Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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why insinuate breastfeeding may be the cause?
- Denny Rice (6 February 2004)
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Undermining breastfeeding
- Anthony F Williams (6 February 2004)
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Breastfeeding problems deserve skilled investigation
- Magda Sachs (6 February 2004)
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Beware recommended therapy
- Prof. Reuben Steinherz (6 February 2004)
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Circumcision Status and Persistent Crying in Infants
- George Hill (6 February 2004)
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Persistent crying and child abuse
- Jeffrey D. Hubbard (7 February 2004)
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Crying babies - causes multifactorial - often related to Eustachian Tube [ET] Dysfunction
- Renee H Shilkin (7 February 2004)
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persistent crying in babies - a medical emergency?
- Mary S. Norrie (7 February 2004)
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Re: Persistent crying and child abuse
- Lisa C Bakemore-Brown (8 February 2004)
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Undiagnosed illness
- wendy m mclean (8 February 2004)
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emotional effects on infants
- Kaurina Jeeris (8 February 2004)
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Tactful Questioning
- Fiona S Jowett (9 February 2004)
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A family affair!
- Catarina A Canivet, Marissa Alvarez (9 February 2004)
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Dicycloverine is contraindicated in infants.
- Martin H Goldman (9 February 2004)
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Persistent crying in the first year of infancy
- Alex McGlaughlin, Andy Grayson (9 February 2004)
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Crying babies and the alliance of pragmatic puritans
- Richard G Fiddian-Green (10 February 2004)
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Is it gastroesophageal reflux?
- Alejandro Awad, Elizabeth Y. Sapia (10 February 2004)
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Thirsty babies cry
- Tom Hughes-Davies (11 February 2004)
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please don't blame the foreskin
- ross m fisher (11 February 2004)
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Weight gain and feeding patterns are an important part of the assessment of persistently crying babies
- Carol A Walshaw, Jenny M Owens (11 February 2004)
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unpacking 'family dynamics'
- Sebastian Kraemer (23 February 2004)
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crying babies, feeding and reflux
- Anselme G Derese, Sven Deroose, Els Vandedrinck, Myriam Van Winckel (28 February 2004)
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Corneal abrasions can cause persistent crying in infants
- Kristi L. Koenig (2 March 2004)
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Respect: Hair tourniquet and Urinary tract infection
- Girish Gupta, Vishal Sondhi (16 April 2004)
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Touch
- Tracy Hayden (23 April 2004)
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Denny Rice, private practice Dallas, Texas 75002, USA
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I don't understand "what you should do" item number 5; "If she is breast feeding ask whether she has enough milk." The first item indicates you should check baby's weight and head circumfrence. Once that is done, you already know if the baby is getting adequate nourishment. The mother will be looking to you as to whether or not she has enough milk, afterall, you are the medical advisor. She can only give you her opinion, you have the facts. By asking this question, the medical personel are suggesting several things; the crying may be mom's "fault", for not feeding her baby adequately, that mom's milk "isn't good enough, rich enough, etc." and of course, if she believes she doesn't have enough milk, don't you suppose she has enough sense to know that's why the baby is crying? What benefit comes from this question? Because the answer isn't quickly apparent, blame it on breastfeeding. It's time that breastfeeding quit being blamed for crying babies, simply because medical personel cannot find any other reason. This is counterproductive to successful breastfeeding, undermining mom's confidence in providing for her baby. Competing interests: None declared |
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Anthony F Williams, Senior Lecturer / Consultant Paediatrician St George's Hospital Medical School, SW17 0RE
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Gatrad and Sheikh suggest that the breastfeeding mother of a persistently crying 12-week old baby should be asked "If she .....has enough milk". I suggest that this is both unhelpful and likely to undermine her confidence in breastfeeding. National data [1] continue to show that concern about "insufficient milk" is one of the commonest reasons mothers abandon breastfeeding early. It usually just reflects unawareness of a wide normal variation in breastfeeding patterns. Any concern about adequacy of intake can be answered objectively by assessment of the baby's growth pattern. If this is satisfactory the mother needs reassurance and support. If it is not, a feeding history and observation of a feed will in most cases identify a problem which can be rectified. Breastfeeding is already undermined by too many influences in society, and often other members of the family. Worried mothers need support, not more doubt about their parenting ability. [1]. Hamlyn B, Brooker, S, Oleinikova K, Wands S. "Infant feeding 2000". The Stationery Office. London, 2002. Competing interests: I act as a voluntary professional advisor to a number of charities engaged in breastfeeding promotion and support. |
