My Baby’s Crying and Won’t Shut Up! https://www.youtube.com/watch?v=6TjmHkVMEdI 2016

Objectives Understand normal from abnormal crying List causes of excessive infant crying Develop an approach to the assessment/evaluation of the crying infant

Why do babies cry? How many of you have children. How many of you were children. How many of you still act like children. Crying is part of normal psychomotor and psychosocial development. An infant’s source of communication. A signal of unmet needs like hunger, diaper change, needs to sleep, too hot, too cold, needs to burp, wants to be held, wants less stimulation, wants more stimulation, distress or pain. Can the parent interpret this crying language.

Normal vs Abnormal Normal behavioral development Spectrum of quantity and intensity About 5% will have abnormal cry due to disease 6 properties of normal crying Typical pattern of crying 3 important tasks for physician – detecting organic disease, managing the crying and caregiver concerns, providing appropriate f/u care Increased crying in the first 3-5 months – has been cause of parental frustration, stress and anger for generations It is a manifestation of normal behavior rather than an indication of abnormalities in either the infant or caregiver. Essential to this concept is that all infants manifest similar patterns along a spectrum of quantity and intensity from fussiness to inconsolable crying. Those at the higher end of spectrum present 6 properties of normal 1.increase by week with peak in 2nd month. 2. bouts are unexpected and unpredictable. 3. resistant to soothing 4. Appears in pain but is not 5. bouts are longer than at any other age 30min-2hrs. 6. cluster in late afternoon/early evening After 4-5 months crying becomes more intentional

Hours of Distress Pattern

Abnormal Cry High Pitched Crying is not the only symptom Late onset of crying(after 3rd month) Unusual and excessive persisting beyond 4m

Red Flags Distended Abdomen Fever Lethargy

Colic Crying for > 3hrs/day > 3days/week > 3weeks This is the Wessel Criteria Referred to as typical colic. Increasing into 2nd month and continuing past 4months usually accompanied by loss of positive caregiver-infant interaction – mother-infant distress syndrome (about 3% of infants). Another pattern is sustained crying beginning after 4 months and persist into later months – difficult temperaments (about 3% of infants)

Management Inform caregivers – typical crying Reassure caregivers of normal exam Counseling caregivers – rocking, carrying, soothing, responding promptly to signals, using pacifier Never shake Support person Meds ?, Change formula? You can’t spoil infant less than 3 months Never shake but you can lie them down in safe place an walk away to get calm, return every 10-15 min to check on baby Probiotics – yes for breast fed, Dicyclomine – yes but contraindicated in < 6mos, antireflux meds – no, simethicone- no

It’s a Symptom, stupid When did it start? What time of day? How long? What seems to provoke it? What alleviates it? What is the quality of the cry? Any related symptoms? Vomiting etc

Common Pitfalls Not undressing the infant Not examining the oropharynx Failing to consider abuse Failing to establish close f/u

Case #1 5 week old male has been crying a lot. He cries every night from about 5pm until 8pm. It has been going on for the past month. When he is crying he pulls his legs up and acts like he is in pain. Mom can’t get him to stop even though she tries changing his diaper, giving him pacifier and rocking him. Vitals and exam are normal. He is not crying at time of exam. Growth is normal.

Case #1 What other questions do you have for mom? Do you want any tests? What is differential diagnosis?

Case #1 Infant Colic Rule of 3’s Affects about 10-40% of infants Peaks at 6wks, resolves by 3-6months age Associated with parental guilt, frustration, postpartum depression and shaken baby syndrome Despite decades of research the cause is not known Equal in sexes, Equal in bottle fed vs breast fed, no association with gestational age, socioeconomic status or season Meds – no. Dietary modification – mothers of breast fed infants on no cow’s milk, eggs, nuts, wheat, soy had less crying Hydrolyzed formula may improve colic

Case #2 6 month old male brought in because of crying. It started 2 days ago with periods of fussiness followed by inconsolable crying for over 1 hr. This morning would not eat and vomited 2 times over the past couple hours. Last BM was last night before going to bed. He woke several times during the night with crying and fussiness but did not want to feed.

Case #2 Vital signs normal Infant very irritable ENT normal, CardioResp exam normal Abd mildly distended but soft. He starts crying after your palpation. What do you do next?

Case #3 Tests? Procedures? DDx?

Copyright © 2016 McGraw-Hill Education. All rights reserved. From: Inguinal Hernia Strange and Schafermeyer's Pediatric Emergency Medicine, 4e, 2015 Legend: The infant presented with inconsolable crying and a few episodes of vomiting. Inguinal hernia may be either unilateral or bilateral. This patient's hernia (hernia sac contents) could not be reduced into the abdominal cavity and the patient required surgical repair. Date of download: 3/5/2016 Copyright © 2016 McGraw-Hill Education. All rights reserved.

Case #4 4 month old girl presents with inconsolable crying for past 24 hrs. Parents have tried everything they can think of to soothe her. They have not noted any fever, cough, runny nose or vomiting. Stools have been normal. Feeding has been decreased due to the crying.

Case #4 Vital signs normal for age ENT normal CardioResp normal Abdomen normal No rashes on the trunk or face What do you do next? Tests?

Copyright © 2016 McGraw-Hill Education. All rights reserved. From: Crying Infant Strange and Schafermeyer's Pediatric Emergency Medicine, 4e, 2015 Toes, fingers, penis. Can be thread or hair. Techniques of removal Legend: Hair tourniquet. (Used with permission from Roger Knapp, MD.) Date of download: 3/5/2016 Copyright © 2016 McGraw-Hill Education. All rights reserved.

Case #5 8 month old girl brought to the office by mom for crying episodes for the past 3 weeks. She is irritable, cries for up to an hour at a time, inconsolable. Seems to be worse when moving her, dressing her and better if she is lying still. No fever or other signs of illness noted by mom. Appetite is decreased, sleeping less due to crying spells.

Case #5 Vitals normal, appears somewhat lethargic ENT normal CardioResp normal Abdomen normal Genetalia normal Extremeties normal She is irritable with the examination

What do you do next? Ask more questions? Order tests? Case #5 What do you do next? Ask more questions? Order tests? Developmental – she will not crawl Social Hx – parents split up, father has child on some weekends Birth hx normal Started 3 weeks ago after a visit with the father.