What Should I Do? I Just Can't Get Him to Stop Crying?

A 2 month old male came to clinic for his health maintenance examination. His parents state that he is a very fussy baby. He cries at all different times of the day that does not consistently respond to feeding, rocking, bundling, swinging, massaging, being left alone, baths or riding in a car or stroller.
Most days, he cries during the day and evening . Generally, from midnight to 5-6 am he sleeps well except to feed. He sleeps well at other times once he is asleep, but he can be hard to settle to sleep. The episodes can last from 5 minutes to > 1 hour in length. He is breastfeeding exclusively and has a small amount of effortless spitting up after feeds.
He has normal bowel movements and urination. He is currently smiling and making cooing noises.
The past medical history reveals an episode of premature contractions at 23 weeks gestation. He was full-term with an otherwise unremarkable prenatal and natal history. The crying spells began on the first day of life.
The review of systems is negative.
The pertinent physical exam shows the child to be 50% for weight, 25% for height and head circumference. His examination is unremarkable.
The clinical diagnosis of colic was made and the parents were reassured that over time that his crying would improve. In addition to discussing the usual natural history of colic, they were offered other ideas for calming the child such as using a white noise or motion generator.
They were also counseled about the normal feelings of frustration, anger and resentment that many parents feel towards a child who is difficult to console.
They were told to take regular breaks from the baby, and to just put the child down in a safe place and walk away if they felt they might hurt the baby. They were told to call the clinic if they had any concerns.
Over the next few months, the patient’s clinical course showed a consolidation in his crying with fewer but more intense episodes. These episodes sometimes occurred when he was tired and generally were in the afternoon and evening. The crying would last 20-60 minutes. Often he could be calmed by being placed upright against his parents chest with them swinging their upper body forcefully back and forth in a rhythmic motion while walking/marching and singing certain songs.
These episodes decreased dramatically by 12 months of age. At 3 years of age, this child wants to be consoled in a similar manner when he is crying from a temper tantrum or other emotional event by having his parents walk with him upright in their arms. He is otherwise developmentally normal and said to be very well-mannered by his daycare providers.

Discussion
Colic is often defined by Wessel’s rule of threes: crying 3 or more hours/per day, 3 or more days per week, for 3 weeks or more. Colic is a diagnosis of exclusion based upon through history and physical examination in a healthy growing child being fed properly. It usually starts at 41-42 weeks gestation, stops around 3-4 months and has no predictable long-term outcomes such as behavioral, tempermental or psychological problems. There are generally two patterns:

  • A hyperirritable baby who cries at all times of the day in response to unidentifiable or ambiguous stimuli
  • A paroxysmal fussy baby who has a crying period in the early evening. The child is easily consoled at other times of the day.

The crying is often associated with motor behaviors and facial expressions such as legs over the abdomen, clenched fists, or pain facies. There may also be gastrointestinal symptoms such as distention, gas or regurgitation. The inability to soothe is also characteristic and the episodes appear to stop and start without reason.

Normal amounts of crying changes with the infant’s age, averaging: 2 weeks old = 1 hour and 45 minutes, 6 weeks old = 2 hours and 45 minutes, and at 12 weeks of age = less than 1 hour.
There are many theories of colic’s etiology but none have been proven conclusively. These include gastrointestinal problems (i.e. cow’s milk intolerance, lactose intolerance, abnormal feeding practices, immature gastointestinal tract), hormones causing enterospasm (i.e. serotonin, motilin, progesterone), temperment and parent handling.

Important history questions to ask:

  • When does the crying occur?
  • How long does it last?
  • What do you do when your baby cries?
  • What does the cry sound like?
  • What and how do you feed your baby?
  • How does it make you feel when your baby cries?
  • How is it affecting your family?
  • What do you think is causing the crying?

The physical examination needs to rule out medical problems that can cause pain or discomfort and also helps to reassure the family that the baby is healthy. This is especially important in a hyperirritable baby.

