BMJ  2004;328:330 (7 February), doi:10.1136/bmj.328.7435.330

Primary care

10-minute consultation

Persistent crying in babies

¹ Manor Hospital, Walsall NHS Trust, Walsall WS2 2PS, ² Department of Community Health Services: GP Section, University of Edinburgh, Edinburgh EH10 5PF

Introduction

A young mother presents with her 12 week old son, complaining that he "cries all the time." She also has a three year old daughter who was "never a problem."

What issues you should cover

Elicit the mother's views—What does she think the problem might be? Take seriously any specific concerns she has. How experienced is she? For example, does she appreciate that the duration and frequency of crying can vary considerably between infants and at different times in the same infant? How is she coping? Is she depressed? Ask about what sources of support she has at home or among her wider circle of friends and relatives and whether she needs any additional help.

Nature of the crying—Excessive crying is defined medically as crying that lasts at least three hours a day, for three days a week, for at least three weeks. Is there any pattern to the crying? Babies cry for a variety of reasons, including hunger and thirst, being hot or cold, wanting attention, tiredness, discomfort, and pain. Although there is little evidence that it is possible to determine the cause from the pitch of the cry, the pattern of crying may indicate where the problem—if there is one—lies. For example, "infantile colic" (excessive crying in an otherwise healthy baby) may manifest as long bouts of crying in the early evening.

Other symptoms—Ask about any associated symptoms. For example, difficulty in feeding may be due to a blocked nose, vomiting may indicate a gastrointestinal problem, excessive straining may be due to constipation, and eczema suggests discomfort from itching.

Feeding—A detailed feeding history can help determine an underlying cause, such as overfeeding or premature weaning. The baby may inadvertently be swallowing air, particularly towards the end of a bottle feed.

Home environment—The home environment and family dynamics may be having an effect on the baby. The views (if available) of the father and other members of the family may provide useful insights. Also ask about sleeping arrangements and the baby's pattern of sleep.

Useful reading Garrison MM, Christakis DA. A systematic review of treatments for infantile colic. Pediatrics 2000;106: 184-90[Abstract/Free Full Text] Kilgour S, Wade S. Infantile colic. In: Clinical evidence. Issue 9. London: BMJ Publishing, 2003: 385-94 (an earlier version is available at BMJ 2001;323: 437-40[Free Full Text]) Lucassen PLBJ, Assendelft WJJ, Gubbels JW, van Eijk JTM, van Geldrop WJ, Knuistingh Neven A. Effectiveness of treatments for infantile colic: systematic review. BMJ 1998;316: 1563-9[Abstract/Free Full Text] Morris S, St James-Roberts IS, Sleep J, Gillham P. Economic evaluation of strategies for managing crying and sleeping problems. Arch Dis Child 2001;84: 15-9[Abstract/Free Full Text] For parents Health Promotion England. Birth to five. London: Health Promotion England, 2000: 22-4

What you should do

• Check the baby's growth chart, assessing weight gain and head circumference.
  
• Expose the baby fully. Complete exposure may point to the underlying cause, such as areas of eczematous skin or nappy rash that may be irritating him.
  
• Examine his orifices: look for a tight phimosis; anal fissures will show as small tears around the anal margin; check his mouth for evidence of thrush or teething; check his ears for otitis media.
  
• If you think there is a feeding problem advise the mother on feeding techniques, such as how to make up a feed and how to help stop the baby swallowing too much air while feeding. Check that the hole in the teat of the baby's feeding bottle is not too small, resulting in his gulping air.
  
• If she is breast feeding ask whether she has enough milk. A health visitor may be able to advise.
  
• Enlist further support from the health visitor if you have concerns about her parenting skills or mental state. If she has postnatal depression she is likely to need treatment and support.
  
• There is some evidence that whey hydrolysate milk and dicycloverine can help in infants with colic. However, dicycloverine is associated with an increased risk of anticholinergic side effects.
  
• Consider referring the baby for a clean catch urine specimen and further assessment if you suspect a urine infection.
  
• In most cases no underlying cause will be found. In such cases the problem will probably subside with time, and other than reassurance and ongoing support no further investigations are warranted.
  

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The series is edited by general practitioners Ann McPherson and Deborah Waller (ann.mcpherson{at}dphpc.ox.ac.uk)

The BMJ welcomes contributions from general practitioners to the series

This is part of a series of occasional articles on common problems in primary care

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