The baby who cries and fusses: an overview for health professionals

Published 27 August 2015 in Developments: a newsletter for General Practitioners, produced by Children’s Health Queensland Primary Care Liaison team   The afebrile fussy baby is a complex, if common, presentation in the first few months post-birth. Thorough history and examination excludes the 5% who require investigations for underlying medical conditions; routine investigation is unnecessary. Parents can be reassured that excessive crying usually passes around 16 weeks without harmful effects. However, clinicians need to know that these babies are at increased risk of:
  • developmental and behavioural problems
  • migraine in later childhood
  • premature weaning
  • child abuse.
Unsettled behaviour is one of the most common reasons parents give for introducing formula, and is a modifiable risk factor for postnatal depression. Early intervention with a systematic evidence-based approach to identification and management of any underlying feeding problems, sleep problems, the baby’s sensory needs, and parental mental health is essential.1, 2 Some key points: 1. Refluxate is close to pH neutral for two hours after a feed of either breastmilk or formula, so holding the baby upright after feeds or sleeping on wedges is not helpful. 2. Oesophagitis or gastro-oesophageal reflux disease (GORD) is very rarely a cause of cry-fuss problems. Anti-secretory medications are no better than placebo, and increase the risk of infection, and possibly allergy. 3. In breastfed babies, a bloated abdomen and copious wind causes crying in the context of frothy explosive stools, very frequent feeding, and excellent weight gain. These are signs of a functional lactose overload and require simple breastfeeding management, but are commonly misdiagnosed as allergy or GORD. Positional instability at the breast, resulting in back-arching and fussing, or refusal of feeds, is also commonly misdiagnosed as GORD or allergy. 4. Large cohort studies show that breastfed babies gain on average 200-250 gm a week at this age, and many babies cry due to poor satiety. The figure of 120 gm a week which had previously been considered to be adequate weight gain may be insufficient - although if the baby is settled and well then this is still just fine. Impaired breastmilk transfer results in marathon feeding, excessive night-waking and cry-fuss problems, and requires the help of breastfeeding experts. 4. Formula-fed crying babies may benefit from extensively hydrolysed formula (once all other factors have been considered.) For a comprehensive approach, see our BMJ article ‘Managing infants who cry excessively’ or the Australian Doctor’s ‘How to treat’ (ignore the questions at the end of the latter!)