Crying Infants

Authors: Charlotte Davies (and baby) / Editor: Liz Herrieven / Codes: NeoC5, SLO5 / Published: 24/01/2023

Crying babies are frequently brought to the emergency department because the child cries so much that the parents believe there must be something physically wrong. It’s not officially covered in any part of the EM syllabus and, in some departments because these children are invariably less than one year old (so RCEM says need a senior review), they will get seen by paeds, but it’s worth having a few strategies up your sleeves. The history is very important and, whilst we’re waiting for AI to be developed to help with translation of the cries, having some idea of potential causes is useful.

Taking a history is very difficult if you are trying to talk at the same time as having a screaming child in your ear, and the parents will be distracted by their emotional connection and desire to stop the screaming. The parents have probably already tried the traditional methods of resolving the crying problem – here’s some details on them (especially for those of you without personal experience), and some suggestions.

It’s worth saying that unwell children also cry. Their cry is different to a “normal” cry and they will often look poorly – they’re unlikely to be moving their limbs with the same super strength of a “well” crying child, and their cry may lack volume. If you suspect the child might be crying because they’re really unwell, get senior help, as assessing them and identifying the cause might be difficult.

The Baby Whisperer talks about how to interpret your baby’s cries, and suggests listening to the pattern and observing what is happening. Most parents consider this is aspirational, especially at the stage where they are considering attending ED!

For the likely well child, consider:

1. Is the child hungry?

It’s difficult to know, particularly with breastfed babies, whether the child is actually hungry or not. Breastfed babies will often comfort-feed making it really hard to know whether they want a snuggle (and are getting minimal milk) or whether they are actually hungry. In all babies, the signs they make when they’re hungry are similar to the signs that they show when they’re tired so interpreting this is really, really, really hard. The cry is apparently a coughlike sound, then a short cry followed by a steady waa, waa (from The Baby Whisperer). The old adage is if in doubt feed the child and this is certainly something that is worth trying – get the parent to feed the child, watch, and if that doesn’t resolve the crying, it must be caused by something else. Sometimes parents have been so focussed on stopping the crying, they haven’t realised time has flown and it is now time for a feed. Whether the baby is breast or bottle fed, making sure feeding involves lots of skin-to-skin contact may also reduce duration of crying.

Many parents of breastfed babies worry that they’re not making enough milk for their baby – this is really unusual, but if you’re not sure, a trial of formula to see if it settles the baby won’t cause any harm – there’s some thoughts that using a bottle (or dummy) before breastfeeding is successfully established – normally at around 6 weeks – might cause “nipple confusion” but this too can be resolved. A baby who settles on feeding but cries very shortly after may suffer from reflux, with the milk settling the burning pain. A baby who was settled but is now crying, particularly in the evening, may be receiving less milk with the onset of maternal menstruation and may need feeding more often. Your history will help.

Successful breastfeeding relies on a “good latch”. I’d always suggest asking your hospital’s infant feeding team (available via the maternity ward) to help as this is more complicated than “it looks right”. Parents can also contact lactation experts and breastfeeding peer support groups for more advice. If you as a doctor are also about to breastfeed your own little squidge, there is a very active peer support group on Facebook. Even if you’re not a breastfeeding expert, it’s worth asking how it’s going, whether it’s painful, if there are any signs of nipple trauma, how often baby feeds for, and if the breast feels empty after feeding. If there’s pain or nipple injuries, make sure you advise contact with the health visitor for help. There’s more breastfeeding troubleshooting on DFTB. It’s worth mentioning there’s (unsurprisingly) a lot of dogma around breastfeeding – breast milk has on average the same number of calories as formula, and the foremilk and hindmilk differentiation is questioned making the need to feed for a set time on each breast controversial.

If you do observe a feed, make sure you provide the feeder with a large glass of water – lactation is thirsty (and hungry) work.

For formula feeds, the NHS choices website has lots of good information. It’s good to ask what size teat the baby is using, as if the hole is too big, the baby may gulp lots of air causing discomfort, and if the hole is too small, the milk may be too slow. Teat sizes start with size one – small holes. All babies should be on stage one formula (chapter 27 positive breastfeeding book), which meets nutritional requirements for the baby, and is regulated by law. Follow-on formula was created for marketing purposes. Some babies do need to use different baby formulas, some prescribed for conditions such as cow’s milk protein intolerance and others marketed with hungry, constipated or refluxing babies in mind, but that is beyond the scope of this article. Worried, tired parents may have swapped formula brands and types a few times already, in an attempt to find a magical cure for crying, but often letting a baby get used to a particular type of formula is best.

Whether breast or bottle fed, there’s a lot of pressure on parents when it comes to feeding, including any guilt or worry they’ve inflicted on themselves about their choices. Try not to be judgemental and don’t recommend one over the other – the best method of feeding is the one that suits their family.