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Magda Sachs, Breastfeeding Supporter PO Box 11126 Paisley, PA2 8YB
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Gatrad and Sheikh (1) have supplied a checklist for practitioners in the case of a baby of 12 weeks with persistent crying. For a feeding problem suspected in a bottle-fed baby they give specific suggestions for examining the milk composition and delivery of the feed. In the case of a breastfed baby, they do not supply similar suggestions, but suggest querying milk sufficiency. The issue for many breastfed babies is not so much the sufficiency of the milk produced, but the sufficiency of the milk and the quality (amount of fat in the milk) that is accessed (2). That is, a mother may be producing enough milk, but the baby may not be receiving quite as much as he needs. A recent review of evidence in good practice (3), highlighted the importance of ensuring that positioning – that is the physical placement of both mother and baby before feeding – and attachment of the baby to the breast enable effective and pain-free breastfeeding. The skills of observing breastfeeding, and of suggesting changes which may improve not only the quantity but also the caloric quality of the milk the baby receives, are not routinely taught to health professionals in the UK (4). However, these are the practical equivalents of the suggestions made for bottle-feeding, and should help to correct any contribution of feeding to an upset baby. While medical practitioners may not have the time to learn and practice these skills, it is important that they are appreciated and good local referral systems are in place. The further suggestion of checking the baby’s charted growth may also tend to undermine breastfeeding, unless the distinct difference between the shape of a breastfed baby’s growth trajectory in comparison with the shape of the chart centiles is kept in mind. In a multitude of comparisons both in the UK and across the globe, it has been shown that breastfed babies often grow very well in the early weeks, only to appear to ‘falter’ between 2 and 3 months (5). Unless this is kept in mind, a breastfed baby’s normal growth curve could lead to a misdiagnosis of insufficient milk and a misguided suggestion to supplement or to abandon breastfeeding. As with the examination of the other possible causes of infant distress, investigation of a possible contribution of breastfeeding difficulties needs to be thorough. It should also rely on the evidence of best practice in supporting breastfeeding. 1 Gatrad AR, Sheikh A (2004) Persistent crying in babies BMJ 328: 330 2 Woolridge MW (1995) Baby-controlled feeding: biocultural implications, in Breastfeeding Biocultural Implications, Stuart-Macadam P, Dettwyler K eds, Aldine de g Gruyter: New York 3 Renfrew M, Woolridge WM, Ross McGill H (2000) Enabling Women to Breastfeed, The Stationary Office: London 4 UNICEF UK Baby Friendly Initiative (2002), Baby Friendly best practice standards for midwifery and health visiting education http://www.babyfriendly.org.uk/education.asp 5 World Health Organisation (2000) Growth patterns of breastfed infants in seven countries, Acta Paediatrica 89: 215-222 Competing interests: I have been a voluntary breastfeeding supporter in the UK since 1988 |
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Prof. Reuben Steinherz, Pediatrician Reut, Israel
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The authors wrote: "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". On the other hand in the cited refernce -" A systematic review of treatments for infantile colic. Pediatrics 2000;106: 184-90" the use of dicycloverine, is concluded as followed: "However, Merrell Dow, the manufacturer, no longer considers infant colic an indication for dicyclomine and has contraindicated its use in infants <6 months old." Since the paper deals with Persistent crying in babies' i.e those below 6 months of age, it would have been preferable not to mention dicycloverine as a therapeutic option at all. Competing interests: None declared |
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George Hill, Executive Secretary Doctors Opposing Circumcision, Suite 42, 2442 NW Market Street, Seattle, Washington 98107 USA
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Competing interests: None declared |
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Jeffrey D. Hubbard, Paediatric & forensic pathologist St. Peter's Bender Laboratory Albany, New York USA 12208
