Excessive Crying in Babies
“A baby’s cry is precisely as serious as it sounds.” – Jean Liendloff
Crying is the normal physiological response to many stimuli in nonverbal children. Healthy babies at around six weeks of age, cry for approximately 3 hours per day on an average. A variety of terminologies have been used to describe it, such as, incessant, persistent, excessive and problem crying. The most widely used definition is “fussing or crying lasting for a total of more than three hours per day and occurring on more than three days in any one week”. Incessant crying is one of the common reasons for many emergency visits during infancy which often lead to considerable parental stress and anxiety. Consequences of excessive crying may range from financial burden to long-term disturbances in parent–child relationships and child maltreatment problems like shaken baby syndrome resulting in brain damage. It can result in early weaning in these babies because of the mothers’ perception of incessant crying as hunger cries or due to inadequate breast milk. Sleep and feeding disturbances are also associated with incessant crying. An inconsolable cry without any obvious causes such as hunger, thirst, loneliness, soiled diaper, loud noise, requires a detailed search for a medical cause even if it does not fulfil the time criteria. This review article focuses on discussing the common causes of excessive or incessant crying, the social burden associated with it, the change in dynamics of the behavioural pattern of parents, and how to address it and the role of counselling.
Crying is one of the most important methods of communication between infants and their care takers. Infant crying is generally considered to signal an unmet need (hunger, thirst, or the need for attention) on distress (anger, discomfort, or pain). Infant crying evokes a strong desire in most parents to respond to their infant’s need or distress and mothers are usually able to identify accurately the cause of the crying. When parents are unable to identify the cause of their infant’s crying or unable to console the infant, and when the crying continues longer than usual, parents are likely to seek assistance from health care providers. For the non-febrile infant with an acute episode of excessive crying, whose parents are unable to recognize the cause, the key elements of assessment include a careful, methodical, expanded physical examination and a period of observation.
Gormally and Treem have identified the following pointers for underlying organic causes:
- High-pitched/abnormal sounding cry.
- Lack of a diurnal rhythm.
- Presence of frequent regurgitations, vomiting, diarrhoea, blood in stools, weight loss, failure to thrive.
- Positive family history of migraine, asthma, atopy, eczema.
- Maternal drug ingestion.
After conducting a good history and physical examination the aetiology can point to organic or non-organic causes. Some of these have been depicted in Table 1 and are discussed further. Hunger cry is a major cause of crying but incessant crying after adequate feeding or not taking feed while crying makes us suspect other causes of crying, such as those listed below.
- Infantile colic and behavioural cries
Infantile colic is defined as paroxysmal crying more than 3 hours/day occurring, more than 3 days/week, lasting more than 3 weeks in an otherwise healthy child who is more than three weeks and less than four months of age. Some consider it as a spectrum ranging from a normal cry to a distinct behavioural syndrome. Colic is a diagnosis of exclusion made after performing a careful history and physical examination to rule out less common organic causes. Colic is the one of the leading causes of incessant crying during infancy. Reflux oesophagitis, urinary tract infections, intolerance to cow’s milk protein and/or lactose are some causes with varying strengths of evidence for colic. These episodes usually resolve by about four months of age.
Apart from colic, conditions such as persistent mother-infant distress syndrome, temperamentally difficult and deregulated infant syndromes are described in older infants. Postpartum depression in mothers is a known risk factor for behaviourally disturbed infants and this should also be assessed. Incessant crying beyond three months of age is associated with hyperactivity, cognitive deficits, poor fine-motor abilities and disciplinary problems when children reach five years of age.
- Genitourinary system
Urinary tract infection (UTI) is the one of the most common occult infection leading to excessive crying. Incessant crying may be the main symptom of UTI in some a febrile infants. Other less common causes include torsion of testis, urinary retention, obstructed inguinal and femoral hernias. Thorough clinical examination and ultrasound examination are important to diagnose above conditions and help in the management.
- Other Infections
An underlying infective cause should be searched for in any febrile infant with incessant crying. Apart from urinary tract infections, other conditions such as acute otitis media (AOM), meningitis, herpes infection, pneumonia, cellulitis and viral illness were reported in incessantly crying children.[5-7] AOM is the most common problem among infants with unexplained crying.[5,7]
- Gastrointestinal Anomalies
The causes under this category include constipation with or without anal fissure, gastro-oesophageal reflux disease (GERD), intussusceptions and intestinal obstruction.[5-7] Diagnosis of this group is not difficult as they present with a history of vomiting, feeding difficulties, abdominal distension, etc. Intussusception needs a high index of suspicion as a combination of mass in the abdomen, rectal bleeding and vomiting, is present in only about one third of the cases.