  • Head – hydrocephalous, hemorrhage
  • Eyes – corneal abrasion, glaucoma
  • Ears – otitis media
  • Mouth – oral herpes
  • Abdomen – diarrhea, constipation, gastroesophgel reflux, anal fissures
  • Cardiac – supraventricular tachycardia
  • Genitourinary – posterior urethral valves, hernia, urinary tract infection
  • Skeletal – fracture, tourniquet on toe/finger
  • Miscellaneous – drug withdrawal such as narcotics, genetic syndromes

Learning Point
As the etiology of colic is usually not clear several suggestions are given to parents for treatment of colic. No treatment works for all infants and each suggestion works for about 30% of infants.
Additionally, one of the most important treatments is parental support. This includes informing the family what is known about colic’s etiology and time course, and empathizing with parental feelings.
Many parents feel guilty that they have done or not done something to cause colic.
Many parents will not say that their child causes them to feel angry or resentful. Acknowledging to the parents that these feelings are normal and that all parents have these feelings at some time about their colicky infant can be helpful.
As well as acknowledging that the parents are not bad people for having those feelings. It is also helpful to discuss what they can do when they have feelings of resentment or anger towards the child such as telling them to place the child in a safe place and walk away for a short time.
Even if the parents does not feel angry or resentful, taking short breaks can help the parents overall coping with the situation.
If a parent states that he/she feels that they will harm the child and cannot cope with the situation, then this information needs to be taken seriously and hospitalization may be necessary to provide respite, and social/psychological support. Close follow-up with the family also allows further discussion
and reassurance and support to the family.

Possible treatment options include:

  • Medications
    • Antispasmotics should NOT be used as they could cause respiratory arrest
    • Herbs – mint, fennel, verbena or licorice (often given as tea)
    • Simethicone is probably harmless but itsefficacy is not proven
  • Altering the sensory environment

    • Audiotape of human heart beat or white noise generator
    • SleepTight® – vibrates a bed and generates white noise simultaneously.
    • Carrying the child
    • Car seat on dishwasher or dryer – must be observed because of movement of the seat
    • Massage
    • Pacifier
    • Riding in car – not advised at night because of driver drowsiness
    • Scenery change
    • Swinging
    • Swaddling
    • Warm water bottle
  • Nutrition

    • Change formula – may or may not help, may be more expensive
    • Change mother’s diet – eliminate cow’s milk, caffeine, etc.
    • Change feeding practices such as substituting a different bottle/nipple, feeding in an upright position, more frequent burping
    • Sugar water

Questions for Further Discussion
1. What are the classifications of tempermentally difficult children?
2. Is there a correlation between infants with colic and child abuse and neglect?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Information prescriptions for patients can be found at Pediatric Common Questions, Quick Answers for this topic: Crying and Colic.

To view current news articles on this topic check Google News.

Parker S, Zuckerman B. Behavioral and Developmental Pediatrics. Little, Brown and Company, Boston, MA. 1995; 101-105.

Boychuk RB. Infant Colic. University of Hawaii Case Based Pediatrics For Medical Students and Residents.
Available from the Internet at http://www.hawaii.edu/medicine/pediatrics/pedtext/s09c01.html (rev. 4/2003, cited 9/7/05).

Rudolph CD, et.al. Rudolph’s Pediatrics. 21st edit. McGraw-Hill, New York, NY. 2003:414-417.

ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effecively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    8. Health care services aimed at preventing health problems or maintaining health are provided.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.

  • Interpersonal and Communication Skills
    17. A therapeutic and ethically sound relationship with patients is created and sustained.
    18. Using effective nonverbal, explanatory, questioning, and writing skills, the healthcare professional uses effective listening skills and elicits and provides information.

    Author
    Donna M. D’Alessandro, MD
    Associate Professor of Pediatrics, Children’s Hospital of Iowa

    Date
    November 7, 2005