Makindo Medical Notes

Crying is a common reason for paediatric consultations. It is essential to assess and manage crying in infants to rule out serious causes, provide reassurance to parents, and ensure proper care.

Clinical Approach to the Crying Baby

• Obtain a Detailed History
  • Duration and Timing of Crying:
    • How long has the baby been crying?
    • Does the crying follow a pattern? (e.g., evening crying or persistent crying throughout the day)
  • Associated Symptoms:
    • Fever, vomiting, diarrhoea, or feeding problems?
    • Recent changes in feeding, sleep, or bowel habits?
  • Family History: Any history of food intolerances, colic, or allergies in the family?
  • Perinatal History: Any complications during pregnancy or delivery?
• Physical Examination
  • General Appearance:
    • Is the baby irritable, lethargic, or well-appearing?
  • Vital Signs: Check for fever, tachypnoea, or signs of distress.
  • Growth Parameters: Assess weight, length, and head circumference.
  • Head-to-Toe Examination:
    • Head and Neck: Inspect for trauma, fontanelle bulging (increased intracranial pressure), or signs of infection (otitis media).
    • Abdomen: Check for distension, tenderness (consider gastrointestinal causes such as intussusception or hernia).
    • Genital Area: Inspect for signs of hernia, testicular torsion, or skin irritation (e.g., diaper rash).
    • Extremities: Check for trauma, fractures, or signs of injury.
    • Skin: Look for rash, signs of infection, or other skin abnormalities.

Differential Diagnosis: grouped into benign and serious causes.

• Benign Causes
  • Hunger: Ensure the baby is feeding adequately.
  • Fatigue: Babies cry when overtired.
  • Colic: Common in infants <3 months, characterized by excessive crying without a clear cause.
  • Diaper Rash or Irritation: Check for wet/soiled diapers, tight clothing.
  • Overstimulation: Some babies cry when overwhelmed by the environment.
• Serious Causes:
  • Infection: Fever, irritability, and lethargy may indicate sepsis, meningitis, or urinary tract infection.
  • Gastrointestinal Causes: Gastroesophageal reflux disease (GERD), milk protein allergy, or intussusception (especially with abdominal pain and vomiting).
  • Trauma: Fractures or injuries, especially non-accidental trauma.
  • Neurological Conditions: Raised intracranial pressure, intracranial haemorrhage, or hydrocephalus (bulging fontanelle, vomiting).

Investigations

• Blood Tests: If infection is suspected, consider CBC, CRP, blood cultures.
• Urine Analysis: Rule out urinary tract infection, especially in infants with fever.
• Imaging:
  • Abdominal Ultrasound: If abdominal pain, vomiting, or intussusception is suspected.
  • Brain Imaging (CT/MRI): If neurological causes or trauma is suspected.

Management

General Measures:

• Reassurance: Educate parents on normal crying patterns (e.g., evening fussiness in the first few months).
• Swaddling, Soothing: Use of swaddling, rocking, or white noise to comfort the baby.
• Feeding: Ensure regular and sufficient feeding, correct breastfeeding technique, or formula if necessary.

Treating Underlying Causes

• Infection: Antibiotics or antiviral treatments for sepsis, otitis media, or meningitis as required.
• GERD: Use of thickened feeds, positional therapy, or medications (e.g., H2 blockers, proton pump inhibitors).
• Colic: Reassurance and support; consider probiotics, changing feeding techniques.
• Milk Protein Allergy: Elimination of cow's milk from diet and use of hypoallergenic formulas.

Follow-up

• Schedule a follow-up visit to reassess the infant’s crying and the parent’s concerns.
• If the crying persists or worsens, reconsider the diagnosis and investigate further.

Red Flags Requiring Immediate Attention

• Fever in infants <3 months.
• Lethargy or poor feeding.
• Persistent vomiting or diarrhoea.
• Bulging fontanelle or seizures.
• Inconsolable crying despite attempts to soothe the baby.
• Signs of trauma or non-accidental injury.