1. CLINICAL PRACTICE GUIDELINE (1st edition) Office of Kids and Families January 2016 Acute Management of the Unsettled & Crying Infant 0

2. Overview of the Guideline provide a structured approach for the assessment of infants who present to ED with excessive crying and unsettled behaviours provide a framework for the management of common causes of excessive crying provide advice on discharge planning and follow up plans for well infants with crying and settling problems 1

3. Key Topics in the Guideline What is normal, new and problematic crying Identifying organic and non-organic causes Safety and wellbeing concerns for infants and siblings Sleep and settling infants Talking to parents and carers Resources and support for families 2

4. KEY POINT Parental anxiety should not be discounted – It is often significant even if the child does not appear especially unwell. Statement in all NSW Health Paediatric Clinical Practice Guidelines 3

5. Normal Infant Crying Cry for a variety of reasons, e.g. hunger, thirst, tiredness, discomfort. First three months of life is the period of ‘peak’ crying. starts at 2 weeks of age peaks at 4-6 weeks resolves around 4-6 months Crying tends to be concentrated in the late afternoon or early evening Occurs in prolonged bouts, and often with no apparent trigger Infants often go red in the face, pull up their legs, or pass wind. This may not necessarily represent abdominal pain. 4

6. ‘New’ Crying It is important to look at the pattern of crying behaviour: Has the infant had problematic crying for some time? Is this ‘new’ crying behaviour not characteristic for this infant? Is the tone or pitch of the crying different to usual crying? If it is ‘new’ crying, Is the infant unwell? Has anything changed in the care of this infant, e.g. introduction of formula (even once), and changes in stool/urine colour or odour 5

7. Definition of Problematic Crying Commonly used definition is Wessel’s ‘Rule of Three’: 1.Crying that lasts for more than 3 hours per day, 2.Occurs on more than 3 days per week 3.Persists for more than 3 weeks 6

8. Aetiology of Problematic Crying Aetiology is poorly understood. May be an altered balance between: parental expectation infant temperament and physiological or pathological causes Factors associated with increased infant crying behaviours; maternal and paternal depression family stress complications during the pregnancy or delivery Cultural and individual variation in perception of what is ‘normal’ crying 7

9. Effects Of Excessive Crying Excessive crying in an otherwise healthy baby may be associated with: Parental anxiety and depression Parental sleep deprivation Attachment difficulties between parent and infant Physically abusive behaviour towards the infant, in particular, inflicted traumatic brain injury. 8

10. Presentations of Excessive Crying When parents present to the ED with a crying infant they are generally seeking three things: 1.Reassurance about their actions to try to manage their baby 2.Exclusion of serious disease or problem 3.Coping strategies for the future including social supports 9

11. Assessment Algorithm 10

12. KEY POINT It is important that infants presenting with crying to ED who are sick or unwell are recognised early and assessed promptly. Clinicians should refer to Recognition of a Sick Baby or Child in the Emergency Department Guideline or Paediatric Sepsis Pathway Neonates and premature infants are particularly high risk groups that can deteriorate quickly. 11

13. Life Threatening & Serious Illness The first step to exclude serious and life-threatening illness. Assessment of the infant’s; Airway Breathing Circulation Disability (neurologic state) Exposure (temperature and rashes) Fluids status (fluids in/fluids out) Glucose (blood sugar level should be performed) 12

14. Possible Organic Causes If an infant is not acutely unwell or needing resuscitation, then complete a structured history and physical examination to identify whether there is an organic cause History-taking should be focused on obtaining possible clinical features indicative of organic disease Abnormal vital signs may indicate possible organic disease Refer to Table 1 & 2 in the guideline 13

15. Physical Assessment A head to toe physical examination done with proper exposure of the infant is essential to avoid missing important physical findings, inc; 1.Neurological assessment - tone, eye movements, reflexes 2.Skin - rashes or bruising 3.Limbs and joints - tenderness, swelling or deformities 4.Urinalysis - for microscopy and culture 5.A heel prick - blood sugar level if clinically appropriate (e.g. in infants with poor feeding). Consider Differential Diagnoses Refer to Table 3 in Guideline 14

16. Organic Disease Suspected Vital sign observations outside normal range (Blue, Yellow or Red Zones on Standard Paediatric Observation Charts (SPOC) If an organic disease is suspected then appropriate investigations should occur e.g. blood tests, urine tests, imaging Second-line investigations should be only performed after discussion with a senior clinician e.g. lumbar puncture, head or abdominal CT Refer to Table 4 and Table 5 in guideline 15

17. KEY POINT Remember that even when an organic cause has been identified, clinicians should keep in mind the question, “Is this infant at any risk of harm?” Any psychosocial concerns for parents/carers must be explored and addressed. 16