2. Is the child cold or hot?

General advice is that the child should always have what you’re wearing plus one layer. To check their temperature parents are advised to feel the back of the infant’s neck – but if they’ve been screaming this may be falsely warm, and if they’ve just had a posset this may be falsely cold because it’s wet. Trial and error – snuggle the baby up to you and see if it helps. Make sure they’re out of any draughts, out of bright sunlight (or strip-lights) and see what happens.

If the history describes the baby crying in their cot, it might be that a wet nappy or a posset has made the sheet wet and therefore cold. Plenty of spare sheets are needed, and you might find a muslin (carefully tucked in) under the baby’s head prevents having to change the entire sheet.

Some parents swear by warming up bedding before putting the child on it – a hot water bottle or sitting on it themselves (so it also smells of them).

3. Winding

Routine winding is unlikely to be helpful. If the baby is writhing and screaming then suddenly stops, trapped top or bottom wind is probably the culprit, especially if the cry is shrill and high pitched with breath holding (The Baby Whisperer). Vigorous winding is unlikely to be necessary and NHS choices has good suggestions on technique.

Another favourite position is “tiger in a tree” – whether this stops crying because of the pressure/reassurance on the chest or because of the winding approach, who knows. But it might work – and works better if you’re standing up and wiggling slightly.

Amazon sells mini flatus tubes for babies. Using these doesn’t appear to be UK practice, and I wouldn’t advocate it at all but they seem commonplace in other European countries, and are reported to have really good results at passing flatus and relieving distress. Find a colleague from a different country and ask them what they think, and put the results in the comments.

4. Nappy Change

Even if parents have just checked the nappy, babies are sneaky, and might wee/poo without you noticing! Most nappies have a colour change strip – it starts yellow and turns blue after contact with urine. But be careful – if the bit of the strip you look at isn’t blue, another bit of the strip might be! And poo doesn’t turn the strip blue. A nappy change is also a start to checking nothing is trapped tightly in a nappy causing pain. If the nappy needs changing a lot overnight, moving to the next size up can be useful.

5. Hold the baby

This one may or may not help. Sometimes, stressed out parents really appreciate someone else taking the baby for a while. Anxiety is catching and babies are great at picking up on how their parents are feeling. Removing baby from that angst, and the smell of milk if breastfed, can help. Holding the baby also gives you a chance to assess tone and responsiveness. However, it can be demoralising for an already anxious parent to see someone else settle their baby when they couldn’t. Ask whether they’d like you to hold the baby or whether they’d rather continue themselves. If they’d rather keep hold, reassure them, support them and don’t let them see you get frustrated with the noise.

6.  Walk with the Baby

A very small study (it wouldn’t pass critical appraisal) has suggested walking with a baby, and then sitting with them will help settle them quickly. Chances are the parents will be delighted if you want to take their screaming baby of fury, and walk with them whilst their ears rest. Be a human swaddle and make the baby feel secure and snug. Experiment with different walking positions – eg. cradled in your arm, vertical against your chest and see what works.

7. White Noise

This works like witchcraft. Download an app on your phone and hit go! There’s some discussion that the loud noise can be bad for baby’s hearing – start loud enough to calm the baby down, and then turn the volume down. It seems to work better than swinging and movement.

And once they’ve settled (or your ears have grown accustomed to the noise)…

You may think paracetamol a good idea – it’s not recommended for less than 3 months old (apart from for imms). Sugar free versions may make babies windy.

History

It feels to the parents like the crying never stops. You need to drill down into this a bit further in your history – is it really every minute of the day, or are there brief periods of respite? Has the infant always been crying or is it a new thing? Does the child sleep? What makes the crying better and what have they tried? What makes the crying worse? What does the infant do when they’re crying – e.g. leg cycling or rooting. What do they think has caused the crying, and what are they worried about? Any preceding symptoms or trauma (be sensitive – crying flailing children are remarkably strong, and parents might feel the baby lurched away from them resulting in a rough catch).

How is the baby otherwise? Have they noticed lumps and bumps anywhere? Are they meeting milestones? Are they growing?

What is the home environment like? Family dynamics may have an effect on the baby.

How are the parents doing? Spend a lot of time on this – how does the crying make them feel? Who is supporting them? What’s their crying crisis plan? Ask if they’ve felt frustrated with the crying and found themselves vigorously shaking. It’s all well and good telling parents they’re OK to put the baby down and let the baby cry, but talking through how and when to do this can help. Do they know about cry-sis? or ICON? If co-sleeping is in their crisis plan (or their everyday plan), have they read the Lullaby Trust safe sleep guidance?

