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Abstract
There is much written in the medical and lay literature about managing babies who cry too much. Healthcare professional often feel bewildered about how to go about trying to help a baby and their carer, usually the mother. They often undertake investigations, prescribe medication or alter the baby's diet. The assumption made by this approach is that the crying reflects pain or discomfort. In a normal infant who is growing well, it is rare to be able to identify any quickly treatable medical underlying disorder.1 Those who are inexperienced may find the idea of a behavioural approach very challenging but perhaps this would be a better alternative.
- Paediatric Practice
- Comm Child Health
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Why do babies cry?
Mammals and birds all use vocal signals to promote attention and proximity between adult and offspring. In humans, a newborn's cry promotes the secretion of oxytocin in the mother and this in turn promotes responsiveness.2 Crying, then, mediates nurturing and safety which in turn facilitate attachment. As a rule, babies normally cry for less than 3 h a day up to the age of 3 months when other signals such as smiling operate to continue attachment development.
Why do babies cry too much?
By the time a baby is brought to the attention of secondary care, parents will have tried a variety of remedies and will have been given much advice, often conflicting. Crying may be reported for up to12 h a day and a problem from birth. This is what the parents perceive and so this is what is important. The term ‘colic’ implies that there is something wrong with only the infant, whereas the term ‘troublesome crying’ suggests a problem of the dyad of mother and baby. Colic is the commonest ascribed diagnosis, and ‘wind’, the reason for the discomfort. Babies during long bouts of crying certainly can be observed swallowing air, and it seems more plausible that wind is a result, rather than a cause, of the crying.
Many other reasons have been proposed. These are presumably temporary as excessive crying eventually settles over the first year. Gastro-oesophageal reflux, lactose intolerance and cow's milk allergy have often been blamed but these are very unlikely.1 Crying is the commonest trigger for physical abuse of an infant.3 All infants must be examined bearing this in mind. It is also a reason for stopping breast feeding early as the mother believes that the infant's crying reflects hunger that she has been unable to satisfy.4
In truth, the reason for excessive infant crying is poorly explained. A common observation is that if babies are admitted to hospital excessive crying improves very quickly, within days.5 Unfortunately, this intervention cannot be examined by a randomised clinical trial as too few parents would consent to randomisation of hospital versus home care. However, the observation suggests that the problem is behavioural rather than medical. What is it then that happens during a hospital admission and can this be replicated at home?
What to do?
Baseline history
The essence of good history taking for any problem of behaviour is to hear how it affects the parents and family as well as the child. A feeding history will often indicate difficulties, many feeds in the day being offered to try to pacify the infant, difficulty in suckling with head thrusting and back arching in response to a feed being offered. In spite of this, infants usually thrive. A birth, family and social history should focus on the parents’ circumstances, who is available for support, the health of the mother before, during and following pregnancy, living conditions, the name of the health visitor and so on. Troublesome crying appears to be more frequent in infants of depressed mothers and those living in adverse social conditions.6
Assess distress
Asking parents to read through a questionnaire (table 1) introduced as ‘some things other parents have reported’ may help the parents to see that they are not alone and taking time with this can help them feel heard. Among other things, the questionnaire acknowledges the frustration all parents feel about troublesome crying. The average score for answers is 7 out of 10, compared to 3 in controls.5 Responses need not be discussed in detail.
Distress questionnaire
Ask about parents’ interventions
Asking the parent(s) what they do when the crying becomes intolerable is revealing. Prompting may be necessary. Offering a feed or dummy, lifting, patting, winding, jigging, walking about, distracting with toys and passing the baby around are commonly reported. Parents work hard to try to soothe their baby and this should be acknowledged. Nearly, all will have tried proprietary medication. It is at this point that it may be worth observing to the parent(s) that babies with excessive crying who are admitted to hospital seem to improve quite quickly—perhaps a hospital environment is calmer for the infant and thus reduces arousal. This will inform the subsequent advice.
Advice to reduce overstimulation
Asking a parent to leave their baby alone to ‘cry it out’ is asking them to ignore a basic instinct. There is no evidence that this strategy works in babies where crying is reported excessive.7 Advice like this is likely to alienate a parent. Taking time to explain how to find a quiet environment, swaddle the baby in light clothing, hold the baby close until the crying stops and giving up all the other stimulating measures, such as jigging and winding, seem to help many babies.5 It has recently been shown that rocking a crying baby, an age-old intervention, is soothing and reduces the baby's heart rate (for an example, see this paper's excellent video online).8 Demonstrating these interventions provides emphasis, particularly if the baby is crying during the interview. Trying to feed a baby in a state of high arousal is counterproductive. Demonstrating to parents how to seek eye-to-eye contact with their baby when they are both relaxed encourages an important developmental step. The emphasis should be about being gentle. The parent(s) should be reassured that they will not be left to carry this out unsupported and a time for a follow-up telephone call should be agreed.
Investigations and medication in a normal infant who is growing normally are not necessary. Feeding difficulties nearly always resolve when the crying improves.
Although the family's health visitor and GP should be appraised of the advice given, involvement of other healthcare professionals at this stage is unnecessary and risks conflicting advice and confusion.
Follow-up
This is crucial for all parents and should be done by the person who has advocated the ‘be gentle’ intervention. A relationship has been made with the parent(s) and the health professional involved must see the problem through. Telephone follow-up should be undertaken within 48 h and at 1 week or sooner. If at this point the mother is very distressed and ‘just can't do it’, then a hospital admission can be offered. This is particularly important for isolated parents and should allow them to catch up on sleep. They should be told that the baby will not be ignored. A supportive environment, help with feeding and structuring of the day can be very rewarding, providing staff are ‘on board’. Admitting a baby ‘just for crying’ may seem an anathema to some healthcare professionals but can be life-changing for distressed parents if done with sensitivity. During an admission, which need only last until the crying has resolved, an informal judgement of maternal health and home conditions can be made. The baby's health visitor should be informed of the strategy and included in the discharge plan. She with the general practitioner should be able to address any maternal health problems, such as postnatal depression. A telephone call the day following discharge is reassuring and can be repeated as necessary.
Summary
Troublesome crying in infancy is extremely distressing for parents. Acknowledging this is part of the management. Investigations and medication are not necessary in a healthy baby. Advice to reduce stimulation and thus arousal is helpful. Continued support at home is important but if this is unsuccessful, a short hospital admission can be life-changing.
Learning points
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Excessive crying is whatever the parent(s) find troublesome.
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It can be helped.
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It is the commonest trigger for physical abuse.
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It is the commonest reason for early stopping of breast feeding.
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Advice to reduce overstimulation helps.
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Parents must be supported until they feel they can cope.
Footnotes
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Competing interests None.
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Provenance and peer review Commissioned; internally peer reviewed.