CRYING CHILD

DR.B.P. JAISWAL
M.B.B.S (PAT.), DCH, M.D (PED.) PAT, FIAP
ASSOCIATE PROFESSOR
DEPT. OF PEDIATRICS
NMCH, PATNA
PRESIDENT, IAP , BIHAR (14,15)
PRESIDENT, NNF, BIHAR
BABIES CRY…BECAUSE THEY CAN’T TALK!
 INTRODUCTION

• Crying is a normal physiological response to many stimuli in non

verbal children.

• Healthy children cry for about 3 hours per day on an average at 6

weeks of age with the peak occurrence between 3 pm and 11 pm.

• It is high in infants below 3 months of age and decreases considerably

beyond 6 months of age.
• Often the increase in crying coincides with dismissal from the neonatal
ward and can cause anxiety and loss of confidence in parents.

• Consequences of incessant crying may range from economical burden

to long term disturbances in parent child relationships and child
maltreatment problems like shaken baby syndromes resulting in brain
damage.

• A few studies have reported early weaning in these babies because of

mother’s perception of incessant crying as hunger cries or due to
inadequate milk.
• Reported incidence of serious underlying organic cause is around
5-10 % .

• An inconsolably cry without any obvious cause such as hunger , thirst,

loneliness, wet diaper, loud noise requires detailed search for a
medical cause even if it does not fulfill time criteria.
 HOW MUCH CRYING IS NORMAL?
WESSEL’S RULE OF THREE

• It states that crying in an otherwise healthy baby aged 2 weeks to 4

months that occurs more than 3 hours per day, more than 3 days a
week for at least 3 weeks may be called excessive.

• Either an e-diary or a paper diary is useful in objectively measuring

both duration of crying and behavior of caregivers.
 EVALUATION
FOLLOWING ARE THE POINTERS FOR UNDERLYING ORGANIC CAUSES-

• High pitched/ abnormal sounding cry.

• Lack of a diurnal rhythm.
• Presence of frequent regurgitation, vomiting, diarrhea, blood in
stools, weight loss, failure to thrive.
• Positive family history of migraine, asthma, atopy, eczema.
• Maternal drug ingestion
• Positive physical examination (including eyes, palpation of large
bones and neurologic, gastrointestinal and cardiovascular
assessment).
• Persistence of crying past 4 months of age.
ETIOLOGY
 INFANTILE COLIC AND BEHAVIOURAL CRIES

 Defined in infants from birth to 4 months of age as -

• Paroxysm of irritability, fussing, or crying that start and stop without
obvious cause.
• Episodes lasting 3 or more hours per day and occurring at least 3 days
per week for at least 1 week.
• Absence of failure to thrive.

 Colic is a diagnosis of exclusion made after performing a careful

history and physical examination to rule out less common organic
causes.
 CAUSES OF COLIC-

• Carbohydrate malabsorption
• Lactose in the diet, CMPA
• Increased gas in the infants with colic??
• Behavioral factors such as feeding abnormalities, infant positioning
while
• Feeding
• Psychological factors like parental skills , anxiety and stress.
 GASTROINTESTINAL CAUSES

• Constipation with or with out anal fissure

• Gastro esophageal reflux disease
• Intussusception
• Intestinal obstruction.

 Intussusception needs a high index of suspicion as a combination of

mass in the abdomen, rectal bleeding and vomiting.
 NEUROLOGICAL

• Neonatal drug withdrawal

• Increase intra cranial pressure
hydrocephalus
mass
intra cranial hemorrhage
cerebral edema
• Meningitis / encephalitis.
 GENITOURINARY SYSTEM

• UTI is commonest accounting for 25% of all serious etiologies.

• Other causes include-
• Torsion of testis
• Urinary retention
• Obstructed inguinal and femoral hernia.

 Thorough clinical examination of genitals and USG is necessary to

confirm the diagnosis.
 MUSCULOSKELETAL SYSTEM

• Non accidental trauma with fractures especially to ribs, skull bones

and long bones.
• Septic arthritis
• Osteomyelitis
• Tourniquet entrapment of digits.