18. Gastro-Oesophageal Reflux (GOR) physiological passage of stomach contents back into oesophagus GOR is not a cause of crying/ unsettled behaviour in most infants Gastro-Oesophageal Reflux Disease (GORD) is less frequent but has much greater consequences due to large, frequent regurgitation GORD can cause problematic crying in a small number of infants 17 GOR and GORD

19. Not a cause of persistent crying in the majority of infants Most infants with CMPA present with specific symptoms rather than persistent crying If concerned about CMPA refer to a paediatrician, paediatric allergy specialist or paediatric gastroenterologist No evidence to support stopping breastfeeding and changing to formula in breastfed infants unless there is proven CMPA Any elimination diet (for mother or infant) should be done in conjunction with and follow up from a paediatrician 18 Cows Milk Protein Allergy (CMPA)

20. Safety & Welfare of the Infant Consider if the infant is at any risk of harm. Things to ask/ think about: Are the parents coping with the care of the infant? Is there support available to the family if they need a break? Any concerns regarding parental mental health e.g. post-natal depression? Any concerns regarding domestic violence? Any concerns regarding parental drug use or alcohol use? Any signs of possible neglect? 19

21. Are there concerns for the safety and wellbeing of siblings? How are siblings responding to the new baby? Is there a source of tension in the home? Are there any specific concerns regarding the safety and wellbeing of siblings? 20 Safety & Welfare of Siblings

22. Response to Safety & Wellbeing Concerns KEEP THEM SAFE & Mandatory Reporter GuideKEEP THEM SAFEMandatory Reporter Guide Respond as per NSW protection policies /procedures Document all concerns or injuries Seek advice from paediatrician/child protection specialist Support the engagement of a social worker (if available) Consult the NSW Health Wellbeing Units 1300 480 420 If in doubt - admit 21

23. KEY POINT Remember, no matter how frustrated the parents may feel with their baby’s crying, shaking the baby is never acceptable. Suggest that the parents consider putting their baby safely in the cot or on the floor, then shutting the door and walking away for a few minutes 22

24. Management Of Sleep and Settling Issues Some general principles are; Help parents cope with the infant’s crying Help establish bonding between parent and baby Address any feeding difficulties Offer practical advice regarding settling techniques Reassure parents that cuddling and carrying will not ‘spoil’ their baby Address any psychosocial factors that may impact on infant crying 23

25. Settling Techniques Make sure the baby … is not hungry, has a clean nappy, is not over/ under dressed and is comfortable. Settling techniques include… Pre-sleep routine - can help your baby develop positive sleep patterns Gentle ‘ssshhh’ sounds Talk quietly, using comforting tones Pat gently and rhythmically Apply gentle contact on your baby’s body, leg or arm Gently and slowly rock your baby’s body side to side Stroke gently and rhythmically, e.g. forehead or head, arm, leg 24

26. KEY POINT Discharge from the hospital ONLY if no underlying organic disease AND it is safe to do so 25

27. TALKING TO PARENTS AND CARERS Reassure parents/ carers that: At the moment, their baby has been assessed as medically well This period of crying may be part of what is normal crying Crying in infancy occurs across all cultures, with the same peak time In most cases, the crying will improve over time In a difficult time such as this, it is important for the parents to look after and care for themselves and each other 26

28. Support for Parents And Carers If they feel that they want further help or reassurance about their baby, their options are: Call their local Child and Family Health Nurse See their GP or Paediatrician Contact Tresillian or Karitane Return to ED for another assessment 27

29. Discharge Planning Discharging from ED and Resource Information Decide on appropriate resources Determine availability of resources Consider any literacy issues Specific follow up appointment Provide “Crying Baby Fact Sheet” which has contact numbers for Health Direct, Tresillian and Karitane Culturally Specific Services In addition (and where appropriate) provide information about Aboriginal Health Workers, Aboriginal Medical Services, Transcultural Mental Health and local bilingual counsellors. 28

30. Crying Baby Factsheet All parents must be given a “Crying Baby” Factsheet and any question or concerns addressed before it is safe to discharge It is important that clinicians discuss the Fact Sheet with parents, rather than just handing it to them Give the parents “permission” to leave the crying infant for a short break e.g. 1-2mins Provide strategies on how parents can calm themselves or ask for help 29

31. SUMMARY Common presentation - concerns about a baby’s crying and unsettled behaviour Occurs in normal healthy infants but may indicate a more serious underlying problem These presentations may not be straightforward Overly aggressive pharmacological treatment or failing to investigate and manage organic disease may cause harm Psychosocial factors can impact on infant crying Staff can find it challenging to manage parental anxiety, assess parents’ ability to cope and exclude child protection concerns It is important to ensure that community follow up occurs within 48 hours of discharge from the emergency department 30