- Musculoskeletal system
Non-accidental trauma with fractures especially to ribs, skull bones and long bones should arouse suspicion of conditions such as shaken baby syndrome and child abuse. Incessant crying is a precipitating factor as well as a sequel of child abuse.[4,8] One should gently palpate the whole body and look for restriction of movements, skin bruises and muscle haematomas.
Examination of eyes and conditions related to it are often missed by physicians. Corneal abrasions, ocular foreign body, retinal haemorrhage, retinal detachment and glaucoma should be ruled out in every crying infant.[5,6] Presence of retinal haemorrhages and retinal detachment indicate child abuse.
- Other causes[5,6]
- Foreign body in airway
- Supraventricular tachycardia
- Diaper rash
- Cow’s milk allergy
- Sickle cell anaemia and crisis
- DTP immunization
- Insect bites
- Pseudotumor cerebri
- Electrolyte and acid base imbalance
Some babies cry more than others but finding the cause of crying remains a mystery for a physician. A comprehensive history with detailed physical examination is the basis of reaching an accurate diagnosis in a crying infant. History should also focus on comorbid medical conditions, sibling and family history, recent vaccination, photophobia, feeding and sleep behaviour. Duration, frequency, periodicity and intensity of crying episodes with aggravating and alleviating factors should be assessed as well. Mother-infant relationship, maternal fatigue and stress should also be assessed. Parents are the best assets for obtaining a history and will describe the signs and symptoms in the best possible way.
Examination and arriving at a diagnosis are always a concern when evaluating a crying infant at the emergency department. During physical examination we should ascertain first whether the infant is healthy or sick looking as life-threatening conditions are not uncommon with incessant crying.
We should record vital signs and the entire body should be examined including genitals, eyes, ears and skull, should be thoroughly inspected. Eyelids should be everted to look for ocular foreign bodies. Some infants may continue to cry throughout the initial assessment and we should further observe and re-examined them during normal periods. The infant’s crying behaviour should be documented, including time of day, length of episodes, and how often the infant is sick. Diagnostic clues can be found from detailed examination of pattern of cry and frequency and duration of cry. Sometimes high-pitched, incessant cries may indicate a central nervous system infection. If a continuous cry is associated with grunting it may indicate a respiratory infection or foreign body in the respiratory tract. Screaming cries associated with pulling of the ears may indicate acute otitis media (AOM). Intermittent bouts of crying associated with pallor, with the knees drawn up over the abdomen may indicate intussusception. Paroxysmal crying episodes in an otherwise healthy infant less than four months of age typically occurring in the late afternoon and evening may suggest infantile colic.
Physical examination should be systematic including head to foot examination. The following are some commonly missed findings during physical examination:
- Anal fissure
- Corneal abrasion / ocular foreign body
- Retinal haemorrhage / detachment
- Bulging tympanic membrane
- Incarcerated hernia
- Hair tourniquet
- Rib fractures
- Open diaper pin injury
- Teething- tender swollen gums
- Megalocornea – glaucoma
The role of investigations in identifying the cause of crying in infants is limited. There is no clear role for routine screening tests such as corneal fluorescein staining, urine microscopic examination and culture, stool occult blood testing and rectal examination in all cases of unexplained crying. The clinical assessment should guide decision making about sequential investigations. At times negative results help in ruling out serious illness and for reassurance.
Crying is a ‘common denominator’ for a variety of illnesses and physiological disturbances. Management of these incessant crying episodes will depend on the diagnosis obtained.
1) Explanation of condition and reassurance of parents.
Most of the times crying is due to hunger, so we should encourage the mother to breastfeed baby and teach her proper positioning, ensure correct latching on and make sure both mother and baby are comfortable while feeding.
Parents need to be explained normal crying and sleep patterns. We can use a sleep/cry diary to explain the infant’s cry/sleep/feeding patterns. We should encourage parents to recognize signs of tiredness (frowning, clenched hands, jerking arms or legs, crying). We should assist parents to help their baby deal with discomfort and distress and help them establish pattern to feeding/settling/sleep. Avoid excessive stimulation noise, light, and handling of baby. Most babies find a low level of background noise soothing. Assess maternal and emotional state and mother baby relationship. Talk to the mother and encourage her. Ascertain whether the mother is worried that she is depressed. Consider screening for postnatal depression using the Edinburgh Postnatal Depression Scale. Supportive care is very essential when no underlying medical cause is found. Mother’s emotional state and the mother–baby relationship should be addressed. Ensure that the baby is adequately fed and rested. Some general measures such as firmly holding the baby, swaddling, and massaging, singing and playing white noise may be tried. White noise has a soothing effect on crying and irritable infants. It is a steady stream of subtle monotonous sound such as vacuum cleaner, water shower, rain, shower, washing machine, fan etc.
