin any time The many portrayals of perfect babies on social media can Auckland sons, to express discomfort right through to life-threatening up to 12 months of age. True/False further demoralise these parents. illness. It should enable identification of the small number 2. Fewer than 5 per cent of children with inconsol- Coupled with healthcare practitioners who wish to of children with pathology (versus colicky babies, in whom able crying have organic disease. True/False do something, or fix it, this makes the condition one the crying will improve with time). The article also aims 3. For gastro-oesophageal reflux disease in babies, where many treatments (pharmaceutical and non- to allow the practitioner to avoid unnecessary or lengthy regurgitation is not that often a feature. True/False pharmaceutical) have been trialled, some with relatively medical treatments with no or minimal benefit, and 4. Any trial of omeprazole in a baby requires little benefit and contradictory evidence. to provide care and support to parents in the extremely clinical review after three or four weeks to Practitioners want to do the best for their patients, and challenging situation of a crying child. assess for significant improvement. True/False this leads to many different approaches being tried. Thus, The discussion is divided into colic, gastro- 5. For most babies, the cause of non-IgE-mediated the parents may frequently spend a lot of time and effort oesophageal reflux disease (GORD), cow’s milk protein gastrointestinal food allergy is cow’s milk. (and money) trying to find a “cure”, with minimal clinical intolerance (CMPI) and other pathology, but with a par- True/False benefit. It is also very difficult for parents to reconcile the ticular focus on colic. For some children, there may be fact there is often no medical “cause” for the crying when overlapping symptoms, to a small degree. Taking a care- Answers on page 37 their babies are clearly in distress (and so “something must ful history, reviewing the growth trajectory, a full clinical be causing that distress”). examination and occasional investigations can help tease In addition, the literature provides indirect evidence that out a most likely cause for crying. However, I appreciate EARN RNZCGP CME CREDITS infant crying, especially in the first four months of life, can this can take time, which is in short supply in primary This continuing medical education be associated with non-accidental head injury; however, it healthcare. activity has been endorsed by the is important to appreciate that this issue is complex and One of the most important roles for primary health- RNZCGP and has been approved for multifactorial, with difficulties in obtaining caregivers’ care providers is to provide support. While infant crying up to 1 CME credit for the General Practice Educational Programme acknowledgement of shaking in response to crying. A is well-recognised throughout human history, for each and continuing professional development purposes 2004 Dutch study reported 5.6 per cent of caregivers reacted family it is uniquely distressing and an issue they did 1 (1 credit/hour). To claim, complete the ELearning assess- physically at least once to their baby’s crying. Observational not anticipate, especially if it is their first baby, or first ment at nzdoctor.co.nz. Click on the EDUCATION button. studies have reported an association with parental “crying baby”. 14 April 2021 RATA AOTEAROA NEW ZEALAND DOCTOR 33 How to treat The irritable baby Consider other causes before ascribing a baby’s crying to colic olic comes from the Greek word kolikos, meaning While known of since the beginning of time, the diagnos- colon. The typical pattern of behaviour of clenching tic criteria for colic were only defined in the medical literature PANEL 1 Cof the fists, flexion of the hips and knees, redness of in 1954, by Matthew Wessel and colleagues “Paroxysmal Rome IV criteria for colic* the face and crying leads to the observation that colic could fussing in infancy, sometimes called colic”. They described be due to abdominal discomfort.3 the “rule of threes” – crying for more than three hours a day 1. Starts at less than five months of age. Colic has been described through the ages. The earliest on more than three days a week for more than three months. 2. Prolonged, unsoothable character of crying without description in English is by Thomas Phaer, who wrote about British social anthropologist Sheila Kitzinger wrote: “The obvious cause and which cannot be prevented or resolved “Colike and rumblyng in the guttes” in the mid-1500s. Gripe sound of a crying baby…is just about the most disturbing, by caregivers. water dates from the mid-1800s, when it was used in fever demanding, shattering noise we can hear” (cited in The New 3. Crying for three hours or more per day, during three or outbreaks; at that time, it was a mixture of dill oil, sodium Yorker, 2007).4 more days in the preceding week (this is now more of a bicarbonate and alcohol. Over the years, various remedies However, while colic resolves, it cannot be treated as requirement used for entry into clinical studies). have been proposed, many touting success. But, as colic does entirely harmless. The sleep deprivation and emotion- 4. No evidence of infant faltering of growth, fever or illness. resolve typically by five or six months of age, the skeptic al distress from dealing with a colicky baby can be longer would say it was always going to be the outcome. lasting. There are a few reviews of longer-term childhood * Adapted from Zeevenhooven et al (Pediatr Gastro enterol outcomes of colicky babies. A Finnish observational study Hepatol Nutr 2017 Mar:20(1):1–13) from the mid-1980s showed children who had experi- CASE STUDY 1 enced colic tended to have significantly more issues with sleep initiation, behaviour, etc. A 2005 Italian study of 10- Parents’ concerns about crying baby at six-week check year outcomes in 103 children with severe infantile colic PANEL 2 The crying baby: reported significant associations (p = 0.05) with recurrent * abdominal pain, allergic disease and food allergy in child- Pathological conditions to consider hood. In addition, sleep disorders and some challenging behaviours were also associated with infantile colic.2 u Hirschsprung disease – failure to pass meconium It is unknown whether these associations are due to the within 48 hours, vomiting (especially bilious), abdominal colic, or if the colic results in more difficulties for parents distension, constipation or loose bowel motions. in dealing with subsequent issues. No studies have looked u Incarcerated hernia or testicular torsion – acute onset, into the outcomes in adulthood of colic. abdominal bulging, scrotal discolouration, scrotal tender- The initial Wessel criteria for colic have evolved into the ness to palpation. Rome IV criteria for functional disorders (see Panel 1).5 u GORD, CMPI – vomiting (especially bilious), feed refusal, The reported prevalence of colic can differ widely because diarrhoea with blood/mucus in the stool, failure to thrive. of varying definitions in studies, as well as parental percep- u Localised pain in the long bones or clavicles – tion and cultural practices, but there is a median 17.7 per non-accidental injury, osteogenesis imperfecta (rarely); cent prevalence in recent studies of functional gastrointes- look for swelling, localised redness/tenderness, bruising. tinal disorders in infants from birth to 12 months of age. u Other – hair tourniquet syndrome (naked examination), Baby Aroha and her parents are booked into your clinic by mistake; they normally This correlates with Wessel’s original observation of 25 per anal fissure, corneal abrasion, faltering growth due to inade- see your colleague who is on leave. The appointment is for a routine well-baby check. cent in the Yale New Haven Hospital nursery study. The quate nutrition, hydrocephalus. You have not met the family before. The parents look exhausted, the baby looks well. incidence is equal between the sexes and there is no correla- You perform the six-week check, which is unremarkable: weight 25th centile, length tion with type of feeding (breast or bottle), gestational age, Red flags for serious pathology 50th centile and head circumference on the 75th centile. You reassure the parents that socioeconomic status or time of the year.6 u failure of pass meconium within 48 hours of life Aroha looks well and start the consent process for vaccinations.