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Persistent crying in babies has another association worth keeping in mind when faced with this complaint: child abuse. The two circumstances most frequently mentioned by accused or convicted child abusers as associated with infliction of traumatic injury are persistent crying and [inconvenient] defecation. Unstable families are another risk factor for abuse, as the abuser is most often (not always) the mother’s “boyfriend.” I suggest that to the “Home Environment” section of this excellent summary might be added questions like, “What effect does the baby’s crying have on you (mother) and other people in the household? Does it interfere with sex or sleep? Crying can get upsetting – does anyone get angry when the baby cries?” The authors point out that, “In most cases no underlying cause will be found.” Similarly, in most cases no risk of abuse will be found, but, like the other conditions mentioned, it is a possibility which can benefit from identification and intervention. Competing interests: None declared |
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Renee H Shilkin, General Practictioner seeing distressed babies Raglan Clinic 366 Fitzgerald St North Perth Western Australia 6006
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I have worked with distressed babies for approx 15 years. I believe that many crying babies have a combination of gastroesophageal reflux [GOR] and atopy. I believe this causes ET dysfunction from refluxing acid and enzymes irritating the opening of the ET in the nasopharynx. Because of the atopic disposition the tissues react excessively producing swelling and mucus and this interferes with ET function - resulting in an inability to keep the middle ear pressure at atmospheric - especially when the infant is sucking vigorously or lying down. Many of the infants go on to develop recurrent middle ear infections and/or middle ear effusion - with many possible sequelae because the middle ear problems start very early and may be unrecognised early in the infant's life. I refer to this condition as Eustachian tube Irritation. The children's problems may include other aspects of atopy - particularly food intolerances [dairy &/or soy and heavy grain wheat products] - in the breast feeding mother's diet or later in the infant's diet. Other problems to compound the distress include the reflux itself - though I believe the ET problems are far more common than oesophagitis. About 15% of infants will stop refluxing if dairy products are removed from the diet. Assessment should include a micro urine [to exclude urinary tract infection ? ureteric reflux more common in infants with GOR]ear examination and tympanogram. This is better done on a high frequency tympanometer for infants under 5 months - but a standard frequency [226Hz]tymp showing pressure abnormalities or effusion can be accepted as indicating an ET/middle ear problem. However some abnormalities may be missed because of false negatives in this age group. Infants run a variable course - with exacerbations with increased reflux, URTIs, immunisations, teething etc. The most severe problems are in infants with severe atopy and severe reflux. The problem may occur in several infants in a family. Competing interests: None declared |
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Mary S. Norrie, GP principal South Grange Medical Centre, Eston, Middlesbrough, TS6 9QG
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There was a time when, as Garrad & Sheikh seem to do here, I would have regarded "persistent" crying in babies as yet another symptom among many to be dealt with in the course of a normal working day. That was: until the evening, some years ago, when I watched an episode of a TV programme entitled "Tomorrows World". During this particular episode, the programme concentrated on the issue of persistent crying in babies, as one of its featured articles. What I saw and heard then has changed my approach to this symptom completely. In essence, the main points made were as follows: 1. Measured in decibels, the intensity of a baby's cry (at full voice) is greater than that of a sledgehammer at close range. 2. In terms of pitch, a baby's cry contains those pitches most guaranteed to grate on an adult's mind. The conclusion voiced by the presenters was that no adult could listen to a persistently crying baby for more than a couple of minutes without being driven to do something about it. Most of the time, this worked in the baby's favour: it would be picked up, soothed, made comfortable, fed, whatever. On occasions, however, whatever the adult did was insufficient to pacify the infant; and this is where the real danger lies. That is, persistent crying in a baby can lead, in the "wrong" circumstances, to direct physical abuse - sometimes with a fatal outcome. On an anecdotal level, these conclusions would very much seem to be bourne out. Simply read newspaper accounts of carers (usually male), in court on charges of killing a very young child in their care. How often have these reports contained a statement that these adults' actions were triggered by the fact that "the baby wouldn't stop crying"? Garrad & Sheikh give examples of possible ways of dealing with the symptom of persistent crying in babies, from a medical model only. It is quite possible that other experienced doctors (paediatricians or GP's) could add to these measures. However, it should be stressed that persistent crying in babies - in and of itself - is a much more dangerous symptom than this article would indicate, for the reasons listed above. And this is the point which should be stressed and responded to most, in any such consultation. Competing interests: None declared |
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Lisa C Bakemore-Brown, Psychologist UK
