unsettled or crying babies

Background

- It is normal for babies to cry
- The mneumonic is PURPLE crying

• P for peak of crying. Peaking at about 2 months
• U for unexpected crying. 
• R for resists soothing. 
• P for pain like face
• L for long lasting. Crying can last for several hours a day
• E for evening. Cry more in the late afternoon and evening

- Common non pathological causes of crying 

• Excessive tiredness
• Hunger 

- Differential diagnoses to consider include:

• Cow milk/soy protein allergy 
• GORD
• Lactose overload/malabsorption 

Red flags:

- Sudden onset of irritability and crying should not be diagnosed as colic, a specific cause is usually present
- The maternal and family psychosocial state must be taken into account. Maternal post-natal depression may be a factor in presentation. Note that excessive crying is the most proximal risk factor for shaken baby syndrome

- Suspect cow milk/soy protein allergy if

• vomiting/blood or mucus in diarrhoea/poor weight gain/family history in first degree relative/signs of atopy (eczema/wheezing)/significant feeding problems (especially worsening with time) 
• gastro-esophageal reflux is diagnosed
• lactose malabsorption is diagnosed in formula fed babies

Investigation

• really depends on the history 
• for acute cry
• Urine MCS (if acute crying and vomiting)
• Fluoroscein staining of eyes (if history suggestive)

Management

• Exclude medical cause (including mum--> ? depression) 
• Explanation and reassurance

1. Engage in a partnership with the parents

2. Explain normal crying and sleep patterns

3. Assist parents to help their baby deal with discomfort and distress

• Give mother permission to rest once per day 

4. Assess maternal and emotional state and mother baby relationship

5. Sometimes when you are really frustrated, it is ok to put your baby down few minutes and calm yourself down

Written information

Conclusion

• Most of the time it is normal and no medical cause is found 
• The most important thing is to gain the parents trust
• Give them clear explanation 
• Minimal intervention from us is the best intervention

References:

John Murtagh 

RCH website