Unsettled / Excessively Crying Infant
1. Normal Crying Physiology
| Age | Typical Cry-time / 24 h | Pattern |
|---|---|---|
| Birth → 2 wk | 1–1.5 h | Evenly spread |
| Peak 6–8 wk | 2–3 h (“normal crying curve”) | Often worse late afternoon/evening |
| 3–4 mo | Rapid decline | < 1 h, more predictable |
- Crying is developmental, present across cultures, and usually settles by 4 months
- Parental distress and post-natal depression risk rise in parallel with peak crying
2. Definitions
| Term | Diagnostic criteria | Comment |
|---|---|---|
| Excessive crying / “colic” | ≥ 3 h per day, ≥ 3 days/week, ≥ 3 weeks (Wessel “rule of 3”) | Benign, self-limiting |
| PURPLE crying | Peak Unexpected Resists soothing Pain-like face Long-lasting Evening | Parent-education tool |
| Unsettled infant | Broad descriptor used in Australian ED/GP guidelines when crying is the presenting problem | Focus on red-flag screen |
3. Red-Flag (“Can’t-miss”) Diagnoses
| Domain | Key conditions | Typical clues |
|---|---|---|
| Infection | Sepsis UTI | Fever mottling lethargy poor perfusion |
| Acute surgical | Intussusception incarcerated inguinal hernia testicular torsion | Sudden episodic scream vomiting pale/legs drawn up groin swelling |
| Trauma / NAI | Clavicle # shaken-baby | Bruises retinal haemorrhage inconsistent history |
| Entrapment | Hair-tourniquet | Swollen digit/genital tip inconsolable crying |
| Ocular | Corneal abrasion / foreign body | Tearing photophobia infant rubs eye |
| Painful lesions | Otitis media oral thrush dermatitis | Local signs |
| Neuro-metabolic | Raised ICP seizures hypoglycaemia | Bulging fontanelle focal signs jitteriness |
Any sudden, persistent change from baseline warrants urgent work-up.rch.org.au
4. Targeted History & Examination Checklist
History (SAMPLE + social):
- Onset/character (piercing vs grizzle), duration, diurnal variation
- Preceding feeds, vomiting, position, sleep-wake cycle
- Interventions tried (stimulation, feeding, analgesia) & response
- Weight trends; stool/urine colour, blood/mucus
- Antenatal/birth history; prematurity
- Atopy in 1st-degree relatives (flags CMPA)
- Home stressors, caregiver coping, substance exposure
Examination pearls:
- Full vital signs incl. BP & SpO₂
- Observe cry pattern while undressed & during settling
- ENT/eye check, scalp-to-toe skin & digit tourniquet search
- Abdomen (masses, hernia orifices); genital exam
- Neurologic tone, fontanelle, jittery movements
6. Investigations
| Infant status | Recommended tests |
|---|---|
| Well, no red flags | None required |
| Cry persists ≥ 3 h/day after education or red flag present | Screen urine (dip ± culture) FBC CRP BSL Add targeted imaging/labs per clinical suspicion (e.g., AXR for obstruction, head CT only if neuro signs). |
7. Management
Exclude Medical Causes
- Rule out underlying organic conditions (e.g. infection, CMPA, reflux disease, constipation, trauma).
- Consider need for paediatric review if diagnosis uncertain.
Parental Education & Reassurance
- Explain excluded causes of crying and why they are not suspected.
- Use the “normal crying curve” (e.g. Purple Crying) to explain crying peaks at 6–8 weeks, resolves by ~4 months.
- Discuss normal sleep/cry patterns using a cry/sleep/feeding diary.
- Teach recognition of infant tired cues: frowning, clenched fists, jerky movements, grizzling.
Assess Parental Wellbeing
- Invite parents to talk about emotional stress of caring for a crying infant.
- Screen for postnatal depression (e.g. Edinburgh Postnatal Depression Scale).
- Observe the mother–baby relationship and feeding interaction.
Build Partnership with Parents
- Acknowledge distress and validate concerns.
- Observe feeding and baby-parent interaction during consultation.
- Offer follow-up and access to additional support if needed.
