Indian J Pediatr

DOI 10.1007/s12098-017-2424-z

REVIEW ARTICLE

Crying Infant
Javed Ismail 1 & Karthi Nallasamy 1

Received: 25 May 2017 / Accepted: 6 July 2017

# Dr. K C Chaudhuri Foundation 2017

Abstract Excessive crying is a common complaint in young weeks of age and gradually declining to 1 h per day by 12 wk.
infants, especially in those less than 3 mo of age. Altered The crying follows a circadian pattern with the majority of
circadian rhythm, immaturity of central nervous system and episodes concentrated in the late afternoon and evening [1].
alteration of intestinal microbiota are some of the proposed
mechanisms for this problem. Although it is commonly be-
nign, crying can be the only clinical manifestation of many
Benign vs. Organic Causes of Crying
serious underlying illnesses, thus warranting careful clinical
examination for ruling out organic causes. Urgent care clinics
Infants cry for a variety of reasons which can range from sim-
are best suited for evaluation and treatment of benign etiolo-
ple ones like hunger, pain or need for attention to sinister ones
gies and promptly referring children with red flags to an emer-
like serious life-threatening illnesses. If the duration and fre-
gency department. Routine investigations are not indicated in
quency of crying are perceived excessive by the parents or the
an afebrile infant with no signs of illness on history and phys-
caretakers, it becomes a cause of concern. In new parents, it
ical examination. Excessive crying due to colic often results in
results in a lot of maternal anxiety sometimes leading to pre-
parental stress and exhaustion. Treatment in such cases re-
mature weaning and overuse of sedatives or pain relief medi-
volves more on reassuring the parents and avoiding drugs with
cations. Therefore it is essential for every physician attending
uncertain action and potential side-effects.
to a crying or irritable infant to differentiate organic causes of
crying from ‘colic’ or benign crying in healthy infants.
Keywords Excessive crying . Colic . Infant

Introduction
Incessant crying is one of the frequent complaints for which
young infants are brought to pediatricians. Crying in young
infants is a part of normal behavioral and neuronal develop-
ment. Infants on an average, cry for about one and a half to
two hours a day, this duration peaking up to 140 min by 6
* Karthi Nallasamy
ny.karthi@gmail.com
Infantile Colic
Colic crying, also called as Bcry-fuss behavior^ or Bexcessive
crying^ or Bunsettled infant behavior^ according to some pro-
spective studies has been described in about 3 to 28% of babies
with equal distribution in boys and girls [2, 3]. The convention-
al definition of colic is the Wessel’s BRule of three^ which
mandates an otherwise healthy baby with crying spells that
occur for at least 3 h a day, 3 times a wk for 3 consecutive
weeks [4]. These infants are typically healthy and thriving well.
The recently modified definition [5] includes all of the
following:

1
Advanced Pediatrics Centre, Postgraduate Institute of Medical 1. Paroxysms of irritability, fussing or crying that occur
Education and Research, Chandigarh 160012, India without a cause
 Indian J Pediatr