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If babies are suffering from a condition which leads to persistent crying and greater defecation than normal, it may well be that vulnerable families will become overwrought and some may then hit out at the baby. The incidence of disorders relating to gut problems have dramatically increased (1) in children over the last decade or so, with now a reported 1 in 100 suffering from Coeliac Disease and so it is vitally important that we discover why these conditions have increased, leading to persistent crying, in order to make life better all round. 1. Children's bowel problems much higher than expected BBC News 5th February 20034 Competing interests: None declared |
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wendy m mclean, retired home
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Persistent crying is extremely difficult for parents to handle, yet if the child is growing normally it is not taken seriously by doctors. My own persistently crying child went on to be diagnosed with whooping cough (despite vaccination), repeated ear infections and severe allergy. I believe Dr Shilkin is correct to point out that many of these babies are suffering from undiagnosed illness. Two things that may help the mother - xylitol gum or sweets can delay the transmission of some of the bacteria that cause ear infection. Probiotics in the mothers diet if breastfeeding or for the infant if bottle fed may also be worth considering for their possible effect on allergy and digestive problems. Persistent crying should be taken far more seriously. Competing interests: child who cried persistently |
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Kaurina Jeeris, doula Singapore 468487
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May I suggest one more possibility for why infants may cry for no apparent reason. I had an infant who did that. she was checked several times by nurses and pediatricians who could find nothing wrong. It occured to me, in hindsight, that all the times she cried excessively corresponded to times when I was particularly stressed or upset. It makes sense that an infant would be quite sensitive to its carers emotional state and become upset as well, which could affect its digestion, causing colic etc. Perhaps people looking after newborns should be offered emotional support if they have infants who cry a lot to look at areas of their lives which are causing excessive stress. Competing interests: None declared |
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Fiona S Jowett, GP retainee Stenhouemuir, FK5 3BB
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Breastfeeding problems may well lead to crying in babies. However the suggested intervention "ask whether she has enough milk", is more likely to put a mother off breast feeding and make her feel inadequate than to identify a problem.Breastfeeding mothers get all sorts of nonsense advice from family and friends and, when they are vulnerable with a persistantly crying baby, any hint from a doctor that they are failing is likely to reinforce negative comments from other people. She is then more likely to intoduce formula milk and / or stop breast feeding altogether. It would be much more helpful to encourage her with the breastfeeding, pointing out that breastfed babies get less colic that bottle fed babies. Then ask her if she would like any advice or help with the breast feeding and suggest health visitor follow-up if appropriate. Competing interests: I am a breast feeding mother |
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Catarina A Canivet, Family physician, Ph D Dept of Community Medicine, Lund University, Malmö Univ Hospital, SE 205 02 Malmö, Sweden, Marissa Alvarez
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We are relieved to note that there are already several responses pointing out the inappropriateness of asking the breast-feeding mother whether "she has enough milk". Considering the ample knowledge on the benefits of breastfeeding in the first 6 months, and the fact that there is very little evidence that breastfed infants cry more than bottle-fed, all measures should, on the contrary, be taken to support the lactating mother. Also, when a cow's milk protein-free diet is judged suitable, it can be offered by the lactating mother, and not only by switching to a whey hydrolysate formula Neither is it helpful to put all different types of excessive infant crying under one hat. In the overwhelming majority of cases, early infant crying resolves by about 12 weeks of age, and it is therefore surprising that the authors chose this age in particular to discuss management of the phenomenon. Asking about sleeping arrangements and the pattern of sleep is not a helpful approach to take either, as there is no clear evidence to date that can help guide either the practitioners or the parents in reducing the crying by understanding the infant's sleeping patterns or by changing the sleeping arrangements. A final comment is that while it is mentioned that enlisting the father and other family members would be helpful, there appears to be an underlying attitude that the reasons for the excessive crying lie in the mother-infant dyad, and in particular in the mother, and also that the mother carries the ultimate responsiblity for resolving the crying. There is evidence, however, that infant crying concerns the whole family (1, 2). 1. Barr RG. Infant crying and colic: It’s a family affair: Invited commentary. Infant Ment Health J 1995;46:218-20 2. Raiha H, Lehtonen L, Huhtala V, Saleva K, Korvenranta H. Excessively crying infant in the family: mother-infant, father-infant and mother-father interaction. Child Care Health Dev 2002;28:419-29. Competing interests: None declared |
