Crying babies Katie Lazenby

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Introduction Normal attachment behaviour Peaks 6-8 wks – 2.6 hrs crying/day Problematic in 20% babies “colic” - >3hrs/day, 3 days/wk, >3 wks. 5% organic cause Many caused by inability to self-soothe

History Parents’ views, experience, support Crying patterns Other Sx – blocked nose, vomiting, constipation, diarrhoea, eczema Sleeping & feeding patterns Family stress, maternal depression

Examination Head to toe, explaining to parents Exclude potential cause discomfort eg. Nappy rash/eczema Orifices – phimosis, anal fissure, oral thrush, otitis media Plot weight growth chart

Causes Medical – GORD – Lactose intolerance – Cow/soya milk protein allergy Non-medical – Tired – Hungry – Will not settle – Family psychosocial difficulties

GORD Increased prevalance preterm, GI obstruction, neurological problems eg. CP Features – frequent vomiting shortly after feed, difficulty feeding, crying, failure to thrive, apnoeic episodes, wheeze/cough. Mx – Upright posture post feed, tilt cot, avoid overfeeding – Food thickener – Infant Gaviscon – Hospital Rx – domperidone, ranitidine, omeprazole

Lactose intolerance Controversial theory Low lactase levels – lactose build up - lactic acid 1 wk trial lactase drops (Colief – can buy or Rx ACBS) Use behaviour diary to monitor effect, if response continue to 3-6 months. Low lactose feed not recommended

Cow/soya milk allergy 50% crossover with soya Vomiting, diarrhoea (blood/mucus), poor weight gain, atopy, FHx. Trial diet modification – Breastfed – mother avoid all dairy, caesin & whey. Use soya milk, take calcium supplement – Bottlefed – hydrolysed cow’s milk/soya milk (Nutramigen 1, Pregestimil, Pepti-junior) – 1 wk trial, behaviour diary

Tired baby Average sleep – Newborn - 16 hrs – 2-3 months – 14 hrs Time before tiring – 6 wks – 1.5 hrs – 3 months – 2 hrs Signs tiredness – frowning, clenching fists, jerking limbs Sleep hygiene – consistent place, soothe without picking up, background white noise.

Hungry baby Frequet feeding, not settling post feed, poor weight gain Mother may c/o poor milk supply – HV/breastfeeding counsellor advice Top ups with formula in evening

Will not settle ?delayed neuromaturation – reduced ability to self soothe Distractions – Carry in sling – Minimise separation – Walk in pram/push over uneven surface – Warm bath – White noise

Psychosocial problems Factors affecting baby’s behaviour/parent’s response to crying: – Infant-parent relationship – social and cultural beliefs of family – problems in pregnancy – Post natal depression (can aso be triggered by irritable baby)

Management Exclude medical cause Reassurance Explain normal crying and sleeping patterns Behaviour diary Follow up and ongoing support Websites/helplines HV Assess for post natal depression

Websites CRY-SIS – Charity running telephone helpline and offering useful checklist – Parentline – Home-Start UK – Volunteers providing home visiting scheme –

Medication Anticholinergics effective but not suitable due to S/Es. Simethicone (Infacol) licensed for colic but no benefit over placebo in trials. 1 wk trial may be helpful. Trials of diet modification - cow’s milk exclusion/lactase drops.

When to refer Paediatrics: – Parents not coping despite intervention – Suspected medical cause / uncertain diagnosis – Unable to wean off treatment after 6 months Perinatal mental health service if concerns re severe postnatal depression

AKT question A 3-month-old baby girl is brought to see you by her mother. She reports a 1 month constant crying, which is worse at night. She is bottle- fed and is feeding well. There is no vomiting. Her weight has remained steady on the 25th centile since birth. On examination, she has a well-circumscribed discoid red lesion approximately 8 mm diameter on the top of her thigh. There is an identical lesion on her lower back.

Which is the SINGLE MOST appropriate initial management option for this patient? Select ONE option only. A. Advice and reassurance B. Refer to community paediatrician C. Refer to dermatologist D. Refer to health visitor E. Refer to social services

Answer E. This describes a case of non-accidental injury (NAI)—the discoid red lesions representing old cigarette burns. This would require an immediate referral to social services. This highlights the importance of considering the family and social situation when faced with a crying baby.