2. Episodes lasting 3 or more hours per day and occurring at Diagnosis

least 3 d per week for at least 1 wk.
3. Absence of failure to thrive History

It is a distinct behavioral syndrome in contrast to normal The clinical assessment should include detailed history
development. Colic crying typically starts by 15 d of age, may regarding the frequency, duration, timing and any pre-
peak by 2 mo and resolves by 4 mo of age. Crying spells are cipitating or relieving factors for the crying spell no-
more during late afternoon and evening hours. Bouts of crying ticed by the parents. Recurrent vomiting, fast breathing
may be associated with clenched fists, tightening of the abdo- or cough during feeding should also be sought in histo-
men, arching of the back, and grimacing. In contrast to normal ry. Psychosocial background and parental understanding
infants, colic crying once started is difficult to resolve. In a of the baby’s cues are important to determine if there is
study by Barr et al., it was found that infants with colic cried any threat to baby’s safety.
longer than normal infants despite the frequency of crying
being similar [6]. Colic crying is more often seen in preterm,
small for gestational age babies, neurologically impaired chil- Physical Examination
dren and in babies whose mothers are stressed [7–9]. Some of
the other factors implicated are gastroesophageal reflux dis- A thorough head to toe examination of the baby is always
ease, diversity of gut microbiota and parental smoking. warranted to pick up clinical clues pointing towards treat-
Regional and cultural caregiver practices like carrying, upright able causes. Close observation of the nature of cry, the
positioning, and frequent feeding may also influence colic posture and attitude of the baby while crying often points
crying [10]. It has been observed that carrying and holding towards a specific diagnosis. One should also note the
were associated with 43% lesser duration of crying without parents’ way of holding the baby and the strategies used
affecting the frequency of bouts [11]. Long-term psychologi- by them to calm the baby. Difficulties with breastfeeding
cal problems, recurrent abdominal pain, and allergies seen like problems in positioning, attachment, oral motor dys-
during later childhood have been attributed to excessive colic function or cleft palate should be addressed by observing
crying in infancy [12]. a feeding session. Abdominal examination may be diffi-
cult with a crying child and requires repeated assessments
over time. Examination of genitalia, perianal region for
diaper dermatitis, ulcers, skin lesions, inguinal hernia or
Organic Causes of Excessive Crying torsion of the testis is vital. Extremities should be exam-
ined for finger tourniquets, skin lesions, occult fractures
Organic diseases account for 5 to 10% of infants presenting or dislocations. The ear should be examined for otitis
with incessant crying. In a retrospective cohort of 237 afebrile
infants presenting with excessive crying, about 5.1% had an
Table 1 Causes of excessive crying
underlying cause of which most prevalent was urinary tract
infection [13]. The differential diagnosis of a crying infant is Colic Neurologic
extensive and can involve every organ system (Table 1). A No apparent cause, Intracranial hemorrhage,
detailed medical history and clinical examination can often Wessels’ BRule of threes^ hydrocephalus, degenerative
Gastrointestinal disorders
help in arriving at a diagnosis. Medical Infections
Milk protein allergy, lactose Otitis media, urinary tract
intolerance, gastroesophageal infection, meningitis, septic
reflux, constipation, anal arthritis, osteomyelitis,
fissure, pinworms cellulitis, scabies
Goals of Assessment in an Urgent Care Facility Surgical Skin and Musculoskeletal
Intussusception, malrotation, Fractures, dislocation, digital
Most parents seek medical attention when the crying spells are midgut volvulus, strangulated tourniquet, insect bites
longer than usual or they are unable to identify the cause for hernia Others
Cardiac Trauma, corneal abrasion,
crying, or when there are deviations in the characteristics of Tachyarrhythmia, myocarditis, glaucoma, foreign body, nose
the cry. The key aspects of management should include: congestive cardiac failure block, aphthous stomatitis,
Toxic / Metabolic palatal burns, diaper dermatitis
& Careful assessment to identify infants with a serious Neonatal drug withdrawal
(maternal drug use), electrolyte
illness disorder, IEM, hypoglycemia
& Treatment of benign causes
& Parental guidance and counseling IEM Inborn errors of metabolism
Indian J Pediatr

media, furuncles or foreign body, eye for corneal abra- Management

sions and oral mucosa for aphthous ulcers and thrush.
Specific history and clinical signs may provide a clue to
the underlying diagnosis as listed in Table 2.
BRed flags^ that point towards an underlying serious illness
are given in Table 3. The presence of any of these should
prompt the clinician to provide immediate stabilization and
arrange for referral to tertiary care centers equipped with emer-
gency and inpatient care.
Investigations
There is a limited role of investigations in identifying the
etiology of excessive crying. Studies have shown that labora-
tory investigations were helpful in only 3–5% of cases, in
whom history and examination findings were inconclusive.
As the list of differential diagnosis is exhaustive, investigating
each child for all the conditions will be inappropriate.
Diagnostic studies should be tailored to the clues obtained
on clinical assessment. Routine investigations are not needed
in an afebrile infant without any signs of illness in history and
physical examination. A prudent approach will be to perform
a urinalysis with urine culture as the initial investigation; sep-
tic work up [Complete blood count, C-reactive protein (CRP),
blood culture] in neonates and young infants with suspected
sepsis and electrolytes, blood glucose and an ECG in some
selective cases. An extensive laboratory workup is rarely in-
dicated in these children.
Management depends on the diagnosis obtained in history
and clinical examination. Children with ‘red flags’ require
immediate attention as the underlying diagnosis can be life-
threatening. Stabilization of airway, breathing, and circula-
tion is a priority before they are referred to an Emergency
Department. Infants with respiratory and cardiovascular ill-
nesses require supplemental oxygen. Infants with suspected
sepsis or central nervous system (CNS) infections should
promptly receive intravenous antibiotics. Surgical condi-
tions may need confirmatory tests and urgent referral to
centers with pediatric surgery expertise. An algorithmic ap-
proach of management of a crying infant has been depicted
in Fig. 1.
Several benign conditions that result in excessive crying can
be effectively treated in an urgent care facility. Addressing
simple causes such as hunger, thirst, sleepiness, constrictive
clothing and overbundling is the first step in treating an infant
with persistent crying. Other apparent causes where treatment
can be accomplished are corneal abrasions, tourniquets, oral
thrush, nasal block, otitis media, fecal impaction, anal fissure,
diaper dermatitis and insect bites.
Infantile Colic is a Diagnosis of Exclusion. Since it is be-
nign and self-resolving in about 95% of cases, parents need to
be reassured to avoid unnecessary investigations and medica-
tions. Various calming strategies like prone positioning, warm
compresses and abdominal massages to soothe the baby may
be tried [14]. Parents should be encouraged to follow a cue