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Martin H Goldman, Senior Medical Advisor Medical Department, Forest Laboratories UK, Ltd. Bourne Road, Bexley, Kent, DA5 1NX
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Gatrad and Sheikh have offered readers an excellent overview of problem crying in infants. However, it should be noted that their comments about the usefullness of dicycloverine (also known as dicyclomine) may be hazardously misleading. Whilst there is published evidence of the efficacy of dicyclomine, it is contraindicated in infants (less than 6 months, according to Bandolier)because of serious side effects including apnoea, and Prodigy guidelines point out that dicylomine is unlicensed for use in infants under the age of 6 months. Changes in nomenclature have not helped: it would be easy to not realise that dicycloverine and dicyclomine are the same entity, and the potentially catastrophic consequences of this confusion. Competing interests: I am employed by Forest Laboratories Ltd, producers of Infacol, a treatment for infant colic |
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Alex McGlaughlin, Assocate Dean and Reader in Psychology The Nottingham trent University, NG14BU, Andy Grayson
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Gatrad and Sheikh (Persistent crying in babies BMJ 2004; 328:330, Feb 7th) quite properly end their contribution with the conclusion that no underlying causes will be found for most cases of persistent crying in babies. They also go on to say that: "The problem will probably subside with time." Because of the importance of the implications of such conclusions, we have previously tested them (McGlaughlin, and Grayson, A prospective study of crying during the first year of infancy). Our conclusion is that excessive crying, known to peak in the first three months, does indeed subside substantially by the end of the first year, as also does the lesser crying of matched controls. However, infants identified by their mothers as crying excessively at 3 months do still cry more than controls at 12 months (44 as contrasted with 26 minutes in each 24 hours). But this is rather far less than their earlier crying (134 as contrasted with 68 minutes in 24 hours). Thus most early excessive crying with no discernable underlying cause does fortunately lessen over time. We believe therefore that it is important to emphasise to both mothers and associated professionals that such crying is no one's fault, will improve over time and that help and support can be found through sleep clinics, mutual support groups and excellent books such as that by Pat Gray "Crying baby how to cope". References: Gray, P (1987) Crying baby, how to cope. Wisebuy London. McGlaughlin, A and Grayson, A (1999) A prospective study of crying during the first year of infancy. Journal of Reproductive and Infant Psychology, vol17, no1, 41-52 Competing interests: None declared |
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Richard G Fiddian-Green, None None
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There are two good reasons for babies crying, an energy deficit, or more likely an acquired conditioned reflex that anticipates that event so that it can be averted in a timely manner, and pain. Consider the first in greater depth. The energy deficit could be due to nutritional or to oxygen needs. The first is by far the more common and usually very effectively resolved by meeting that need with a timely feed. A deficit might also develop if the nutrient cannot be absorbed and/or utilised by cells, because for example NAD(+)/NADH pools have been depleted and oxygen uptake and utilisation impaired by cytokines. Examples include those with marasmus or Kwashiorkor. The cytokines could be released acutely or chronically by a variety of stimuli including hypoxia, the translocation of enteric lipopolysacchardide or endotoxin and immunisations. An energy deficit might alternatively be induced by either inherited or acquired mitochondrial dyfunction. Another cause might be mitochondrial dysfunction caused either directly or indirectly by environmental pollutants including sublethal concentrations of carbon monoxide in inspired air. The first response to an energy defict in an adult with obstructive apnoea is arousal probably a reflex response to an energy deficit caused by hypoxaemia. An infant probably wakes for the same reason, unless in pain. An infant who awakens because of an energy defict caused by respiratory obstruction presumably resolves the problem by lifting his/her head and shifting positions unless too weak to do so because of muscle weakness caused by a low degree of inherited or acquired mitochondrial dysfunction. In the latter circumstances the addition of a nutritional need could be another straw that has the potential to break the camel's back and cause SIDS. [Giving a baby time to digest its meal before putting it to sleep might be another simple action that could be profitably employed to avoid SIDS]. Whilst the overhelming majority of babies with persistent crying might have one or more of the common reasons considered in this article, a few might not. It would seem imperative, therefore, to exclude the possibility of an energy deficit before reassuring mothers with persistently crying babies. The easiest and most sensitive way to do this would seem to be to calculate the gastric intramucosal pH in a fasting infant from a sequence of measurements of intragastric pCO2 and the