A noteworthy intervention called ‘REST’ nursing regimen for babies and parents is found to be somewhat useful in reducing infant crying and parental stress. REST for infants consists of Regulation (prevent over stimulation and over tiredness, watch for early warning signs, assist in state transitions and limit crying jags by catching them early), Entrainment (synchronizing infant behaviour with environmental stimuli such as light or noise), Structure (structured routines include bathing and playtime, as well as consistent sleeping and feeding times), and Touch (soothing techniques such as holding or rocking).[9,10] REST for parents includes Reassurance, Empathy, Support from the health care provider and Time out for the parents (for example, rest and renewal).
2) Treat Medical causes
Treatment strategies for infant colic include drugs, dietary modifications and behavioural interventions. If they fail to produce relief, drug and dietary management may be tried. Dicyclomine has been shown to effectively reduce infant crying. Risk of apnoea and seizures should be considered before recommending dicyclomine.[12,13]
Appropriate antibiotic may be given for infective aetiology such as UTI, AOM, and other infections. In case of aetiologies related to ear and eyes respective specialists should be taken into consideration after ruling out other causes. In case of intussusception, early surgical intervention should be considered. Though analgesics do not have a significant role they can be tried to curb down crying related to pain. If organic causes are found they should be treated accordingly.
Crying is a physiological phenomenon. It is the infant’s means of communicating hunger, pain, fear, need for sleep, irritability from illness, and more. Excessive crying can become stressful for parents. It is one of the most common issues encountered in day to day life by general practitioners and paediatricians and the various conditions causing incessant crying could often be missed. Hence, medical practitioners must emphasize on discussing the various causes of excessive crying with the caregivers, so as to correctly identify and manage them.
- Gormally S. Clinical clues to organic etiologies in infants with colic. In, Barr RG, St. James-Roberts I, Keefe M. New evidence on unexplained early infant crying: its origins, nature and management. Johnson & Johnson Pediatric Institute, Skillman (NJ), 2001:133-49.
- Treem WR. Assessing crying complaints: the interaction with gastro-oesophageal reflux and cow’s milk protein intolerance. In, Barr RG, St James-Roberts I, Keefe M. New evidence on unexplained early infant crying: its origins, nature and management, Johnson & Johnson Pediatric Institute, Skillman (NJ), 2001:165-76.
- Roberts DM, Ostapchuk M, O’Brien JG. Infantile colic. American Family Physician. 2004;70:735-40.
- Eshel G, Barr J, Heyman E, Tauber T, Klin B, Vinograd I, et al. Intussusception: a 9-year survey (1986–1995). Journal of Pediatric Gastroenterology and Nutrition. 1997; 24:253-56.
- Poole SR. The infant with acute, unexplained, excessive crying. Pediatrics. 1991;88:450-55.
- Freedman SB, Al-Harthy N, Thull-Freedman J. The crying infant: diagnostic testing and frequency of serious underlying disease. Pediatrics 2009;123:841-8.
- Fahimi D, Shamsollahi B, Salamati P, Sotoudeh K. Excessive crying of infancy: a report of 200 cases. Iran Journal of Pediatrics.2007;17:222-6.
- Barr R, Trent R, Cross J. Age-related incidence curve of hospitalized shaken baby syndrome cases: convergent evidence for crying as trigger to shaking. Child Abuse & Neglect. 2006; 30:7-16.
- Keefe M, Lobo ML, Froese-Fretz A, Kotzer AM, Barbosa GA, Dudley WN. Effectiveness of an intervention for colic. Clinical Pediatrics. 2006; 45:123-33.
- Keefe M, Kajrlsen KA, Lobo ML, Kotzer AM, Dudley WN. Reducing parenting stress in families with irritable infants. Nursing Research. 2006; 55:198-205.
- Keefe M. The REST Regimen: A conceptual approach to managing unexplained early infant irritability. In, Barr R, St. James-Roberts I, Keefe M, Editors. New evidence on unexplained early infant crying: its origins, nature and management. Johnson & Johnson Paediatric Institute, Skillman (NJ). 2001:229-44.
- Garrison M, Christakis A. A systematic review of treatments for infantile colic. Pediatrics 2000; 106:184-90.
- Lucassen PL, Assendelft WJ, Gubbels JW, van Eijk JT, van Geldrop WJ, Knuistingh Neven A. Effectiveness of treatment for infantile colic: a systematic review. British Medical Journal 1998; 16:1563-9.