It’s also worth asking about antenatal care, and maternal drug use during pregnancy, as drug withdrawal can cause a high pitched cry in a baby- but hopefully this will have been picked up already.

Examination

A thorough top to tail examination is obviously needed in case there is a physical cause. If the child is still crying, observations (except maybe a temperature) are unhelpful! The IT CRIES mnemonic can be a useful guide:

• I = Infections (e.g. UTI, Meningitis, Sepsis)
• T = Trauma (e.g. Subdural Haematoma, Fractures, Non-accidental trauma)
• C = Cardiac Disease (e.g. SVT)
• R = Reaction to meds, Reflux, Rectal/Anal Fissure
• I = Intussusception
• E = Eyes (e.g. corneal abrasion, foreign body, glaucoma)
• S = Strangulation, Surgical Processes (e.g. Hernia, Testicular/Ovarian Torsion)

Make sure you examine:

• Skin for any wounds and injuries or rashes – the itch from eczema might cause a lot of discomfort.
• Abdomen (between the screams)
• Hernial orifices, external genitalia for hair tourniquets, phimosis and anal fissures.
• Eyes – consider staining with fluorescein although even if a corneal abrasion is present it may not be causing the crying.
• Ears – look for any evidence of otitis media.
• Mouth – look for oral thrush
• Fingers and toes – look for hair tourniquets
• Weight and head circumference – and plot against a growth chart in the patient’s red book (PHCR)

• A urine sample may be helpful but infection without specific signs is unusual.
• As a parent, I’d be reassured by a blood sugar to confirm that I’m feeding the baby enough, but again, if a baby was hypoglycaemic you’d expect other signs than just crying so this is not evidence based.

Treatment

Unusually for paediatrics, Calpol or Difflam are unlikely to be the answer.

• Assess for feeding difficulty
• Assess and treat perinatal anxiety and depression
• Encourage “cue-based” care rather than rigid routines.
• Encourage physical contact even in moderate amounts.
• Signpost strongly to the purple crying material

Definitions aren’t helpful – the baby is crying excessively in the eyes of the carers otherwise they wouldn’t be attending ED. The official definition of excessive crying is more than three hours a day for more than three days for more than three weeks, which is a very long time. Medicat

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ion options like Infacol are unlikely to be helpful. Listening and exploring the options are likely to be very useful. Tell the parents they’re doing a great job – but they’ll only believe you if you’ve extracted enough information from them to know they’re doing a great job. There’s lots of suggestions on this twitter thread here. 

 

Older Infants

As children get older, they’re more likely to use their words to communicate problems, but if they can’t, a similar approach to the above will be needed, probably with extra consideration to constipation. The history will be very important, together with as much of a HEADSSS assessment as you can get from the patient, and as many relatives as possible.

Teething can occur at any age, but most start at around six months. Symptoms tend to last for eight days. The signs include dribbling more than normal (what’s normal!?), chewing and gnawing on things a lot (but they also explore with their mouths so what’s normal), a mild temperature (according to the NHS website, but a literature review is less conclusive) and a flushed cheek. As you can imagine, this might make the baby a bit more uncomfortable and cry a bit more.

A quick twitter poll suggested the symptoms come and go throughout the day, and the offending tooth normally appears in a few weeks.

To treat use:

• Cold things like teething rings in the fridge, refrigerated damp cloths. Frozen things aren’t recommended as they can freeze and damage the gums.
• Chewy things like gummy gloves, and other things.
• Gel analgesia like aloe vera (I couldn’t find any evidence it worked, but it did provide me with relief), lidocaine (age dependent) based. I’m not sure why babies <2 months can’t use most of these gels but I suspect it is an age / dose related thing. There’s no evidence any gels work, and some evidence they can cause harm so make sure even homoeopathic remedies are licenced.
• Teething powders like Ashtons and Parsons are again not licensed but may be helpful.
• Analgesia like calpol and ibuprofen are useful if the baby is old enough.
• Plenty of distraction. 

Learning Disabilities

Patients with LD may also suddenly cry more than normal, or not be themselves. Again, similar principles apply – have a look at our LD blog to remind yourself of what “TEACH” means. Learning Disabilities in the ED – RCEMLearning.

Hopefully this is a useful reminder of some of the strategies that can help reduce crying in babies. Add your suggestions in the comments.

• Fox SM. Inconsolable Infant. Pediatric EM Morsels, 2015.
• Nickson C. Baby Tim Cries. Life in the Fast Lane, 2020.
• Platt B. Why is my baby crying?, Don’t Forget the Bubbles, 2022.
• Selway J. Inconsolable Crying. RCEMLearning, 2021.
• Abela N, McCreary D, et al. RCEM Belfast Day 2, 2015.
• Peds EM Curriculum. Clerkship Directors in Emergency Medicine (CDEM).