The baby who cries all the time

When a parent comes into the surgery complaining that the baby never stops crying, how can you help? In this article we review how to take a logical history and assess the baby who is crying all the time, what the possible causes of the problem might be, and what we should do next

All babies cry: this is their main means of communicating their wants and needs, emotions, feelings, and sensations.

Sometimes, however, a baby's cry signifies something that needs urgent intervention. Mothers swiftly learn to recognise distressed and urgent crying, as compared to, say the cry of a tired baby. They are likely to present quickly to the practice nurse or GP if they can't discover the reason for the problem, and our role is then to look for the source of the baby's distress.

However, there is another scenario, when a carer tells you that their baby cries ALL THE TIME. Persistent crying, particularly if new, is distressing but potentially worrying. It should lead to the suspicion of significant illness. So how do you assess this situation? Where do you start?

WHAT DOES 'CRIES ALL THE TIME' MEAN?

Taking a good history

You need to find out how unrelenting the baby's crying is, how much the carer's stress is altering her view of the situation (bearing in mind that she will of course be stressed and tired but this might not be altering her view at all).

Before you start to take the history, though, glance at the baby to assess the urgency of the situation. A 'first eyeball' examination as described in Box 1 will help you determine if you are dealing with a very sick child, although this is by no means easy.

THE HISTORY

As with any other symptom you need to discover exactly what has been happening, over what time course, and form a clear picture of the pattern of events.^1,2

What does 'all the time' means? Does it mean:

• Sometimes
• Often
• Most of the time
• All of the time

The further down the list you go the more likely it is that something is significantly wrong — particularly if the persisting crying is of recent onset.

1. About the crying and the baby

• When did it start?
• Is it getting worse?
• How long are bouts of silence if there are any?
• Is the cry in itself a normal cry?
• Are there any obvious things that make the crying worse or better?
• Does the mother have an idea what's causing it? Does something happen or has something happened to start it (e.g. Could the baby have been dropped? Rolled off a changing bench?)
• Prior to the crying how was the baby behaviourally and developmentally?
• Does the baby stop crying to feed?
• Does the baby feed?
• Does the baby produce normal nappies?
• Was the baby born normally? Did he or she go to special care?

2. About the carer(s)

Although the baby is the one who is crying, those caring for the baby are also part of the presentation. Their feelings are a part of the assessment of the situation. This is true for several reasons:

• You are hearing the history through the eyes and ears of the carer
• The carer will have their own views on what you need to do
• The experience of the carer with this and other babies helps you form a judgment (but should not mean that inexperienced carers are dismissed as being over fussy or 'just stressed')
• The constantly crying baby may represent a cry for help
• The constantly crying baby may be at greater risk of non-accidental injury from the desperate, tired parent
• The carers are often exhausted and in need of support

Having the carers listening and cooperating is a critical part of making your suggestions and recommendations work, so you need to know:

• Social situation — who else helps with the baby? What support is there during the night, in particular?
• How does the mother feel about the crying? i.e. is the mother angry, upset, tired, sad, defeated, feeling inadequate (it's likely that there will be some element of all of these things)
• What is the mother's previous parenting experience? An inexperienced mother may be overly worried or not be worried enough. An experienced mother is likely to recognise an abnormal pattern of crying.
• What does the mother hope for today? Somebody to take the baby away? Investigation? Reassurance?
• Does the mother need urgent support? Where could you find this?
• Are there other siblings?
• Is there any significant family history? A disabled sibling?
• Are there existing social services concerns e.g. alcohol, domestic violence, housing difficulties?

EXAMINATION OF THE BABY

Your examination of the baby now needs to be thorough and careful, and to be done with the list of possible causes of the problem in your head, so that as you examine you can rule them out (or not).¹

You should always start by completely undressing the baby apart from the nappy (or by asking the carer to do so). Babies are generally best examined on an examination couch with the carer next to them.

Then go through a careful and systematic examination as listed in Box 2.

CAUSES OF CRYING ALL THE TIME

This list is not absolutely comprehensive — no list could be — but it gives an idea of the things that might cause genuinely persistent crying.²

This gives the practice nurse a chance to operate a diagnostic sieve — that is an approach to diagnosis where you think of serious things and specifically rule them out. If you can't rule them out then you definitely need further advice.

The baby who genuinely is crying CONSTANTLY is likely to present with a short history.

Pain

Three months colic: this usually begins at about 2 weeks and usually stops by 3-4 months. It's a common and very likely cause of babies crying for more than 3 hours a day, every day, in the absence of other medical illness cause. It is thought to be due to spasmodic contractions of the immature bowl of the baby causing pain. It characteristically occurs in the evening and the baby draws up his legs and screams, and is often resistant to any comfort or further feeding. Note colic does not normally have a SUDDEN onset. Parents are often distressed exhausted and confused by conflicting advice.

Intussusception: this is a serious surgical emergency, which is notoriously difficult to detect on examination. It's one of the reasons why persistent crying for which you can find no cause needs further medical assessment, and it normally occurs between two months and two years (although it can occur at any age). Intussuscception is an invagination of a proximal part of the gut into a more distal portion, like one bit of a tube slipping forwards inside the next, and results in bowel ischaemia and necrosis if left untreated. Babies may pass a jelly red stool, but this happens relatively rarely.