bicarbonate in a sample of arterilised blood. Whilst there have been methodolgical concerns reported (1) the measurement has been reported to have clinical utility (2) and more importantly is based upon firmly established pathophysiological principles and practices in adults. Academic puritans are certain to say that there is no evidence-base to support the above statements. They might also claim that I have an undisclosed conflict of interest because of a financial interest in tonometry. UK lawyers I have consulted claim that I do not. US and South African lawyers might have a differnt view. I submit that if I have a conflict of interest it is no more than that of any puritan who believes that associations with industry present an unacceptable conflict of interest certainly for an academic. I further submit that some, such as Baroness Greenfield, who have a very visible foot in both camps can have far more academic objectivity and credibility than those who do not. [Some in the Royal Society might claim otherwise]. Those academic puritans whose existence depends upon an NHS income and grant support may have a far greater conflict of interest. The co-ordinated efforts to enforce academic puritanism in medical practice have, like the efforts to enforce political correctness, done immeasurable harm to patients and to the profssion even if the intent has been to do good. It might, however, be an alliance between big-business, big government and big religion that is the driving fore behind these debates. In the US healthcare benefits have become the major burden to companies operating in the increasingly competitive global market. Companies have a great incentive to move their businesses out of the US to avoid the high costs of healthcare benefits especialy if in so doing their employees are able to receive even more generous disposable incomes and have a beter standard of living. Big-business might even have established an alliance with big religion intent upon addressing poverty, healthcare needs and the redistribution of income in lesser developed countries. Viewed in this context the alliance between big religion and big politics deserves especially close scrutiny by the medical profession. Just like crying babies big busness, big government and big religion have [energy] deficits that need to be met. 1. Thorburn K, Hatherill M, Roberts PC, Durward A, Tibby SM, Murdoch IA. Evaluation of the 5-French saline paediatric gastric tonometer. Intensive Care Med. 2000 Jul;26(7):973-80. 2. Booker PD, Romer H, Franks R. Booker PD, Romer H, Franks R.Gut mucosal perfusion in neonates undergoing cardiopulmonary bypass. Br J Anaesth. 1996 Nov;77(5):597-602. Competing interests: Advised by a university lawyer to resign from my academic appointment to avoid a conflict of interest, a criminal offense in a state institution in Massachusetts |
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Alejandro Awad, Medical doctor Ricardo Gutierrez Children Hospital of Buenos Aires, Argentina Code 1425, Elizabeth Y. Sapia
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In our experience we find infants under 3 months of age with gastroesophageal reflux and its symptomology were signs of esophagitis (crying, irritability, feeding aversion). The management was conservative therapy and lifestyle modification Competing interests: None declared |
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Tom Hughes-Davies, Retired paediatrician Breamore Marsh
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Babies need to satisfy thirst as well as hunger. Breast milk was designed before clothes or shelter and may not provide enough water. This is especially so if the surroundings are hot or the faecal loss greater than normal, perhaps from mild lactose tolerance. Illness may temporarily halt growth, which normally accounts for half the protein taken. This increases the renal urea load and so the need for water. So give all babies the chance to take water as they will, especially when unwell. Without it many do well, some become unhappy, and others grow fat as do mice when their water is laced with sugar. And raise both head and bed head to reduce reflux into oesophagus and Eustachian tube. Competing interests: None declared |
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ross m fisher, consultant paediatric surgeon the children's hospital, leicester le1 5ww
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At the risk of adding another exclusion (but actually simplifying the list) I would challenge the authors (and the rest of the readership) to provide evidence that a "tight phimosis" is ever the cause of crying in small babies.
The foreskin is frequently physiologically non retractile and there is no indication or justification in attempting to demonstrate otherwise. "phimosis" as recognised by the majority of practitioners is therefore normal. there is only one condition in which there is severe phimosis; Congenital Megaprepuce and this condition is entirely pain free. The only time a youngster's foreskin may be to blame for crying is if there is significant balano-posthitis. Once again this should be obvious to anyone simply looking at the child and has nothing whatsoever to do with retractility or otherwise of the foreskin. Therefore, in protection of the foreskin and Paediatric surgical services, can i add this plea? Persistent crying in babies is a significant problem but please don't blame the foreskin. ref: Summerton DJ, McNally J, Denny AJ, Malone PS. Congenital megaprepuce: an emerging condition--how to recognize and treat it. BJU Int. 2000 Sep;86(4):519-22. Competing interests: None declared |
