13 August 2018

What to advise when babies won’t stop crying

Clinical Paediatrics

The screaming infant and the despairing parent are common presentations in general practice, but waiting is often the best medicine, says paediatrician Dr Valerie Sung.

It’s fairly normal for healthy babies to cry excessively, says Dr Sung, who works at the Royal Children’s Hospital in Melbourne. Colic affects around one in every five babies, peaking at six to eight weeks of age and is usually self-resolving at around three to four months. 

That doesn’t stop those first few months from being a hellish experience for parents.

Unfortunately, almost all of the treatments available for colic were ineffective or harmful, said Dr Sung. 

In an article for Australian Prescriber, Dr Sung warned against prescribing anti-reflux medications for colic in infants younger than six months. 

Proton pump inhibitors could cause dangerous adverse effects such as drowsiness, apnoeas and comas. 

Similarly, over-the-counter medications and herbal teas could harm the infant, even if they had some efficacy for colic. 

Feeding too much herbal tea to a baby could reduce milk intake and put them at risk of nutritional deficiencies, Dr Sung said.

The best strategy for GPs was to reassure parents that there was nothing wrong with their baby and that the child would eventually grow out of it.

But Adjunct Associate Professor Pamela Douglas, a Brisbane GP at the Possums Education and Research Centre, said telling parents to wait out the crying period was not enough. 

“Infant crying behaviour is modifiable,” she said.

Dr Douglas has developed a primary care intervention for infant cry-fuss problems called The Possums Approach. 

This model of care addresses five domains: the baby’s health, the mother’s health, and the three neurobehavioural domains of feeds, sensation and sleep. 

A preliminary study of 20 mothers with crying infants found that this intervention could decrease the daily crying duration from around six to three hours after only a few weeks. 

Dr Douglas said colic research had overlooked a number of important variables. For instance, undiagnosed positional instability in breastfed babies (where babies lacked a firm grip on the mother’s breast tissue) could lead to poor satiety and crying, she said. 

Dr Sung said parents would appreciate GPs taking the time to explain why other, more serious, diagnoses had been excluded as causes of their baby’s crying. 

So it helped to take a careful history, perform a physical examination, and then take parents through  the possible alternative diagnoses and explain why none of those fitted. These included cow’s milk protein allergy, gastro-oesophageal reflux disease, lactose intolerance or overload, inguinal hernia, intussusception, infection, hydrocephalus, and a foreign body in eye. 

While colic was a normal part of infant development, it could have a major effect on parental mental health. In extreme cases, colic could cause desperate caregivers to slide into depression, cease breastfeeding early, or even precipitate inadvertent harm casued by by violence from the parent.

GPs could help by offering empathy, support and commonsense advice, Dr Sung said. 

Parents often felt obliged to do everything on their own, and could benefit from a GP telling them it was not a sign of failure to accept help with housework or childcare from friends and family, she said.