MANAGING THE CRYING BABY

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MANAGING THE CRYING BABY

• Doreen Cassar
• MD, Dip Womens Health (ICGP)
• MCFD Jan 06

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Crying what is it?

• A means of communication
• All babies cry part of the normal behavioural
  development of child (Brazelton 1962)
• n shaped curve for crying in first 3 months
• Total crying in 24 hrs tends to increase in first
  few weeks
• Peaks in 2nd month
• Decreases to more stable level by 4th month
• 
  (Konner 1989)

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Crying when is it a problem?

• gt 3hrs/day, gt 3days/wk for gt 3 weeks
• (Wessel et al 1954)
• defined as COLIC
• In otherwise well fed, healthy baby
• Commoner in late afternoon or evening
• Sudden onset for no apparent reason
• Difficult or impossible to console
• Incidence in GP 12-20 of infants

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Manage - who?

• Child
• Parent/carer

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Parent

• Views contrasting info ? anxiety , distrust
• Put at ease
• Concerns health beliefs
• Cope differentiate crying level of exhaustion
• Depressed
• Support
• Family dynamics

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LISTEN TO PARENTS

• parents are more effective than professionals in
  the early diagnosis of a wide range of child
  health problems
• (Hall
  1989,Polnay 1989)

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Child

• Crying - acute / more of the usual
• Acute ? more serious illness
• More of the usual - ? Colic

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History

• Pattern of crying
• Sleep history
• Temperament
• Family dynamics

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History cont.

• Feeding history under / over feeding early
  weaning
• difficulty during feeds associated symptoms
• Past history illness, hospitalisation, surgery,
  allergies
• Pregnancy /birth events maternal / neurological
  
• causes
• Drug history over the counter / prescribed

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Physical examination

• Aim to exclude organic causes of crying
• Systemic examination of all systems is essential

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• lt 5 of crying is due to an organic cause
• Most common organic causes
• Otitis media
• Colic
• Reflux
• Cows milk protein or lactose
  intolerance
• UTI
• Meningitis
• Shaken Baby Syndrome

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Potential causes of crying

• Infections
• Dental / oral
• Genitourinary
• Gastrointestinal
• Trauma
• Cardiovascular
• Toxic / metabolic

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Physical examination

• Ability to be consoled
• Expose baby fully
• Overall appearance
• Stability of vital signs
• Temperature

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In practice

• ? Take over child early in consultation
• Assess consolability how?

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Physical exam. Cont.

• Skin rashes. perfusion, bruising
• HEENT - fontanelle, sclera, corneal abrasions,
  pupillary activity, haemorrhages, otitis,
  pharyngitis, foreign bodies, neck
• Dental / oral new teeth, thrush
• Chest breath sounds ,tachypnea
• CVS murmurs, tachycardia, arrthymias

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Physical exam. Cont.

• Abd.- tenderness, bowel sounds, masses
• GU hernias, torsion, strangulation by hair
  tourniquets, anal fissures, blood pr, nappy
  rash, phimosis,
• Extremities focal tenderness, hair tourniquets
• CNS overall activity level, responsiveness,
  Kernigs, Brudzinskis
• Weight growth chart

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• Examination alone usually reassures parents

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Non organic causes

• Thirst
• Hunger
• Loneliness
• Tired
• Scared
• Full diaper
• Too hot/cold
• Noise
• Lights to bright
• Smoky environment
• Seeking cuddle

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Investigation

• Is it needed?
• If history is typical and examination negative
• no investigations required

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Repeated Crying

• Wise to check -
• Home environment
• Childs room
• Family interactions / dynamics

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Parents anxiety

• Makes major demand on GP time
• - Stems from sense of lack of control
• - Bewilderment
• - Failure to diagnose
• - Unhelpful explanations
• - Various treatment patterns
• More information and education needed

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Treatment

• Explain normal crying / sleep pattern
• Assist parents to deal with discomfort
• Child medication rarely indicated
• Colic mixtures are of no proven benefit
• Formula changes are not usually
  helpful unless proven cows milk allergy or
  lactose intolerance
• Weaning from breast milk not helpful
• Mother treat depression / anxiety, arrange
  support

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Referral when?

• If baby
• Avoids gaze
• Withdraws emotionally and does not respond to
  parents when not crying
• Does not enjoy play
• Remains distressed after 4 months of age
• Continues to have feeding and sleep problems
• Mother -
• Severe postnatal depression risk to self and
  child paranoia

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Key messages

• Listen to parents
• Acknowledge parents difficulties
• In many cases a specific cause of crying may not
  be found
• Overall appearance of child should guide
• Family needs detailed instructions reassure,
  most parents cannot deal with uncertainty
• Follow up essential empower to come again

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• Thank you

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Associated Features

• Temperature
• Difficulty in feeding/feeding history/
• overfeeding/premature weaning
• Vomiting/diarrhoea/constipation
• Curling, arching back, straining
• Difficulty in breathing/cough Urination
• Eczema, itch nappy rash Sleep
  patterns
• Activity level /Irritable
  Ability to be consoled

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Past history

• Illnesses
• Allergies
• Hospitalisations
• Surgery
• Pregnancy complications
• Birth event

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Medications

• Prescribed
• Over the counter