http://bmj.bmjjournals.com/cgi/content/full/328/7435/330?etoc
Persistent crying in babies
A R Gatrad, consultant paediatrician1, Aziz Sheikh, professor of primary
care research and development2
1 Manor Hospital, Walsall NHS Trust, Walsall WS2 2PS, 2 Department of
Community Health Services: GP Section, University of Edinburgh, Edinburgh
EH10 5PF

A young mother presents with her 12 week old son, complaining that
he "cries all the time." She also has a three year old daughter who
was "never a problem."

Elicit the mother's views—What does she think the problem might be? Take
seriously any specific concerns she has. How experienced is she? For
example, does she appreciate that the duration and frequency of crying can
vary considerably between infants and at different times in the same
infant? How is she coping? Is she depressed? Ask about what sources of
support she has at home or among her wider circle of friends and relatives
and whether she needs any additional help.

Nature of the crying—Excessive crying is defined medically as crying that
lasts at least three hours a day, for three days a week, for at least three
weeks. Is there any pattern to the crying? Babies cry for a variety of
reasons, including hunger and thirst, being hot or cold, wanting attention,
tiredness, discomfort, and pain. Although there is little evidence that it
is possible to determine the cause from the pitch of the cry, the pattern
of crying may indicate where the problem—if there is one—lies. For
example, "infantile colic" (excessive crying in an otherwise healthy baby)
may manifest as long bouts of crying in the early evening.

Other symptoms—Ask about any associated symptoms. For example, difficulty
in feeding may be due to a blocked nose, vomiting may indicate a
gastrointestinal problem, excessive straining may be due to constipation,
and eczema suggests discomfort from itching.

Feeding—A detailed feeding history can help determine an underlying cause,
such as overfeeding or premature weaning. The baby may inadvertently be
swallowing air, particularly towards the end of a bottle feed.

Home environment—The home environment and family dynamics may be having an
effect on the baby. The views (if available) of the father and other
members of the family may provide useful insights. Also ask about sleeping
arrangements and the baby's pattern of sleep.

What you should do

Check the baby's growth chart, assessing weight gain and head
circumference.

Expose the baby fully. Complete exposure may point to the underlying cause,
such as areas of eczematous skin or nappy rash that may be irritating him.

Examine his orifices: look for a tight phimosis; anal fissures will show as
small tears around the anal margin; check his mouth for evidence of thrush
or teething; check his ears for otitis media.

If you think there is a feeding problem advise the mother on feeding
techniques, such as how to make up a feed and how to help stop the baby
swallowing too much air while feeding. Check that the hole in the teat of
the baby's feeding bottle is not too small, resulting in his gulping air.

If she is breast feeding ask whether she has enough milk. A health visitor
may be able to advise.

Enlist further support from the health visitor if you have concerns about
her parenting skills or mental state. If she has postnatal depression she
is likely to need treatment and support.

There is some evidence that whey hydrolysate milk and dicycloverine can
help in infants with colic. However, dicycloverine is associated with an
increased risk of anticholinergic side effects.

Consider referring the baby for a clean catch urine specimen and further
assessment if you suspect a urine infection.

In most cases no underlying cause will be found. In such cases the problem
will probably subside with time, and other than reassurance and ongoing
support no further investigations are warranted.

MY RESPONSE


I don't understand "what you should do" item number 5;
 "If she is breast feeding ask whether she has enough milk."
The first item indicates you should check baby's weight and head
circumfrence.  Once that is done, you already know if the baby is getting
adequate nourishment.

The mother will be looking to you as to whether or not she has enough milk,
afterall, you are the medical advisor.
She can only give you her opinion, you have the facts.

By asking this question, the medical personel are suggesting several
things; the crying may be mom's "fault", for not feeding her baby
adequately, that mom's milk "isn't good enough, rich enough, etc." and of
course, if she believes she doesn't have enough milk, don't you suppose she
has enough sense to know that's why the baby is crying?  What benefit comes
from this question?  Because the answer isn't quickly apparent, blame it on
breastfeeding.
It's time that breastfeeding quit being blamed for crying babies, simply
because medical personel cannot find any other reason.
This is counterproductive to successful breastfeeding, undermining mom's
confidence in providing for her baby.

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