 One should gently palpate the whole body and look for restriction
of movements, skin bruises and muscle hematoma
 EYES

• Corneal abrasion
• Ocular foreign body
• Retinal hemorrhage
• Retinal detachment
• Glaucoma

 Examination of eyes is not given due importance during physical

examination by physicians .
Presence of retinal hemorrhage and detachment indicate child abuse.
 OTHER CAUSES

• Acute otitis media

• Foreign body in airway
• Supra ventricular tachycardia
• Burns
• Diaper rash
• DTP immunization
• Insect bites
• Pseudo tumor cerebri
• Electrolyte and acid base imbalance
ACUTE CRYING-ROLE OF A PHYSICIAN

1. To avoid missing a serious or life threatening etiology and

2. To determine the common/treatable diagnoses.

 In their study of 200 crying infants who presented to the ED, Fahimi et
al found that 3 most common diagnoses were colic (29.5%), acute
otitis media (15.5%) and constipation (5.5%).
 DIAGNOSTIC APPROACH
HISTORY
• Duration
• Frequency
• Periodicity
• Aggravating factors
• Comorbid medical conditions
• Sibling and family history
• Recent vaccination
• Feeding and sleep behavior
• Mother infant relationship
 PHYSICAL EXAMINATION

• Vitals should be recorded first

• Head to toe examination include-

• HEAD- anterior fontanel (boggy/depressed)

prominent veins over scalp
suture separation
• EYES- eversion of eye lids for ocular foreign body
• EARS- otoscopy (AOM), foreign body
• NOSE- sinusitis, foreign body
• MOUTH- apthous ulcers, oral candidiasis
• THROAT-vesicles (herpangina)
pooling of secretions (parapharangeal abscess)
• HERNIAL ORIFICES AND GENITALS
Commonly missed findings during physical examination-
• Anal fissures
• Bulging tympanic membrane
• Ocular foreign body
• Incarcerated hernia
• Hair tourniquet
• Open diaper pin injury
• Teething- tender swollen gums
 LABORATORY INVESTIGATIONS

• The role of investigations in identifying the cause of crying in infants

is limited.

• It help in only 3-5% cases where history and physical examination

findings are inconclusive.
 TREATMENT
INFORMING AND COUNSELLING PARENTS

• Recognition, support and reassurance of parents

• Information about normal crying pattern, co- and self regulation and
about prevention of shaken baby syndrome/ abusive head trauma
• Referral to family doctor or pediatrician to rule out medical problems
• Discourage change of feeds(from breast to formula or from formula to
another), breast feeding should not be stopped
• The relationship between parents, child and health care worker is of
great importance
 APPLYING REGULARITY AND UNIFORMITY IN DAILY CARE

Comprises a consistent pattern of-

• sleeping
• feeding right after waking
• positive interaction/cuddling
• playing with a parent, playing on their own
• and being put to bed awake as soon as signs of weariness appear (e.g
yawning, rubbing of eyes, over active behavior)
 VIDEO HOME TRAINING

• VHT is intended for parents with parenting stress

• Effective for improving the interaction between depressed mothers
and their babies.
 BABY MASSAGE

• A Cochrane review showed that baby massage may have a beneficial

effect on infant less than 6 months of age.

• There is some evidence of benefits on mother infant interaction,

sleeping and crying.
 FOR INFANTILE COLIC

• Treatment strategies include drugs, dietary modifications and

behavioral interventions.

• Dicyclomine has been shown to effectively reduce infant crying in 2

randomized control trials.

• Simethicone is relatively safe but has no proven affects on infant

crying when compared with placebo in RCT.
• There is no indication for proton pump inhibitors in crying babies in
the first month of life and a credible concern that PPIs predispose to
food allergies.

• Herbal remedies ( tea containing chamomile, vervain, licorice, fennel

etc) Showed some reduction in crying.
 PREVENTION FOR HIGH RISK GROUPS

• Pregnant women with anxiety and/or little support.

• Parents with depression or other psychiatric problems
• Teenage parents
• Parents with addiction
• Parental unemployment ; financial problems
• Premature and/or small for gestational age children
• Children with an especially high penetrating and loud cry.

 Information on crying, early support and referral to more specialized centers

may prevent serious problems including child abuse.
 SUPPORTIVE CARE

 REST FOR INFANTS

• R- REGULATION (prevent over stimulation & over tiredness, watch for early
warning signs)
• E- ENTRAINMENT ( eg. synchronizing infant behavior with environmental
stimuli such as light or noise)
• S- STRUCTURE ( structured routines include bathing and playtime , as well
as consistent sleeping & feeding times).
• T- TOUCH ( eg. Soothing techniques such as holding or rocking)
 REST FOR PARENTS

• R- REASSURRANCE

• E- EMPATHY

• S- SUPPORT from health care provider

• T- TIME OUT for the parents (eg. Rest & renewal).

 CARRY HOME MESSAGE

• History and clinical examination are the most important tools

• Colic and unexplained crying are the most common than underlying
serious pathologies.
• Ordering unnecessary tests add stress to family and cost burden!
• Sick child, poor growth deserve investigations
• Don’t forget possibility of abuse
• Support, reassurance needed in many.
GOOD NIGHT AND HAVE SWEET DREAMS!
THANK YOU ALL FOR MAKING ME SMILE!