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Carol A Walshaw, GP Oakworth Medical Centre. 3 Lidget Mill. Oakworth. Keighley. BD22 7HN, Jenny M Owens
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Editor. Gatrad and Sheikh discuss persistent crying in babies.1 A careful history should be taken and physical illness excluded. The authors correctly then draw attention to feeding and growth. Since it may be some weeks since the baby has been weighed, (Hall 4 only recommends weighing at this age at times of immunisation or on parental request), a further up-to-date weight is advisable.2 The authors advise taking a detailed feeding history. We suggest that (in breastfed babies) the baby’s feeding pattern should be part of this assessment. We had realised some years ago that many young breastfed babies were gaining weight too slowly; mothers reported that the babies were spending a lot of time crying. This seemed to be associated with dysfunctional “destructive” feeding patterns. The babies had irregular feeding patterns, many having prolonged feeds often from only one breast. Weight gain and the contentment of the babies improved greatly when stable patterns were introduced; the babies feeding from both breasts at each feed, approximately 10 minutes each side, on a 3 hourly routine (with longer gaps at night). We now anticipate that babies’ weights will be above birth centile on the growth chart when they are seen for the routine 8 week Child Health Surveillance examination. Too frequent feeds also seemed not only to slow weight gain but to aggravate colic, making babies more “windy”. We feel that weight gain in breastfeeding babies and the associated feeding patterns should receive more attention. 1 Gatrad A R. Sheikh A. Persistent crying in babies. BMJ 2004 328;330 (7 February) 2 Health for all Children Fourth Edition. Hall D M B. Elliman D. Oxford University Press. ISBN 0-19-851588-X Competing interests: None declared |
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Sebastian Kraemer, Consultant Child and Adolescent Psychiatrist Whittington Hospital, London N19 5NF
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Gatrad and Sheikh give useful brief advice on persistent crying but are too vague about ‘family dynamics’. We know from many studies over the past three decades the powerful effect of the mother’s (and father’s) own early years on her capacities as a parent now (Shonkoff & Philips 2000, Fonagy, 2003). The ‘ghost in the nursery’ (Fraiberg et al 1975) graphically describes the reappearance of long forgotten (or never remembered) emotions around infant care. A useful approach is to ask during the consultation “what kind of baby were you?” and allow a little time for reflection and recall. Dilys Daws’ classic text Through the Night (1989) shows how brief therapeutic work with parents can help their management of familiar but draining baby problems. Some of these can be managed in the surgery but GPs will also need, with health visitors, the support of a network of early years services. Many new parents become depressed with long lasting effects on their children (Murray & Cooper 2003). Early intervention saves a great deal of sorrow and trouble later on (Bakermans-Kranenburg et al 2003, Barnes,2003). Shonkoff J, Philips D. (eds) [Committee on Integrating the Science of Early Childhood Development; National Research Council/ Institute of Medicine] From Neurons to Neighbourhoods: The Science of Early Childhood Development. Washington DC, New Academy Press, 2000. Fonagy, P. The development of psychopathology from infancy to adulthood: the mysterious unfolding of disturbance in time. Infant Mental Health Journal 24:212-239, 2003. Fraiberg S, Adelson E, & Shapiro V. (1975) Ghosts in the nursery: a psychoanalytic approach to the problems of impaired infant- mother relationships. Journal of the American Academy of Child Psychiatry 14: 387-422, reprinted in Fraiberg, S. (ed.) Clinical Studies in Infant Mental Health. London: Tavistock, 1980 Daws, D. Through the Night. London: Free Association Books, 1989. Murray L, Cooper PJ. Intergenerational transmission of affective and cognitive processes associated with depression: Infancy and the preschool years. In Goodyer IM, ed. Unipolar Depression: A Lifespan Perspective. Oxford: Oxford University Press, 17–46, 2003. Bakermans-Kranenburg MJ, van IJzendoorn MH, Juffer F. Less is more: Meta-analyses of sensitivity and attachment interventions in early childhood Psychological Bulletin 2003; 129: 195-215 Barnes J. Interventions addressing infant mental health problems. Children & Society 2003;17:386-395 . Competing interests: None declared |
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Anselme G Derese, Professor of Family Medicine Department of Family Medicine & Primary Health Care Ghent University UZ 1 K3 De Pintelaan 185 B-9000, Sven Deroose, Els Vandedrinck, Myriam Van Winckel