Table 2 Clinical clues in

excessive crying infant
• Episodic evening cry in infants 2–8 wk with drawing up of legs and Infantile colic
termination of episode with passage of flatus/feces
• Crying episodes with arching of back and poor feeding GERD
• Fussiness only during feeding Nose block, aphthous stomatitis, air
swallowing, food intolerance
• Crying with progressive abdominal distension, vomiting and Intestinal obstruction / intussusception
constipation, red currant jelly stools
• Crying while defecation, chronic constipation Anal fissure
• Pulling at ears Otitis media
• Cough, rapid breathing, feeding difficulty Respiratory/cardiovascular illness
• Head banging, vomiting, photophobia, periods of lethargy CNS disorders
• Crying during micturition, abnormal urinary stream, touching Genitourinary causes
and rubbing genitals
• Blinking, rubbing and watering of eyes Foreign body in the eye, corneal
abrasions
• Not moving a limb Pseudoparalysis; osteomyelitis, arthritis,
fracture-dislocation
• Paradoxical irritability (comfortable when lying still, crying on Meningitis, peritonitis, long bone
gentle rocking) fractures
• Inconsistent history with delay in seeking care Parenting problems, Non-accidental
trauma

CNS Central nervous system; GERD Gastroesophageal reflux disease

 Indian J Pediatr

Table 3 Red flags for
underlying serious • High-grade fever
illness • Refusal to feed, lethargy
• Paroxysms of abnormal activity
• Difficulty in feeding, diaphoresis, poor
weight gain
• Recent trauma, unexplained bruising,
inconsistent history
• Caregiver intoxication, mental illness
• Sustained tachycardia >180 /min
• Bilious vomiting
• Bloody stools
• Paradoxical irritability, full fontanel
• Not moving an extremity, tenderness
based care; it has been shown that sleeping in the same room,
skin to skin contact for 10 h a day while awake, feeding or
sleeping and providing various sensory stimuli to the baby
reduces crying by about 50% [15]. Maintaining a consistent
daily childcare routine especially during feeding and sleeping
was found to be beneficial. Caretakers should be discouraged
regarding change of feeds from breastfeeds to formula feeds
during treatment.
Drops composed of simethicone (40 mg), fennel oil
(0.0007 ml) is often prescribed by practitioners for treat-
ment of colic. However, the studies on simethicone have
shown no proven benefit over placebo in decreasing the
duration of crying [16, 17]. Fennel seed (Saunf) oil emul-
sions or extracts were shown to be beneficial in reducing
the crying duration in a few trials with pooled mean differ-
ence of −72 min/d (95% CI -126 to −17) [18]. Use of
prescription drugs should be avoided as far as possible.
Dicyclomine which is contraindicated in infants less than
6 mo of age, should not be used. A meta-analysis of six
studies on the use of probiotics containing Lactobacillus
reuteri showed a significant reduction in crying duration in
breastfed infants (pooled mean difference − 56 min/d, 95%
CI -64 to −47) at 21 d of treatment [18]. The use of proton
pump inhibitors should be discouraged unless there is a
high suspicion of gastroesophageal reflux disease [19]. In

Fig. 1 Algorithmic approach to

Excessive crying
an infant with excessive crying

Detailed history and physical examination

‘Red flags’ Normal physical

examination

Treat simple causes or pain

relief if necessary

Consolable
Stabilization of
airway, breathing, Yes No
circulation if required
Discharge and First episode
follow-up

Colic No Yes

Yes
Normal growth and Observation
development and repeat
Referral to a higher examination
center for evaluation No
and specific
management

Consolable
No

Discuss with consultant, parent

education, discharge with close
follow-up Yes
Indian J Pediatr
most cases, it is the parents who require extra special han-
dling than the infants. The pediatrician has a key role to
play during parental counseling emphasizing on the overall
good health of the baby at the same time acknowledging
the difficulties faced by parents during care of the baby.
Over-simplification of the crying spell during counseling
session may make the parents lose confidence in the clini-
cian and seek help elsewhere. Long-term follow-up
showed that infants in whom crying had persisted up to 5
mo of age are associated with increased risk of behavioral
problems in later childhood [20].
Conclusions
& Infants in whom crying is short lived (stop crying prior to
arrival, or early during evaluation) and have normal clin-
ical examination may be discharged after a short observa-
tion period if feeding is normal. Some babies may how-
ever have an ‘unrecognized condition’. These infants need
a close follow-up after 8–12 h of discharge.
& Infants who stop crying after removal of the offending
stimulus or after an adequate pain control can be
discharged if follow-up is assured.
& Infants with a normal clinical assessment who persist to
cry excessively, are more likely to have a serious illness.
They should be observed with repeated examinations. If
crying continues, the infant should be admitted to an in-
patient unit for detailed evaluation.
Thus to summarize, commonly benign, crying can be
the only clinical manifestation of an underlying serious
illness. A detailed head to toe examination for ‘red flags’
is important to identify organic causes of excessive cry-
ing. Infantile colic is a diagnosis of exclusion that often
results in parental anxiety and stress. Treatment of colic
involves reassurance of parents and avoidance of unnec-
essary investigations and prescription drugs with potential
side-effects.
Contributions JI had done the literature search and drafted the manu-
script. KN had guided the framework of the manuscript and had done a
critical review and had approved the version to be published. Dr.
Muralidharan Jayashree will act as guarantor for the paper.
Compliance with Ethical Standards
Conflict of Interest None.
Source of Funding None.
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