Settling & Soothing Strategies
- Establish routine: consistent patterns for feeding, settling, sleep.
- Settle baby while awake: e.g., wrap, cuddle briefly, place in cot while drowsy but awake.
- Minimise overstimulation: avoid bright lights, loud noise, excessive handling.
- Avoid excessive quiet: low-level background noise can be soothing.
- Darken room for daytime naps.
- Use soothing techniques: baby massage, rocking, patting, gentle music.
- Consider baby-wearing in a front carrier for contact comfort.
- Intervene early—before baby is over-stimulated or overtired.
Care for the Caregiver
- Encourage primary caregiver to rest once daily; assign others to care for baby temporarily.
- Provide printed information—parents may forget verbal advice due to stress.
Medication & Other Interventions
Not recommended:
- Anti-reflux medications – not effective for crying reduction.
- Anticholinergic agents – risk of apnoea/seizure.
- Colic mixtures (e.g. gripe water) – no proven benefit.
- Simethicone (e.g. Infacol™) – no better than placebo.
Probiotic (limited use):
- Lactobacillus reuteri DSM17938 (BioGaia™)
- Only for exclusively breastfed infants <3 months with colic.
- Dose: 5 oral drops daily × 21 days
- Not effective in formula-fed infants.
- Note: Evidence limited and not proven effective in Victorian cohort studies.
Not helpful:
- Formula changes unless proven cow’s milk protein allergy.
- Weaning from breast milk – not beneficial.
- Spinal manipulation – not indicated, potential harm.
When to Refer / Escalate
Refer to paediatric team if:
- Medical cause suspected or confirmed
- Infant appears unwell
- Concerns about non-accidental injury or parental exhaustion
Consider hospital transfer if:
- Care needs exceed hospital’s capability
- Safety concerns for infant or caregiver
8. Key Take-Home Points
- Peak crying at 6–8 weeks is normal; expect marked improvement by 4 months.rch.org.a
- Always screen for infection, surgical emergencies, trauma/NAI, entrapment when cry pattern changes abruptly.
- CMPA is the commonest dietary cause; diagnose by elimination‐challenge, not serial formula changes.
- Probiotics (L. reuteri DSM 17938): reasonable option for breast-fed colic once red flags excluded, yet not mandated in guidelines.www1.racgp.org.authennt.com
- Unproven agents (simethicone, herbal drops) add cost/false hope.
- Supporting caregiver mental health is as critical as assessing the infant.
Non-IgE Cow’s Milk / Soy Protein Allergy
Allergenicity and Sources:
- Cow’s milk and soy proteins can be transferred through breast milk if part of the maternal diet.
- Goat’s milk protein is just as allergenic as cow’s milk protein.
Clinical Suspicion:
- Consider in infants with:
- Persistent feeding difficulties (day and night)
- Frequent vomiting
- Diarrhoea with blood or mucus
- Poor weight gain
- Widespread eczema
Diagnosis:
- Clinical diagnosis—no reliable test for non-IgE allergy.
- Requires a 2-week elimination trial:
- Either:
- Maternal dietary elimination (if breastfeeding)
- Switch to extensively hydrolysed formula (eHF) (requires paediatrician approval)
- Either:
- Followed by rechallenge to confirm:
- Resolution with elimination
- Reappearance of symptoms with reintroduction
Lactose Overload / Malabsorption
Clinical Indicators:
- Consider if:
- Very frequent breastfeeding (short intervals)
- Frothy, watery stools
- Perianal excoriation
Important Notes:
- Primary lactose intolerance (congenital) is extremely rare in infants.
- Secondary lactose intolerance may follow gastroenteritis but is usually transient.
Gastro-Oesophageal Reflux (GOR) vs GORD
GOR (Physiological reflux):
- Common in infants; usually self-limiting.
- Not associated with excessive crying or irritability.
GORD (Disease):
- Rare in infancy.
- Requires symptoms such as:
- Poor weight gain
- Haematemesis
- Respiratory symptoms
Management:
- PPIs (e.g., omeprazole) have not been shown effective for treating infant crying.
- GORD should not be diagnosed based solely on crying or regurgitation.