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We would like to comment on the recommendations given in the BMJ 2004;328:330. 7 February 2004 A R Gatrad and Aziz Sheikh. Persistent crying in babies. · Question a breast-feeding mother if she has enough milk might rather worsen the case: whatever the cause of the excessive crying of the baby, it is very likely that the mother will already fear she is not feeding her baby well. Many times she is stuck in a downward spiral of insecurity, stress and decrease of milk production because of that. Observation of a feeding by an experienced counsellor is a better advice than asking the mother whether she has enough milk. If the baby thrives well, which is the case in most crying babies, there is no reason to doubt the availability of enough milk. A careful problem analysis, good health promotion and reassurance of the mother are of utmost importance; something which lies within the job description of the family doctor. · Change feeding (e.g. to whey hydrolysate milk, for which there is some evidence, or to caseïn hydrolysate, which might be even more beneficial) often has a temporary positive effect, though too frequent changes of feedings are not advisable. · The article does not mention the possibility of gastro-oesophagal reflux (GOR): in this case H2-antagonists might be highly beneficiali. Other studies however ii show that certain GOR-babies keep crying, even when their acid reflux is corrected. Further research that helps to differentiate between babies who would benefit from acid secretion blockers and others who don’t would be very helpful. Apart from this most crying seems to fade away over time … Anselm Derese, Els Vandedrinck, Sven Deroose, Myriam Van Winckel References ihttp://www.aap.org/policy/gerd.html iiDouble-blind placebo-controlled trial of omeprazole in irritable infants with gastroesophageal reflux. J Pediatr. 2003 Aug;143(2):219-23. Competing interests: None declared |
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Kristi L. Koenig, National Director, EMSHG U.S. Department of Veterans Affairs
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Editor – I appreciate the practical advice contained in the BMJ’s “10 -minute consultation” series on common problems in primary care. As an emergency physician who has evaluated babies with persistent crying, I would like to add another important condition to the checklist provided by Gatrad et. al. in their article in the February 7, 2004 edition of the Journal. Infants may be unable to direct health care providers to the source of their discomfort, so if no other cause (e.g. a hair inadvertently wrapped around the genitals) can be found, I recommend performing a Wood’s lamp examination to assess for the presence of a corneal abrasion. Diagnosing a corneal abrasion can provide reassurance to concerned parents. Minor corneal abrasions can be extremely painful, but will generally heal completely in 24 to 48 hours. Parents should be advised to clip fingernails short to help avoid recurrence. Kristi L. Koenig, MD, FACEP National Director, Emergency Management Strategic Healthcare Group, Veterans Health Administration, Department of Veterans Affairs Clinical Professor of Emergency Medicine, George Washington School of Medicine and Health Sciences, Washington, DC Competing interests: None declared |
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Girish Gupta, neonatologist AFMC,Pune, India 411040, Vishal Sondhi
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ELECTRONIC LETTER to: Persistent crying in babies A R Gatrad, Aziz Sheikh Respect: Hair tourniquet and Urinary tract infection
Dear editor, We read with interest the article “Persistent crying in babies” by Gatrad and Sheikh [1]. The practical advice offered in the above mentioned article is extremely appreciable. As paediatricians who frequently get to evaluate such stressed out babies, we have a few observations: 1. Hair tourniquet syndrome involves hair getting wrapped up around digits (occasionally genitals and uvula) and presenting with swollen and red digits [2,3,4]. It is not exactly uncommon and needs to be ruled out in an afebrile young infant presenting with persistent crying. All it takes is a thorough examination of digits, ensuring to take off socks and having a look at the toes. 2. Urinary tract infection (UTI) in infants has to be respected and it has to be remembered that incidence of UTI is equal in both sexes below the age of 3 months and it can present with non-specific signs and symptoms in this age group. So, if we are not specifically looking for it, we are going to miss it more often than not. We solicit the opinion of authors on remarks. References: 1. Gatrad AR, Sheikh A: Persistent crying in babies BMJ 2004 Feb; 328:330 2. Corazza M, Carla E, Altieri E, Virgili A. What syndrome is this? Tourniquet syndrome: Pediatr Dermatol. 2002 Nov-Dec; 19(6): 555-6. 3. Krishna S, Paul RI. Hair tourniquet of the uvula: J Emerg Med. 2003 Apr; 24(3): 325-6. 4. Strahlman RS: Toe tourniquet syndrome in association with maternal hair loss. Pediatrics. 2003 Mar; 111(3): 685-7. Competing interests: None declared |
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Tracy Hayden, Breastfeeding mum cm3 5zs
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I would ask how often is the baby held. I do believe there is a study taking place currently to investigate if the amount of time held has an effect on crying time. In cultures where babies commonly are "worn" in slings they rarely cry. All their needs are met. At the moment it's popular to force babies into unrealistic routines, to not "spoil" them and carry them around in car seats all day. No wonder babies cry, they need to be held. I'd also look at the caffeine intake and maybe look at if dairy consumption of the mum upsets the baby too. I would also think the baby would be picking up on stress from his Mum. I personally and anecdotally from others have found cranial osteopathy great for crying babies. Competing interests: breastfeeding attached mum |
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