Constipation: this is more common in bottle than breastfed babies but will be a significant cause of chronic colicky pain in the baby, which may persist for days and nights on end, causing persistent crying. There is likely to be a history of hard stools.

Appendicitis: extremely unlikely — it is very uncommon under 3 years of age

Acute infection: e.g. Otitis media, urinary tract infection, meningitis, lower lobe pneumonia: any of these conditions can cause pain and there may be a lack of specific signs. The tympanic membrane of a tiny baby may be difficult to see and the throat difficult to examine.

Oesophagitis: Most babies have reflux to a degree because the muscular valve at the end of their oesophagus, which acts to keep food in the stomach, hasn't developed properly yet. This is painful for only a small proportion of babies but infant Gaviscon or milk thickeners can help.

Torsion of the testis

Other sources of pain seen commonly in the surgery include:

• sore nappy rash
• skin infection
• hernia
• threads from cloths wrapped tightly around digits
• Fingernails cut too short leading to bleeding
• A thread in the eye
• Teething: Teething can be painful. On average, the first tooth breaks through between 4 and 7 months, but it can happen earlier.
• Blocked nose: A snuffly baby with an upper respiratory tract infection (URTI) may become chronically distressed. Babies need to breathe through the nose to feed, and if the nose is blocked the baby will struggle.

Other causes:

• Being much too warm
• Being much too cold
• Lack of physical contact — lonely babies do usually stop crying when held or rocked. Does the crying stop when the baby is held or taken for a drive? Beyond the age of three months some babies will cry whenever they are left alone but may be happier in a room with others.
• Fatigue — babies can become overtired and irritable. The mother may respond by going to the baby and offering food and nappy changing, the baby may then be further unable to sleep. Asking about sleep patterns may help discover this cause.
• Overstimulation — babies learn from the stimulation of the world around them. Crying can be a baby's way of saying, 'I've had enough.'
• Hunger — a baby would not usually be unrelentingly hungry or thirsty unless there was an underlying medical reason such as diabetes or pyloric stenosis, although a baby who is chronically underfed with breast or bottle milk, may cry persistently. If hunger is chronic the baby will be underweight or failing to thrive.
• Thirst — it is impossible to tell the difference between hunger and thirst when a baby cries but in hot weather in particular persistent thirst can be an issue.
• Bonding difficulties — this is a controversial area to discuss. Difficult, grumpy babies who cry a lot are a challenge and this may affect bonding. Mothers face very high expectations from society and themselves to bond with their baby, but some babies are difficult to bond with. A depressed or stressed mother will find this even more difficult and a persistently crying baby may be a sign that the two are having difficulties bonding with one another. The mother may be exhausted and low, and urgent support may be needed. This could even involve hospital admission.
• Postnatal depression may both cause bonding difficulties as above and increase maternal perception of the crying.

And finally but of the utmost importance:

• Non-accidental injury — for example a baby which has been shaken and had sustained some bleeding inside the skull may then be persistently irritable. There may be no other signs that this has happened, the person who has shaken the baby may not be in the room with you or be aware of what has happened. Remember that non-mobile babies do not bruise themselves nor break their own bones.

HOW MUCH DOES A BABY NORMALLY CRY?

Crying follows a developmental pattern, known as the crying curve, during the first few months of life.^3,4 Crying increases at 2 or 3 weeks of age, peaks between 6 and 8 weeks, and then slows down after that, generally hitting its lowest level by around 4 months. Babies also cry more often in the late afternoon and early evening, which might be when they need to release tension after a long day.

Management^1,2

Firstly and most importantly, if in doubt, seek extra help/admit to hospital.

However, if you are completely reassured that there is no medical cause and no urgent social support need you could consider the following:

• Health visitor referral for advice and support — speak to the health visitor yourself if you can
• Mother and baby groups, the NCT and La Leche
• Use a sleep/cry diary to explain the infant's cry/sleep/feeding patterns: work out the amount of sleep over a 24 hour period then review
• Encourage parents to recognize signs of tiredness (frowning, clenched hands, jerking arms or legs, crying, grizzling)
• Assist parents to help their baby deal with discomfort and distress (Box 3)

Summary

Some babies sleep less than others — and of those who sleep less, some will cry when awake. They may for example awake in the early hours of the morning and habitually stay awake and unhappy for 2-3 hours. This can lead to chronic exhaustion in the parent and the perception that the baby cries all the time. Careful history-taking and understanding will separate these cases from the baby who really had not stopped crying.

However, genuinely ceaseless crying, while it is often due to combinations of tiredness and stress in baby and parent, can also be a red flag for serious disease and should always be fully evaluated.

REFERENCES

1. Lissauer T, Clyden G. Illustrated textbook of Paediatrics (4th edition) Mosby Elsevier; London: 2012

2. Valman B, Thomas R. ABC of the First Year of Life (6th edition) BMJ Books; London:2009. Available as an eBook at https://play.google.com/store/books/details?id=ckmi63u4howC

3. Berry Brazleton T. Crying in Infancy: American Journal of Pediatrics 1962;29(4):579 -588 http://pediatrics.aappublications.org/content/29/4/579

4. ADAM Medical Encyclopedia. Colic and crying: Infantile colic. http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001973/