5 Min In Learning
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Problem representation
A five-month-old child presents with recent onset excessive crying that has not responded to parental self-care intervention.
Hypothesis generation
Crying is a normal physiological behaviour in young infants, which peaks around six to eight weeks of age and usually improves by three to four months. A baby cries, on average, for two to three hours a day. This is usually worse in the late afternoon or evening, but may occur at any time. Parents may perceive crying as excessive when it actually is within normal patterns.
Likely diagnosis
- Colic
- Non-pathological (e.g. physiological drooling, hunger, tiredness, over-stimulation)
- Teething
Possible diagnosis
- Infection (e.g. acute otitis media, gastroenteritis, urinary tract infection)
- GORD
- Intolerance to cow’s milk protein
Critical diagnosis
- Sepsis.
Continued information gathering
Baby May’s age means that all likely causes are possibilities. You ask about her general health, sleeping patterns and feeding routine.
The parents tell you that up until the last couple of weeks, May has been “a good baby”.
She breastfeeds, which has been going “really well”. Apart from the increased crying, the only other thing they have noticed is that she seems to be dribbling more than before. This description seems to rule out a non-pathological cause, but excessive drooling combined with relatively recent onset of crying does fit with teething.
Problem refinement
Information needs to be obtained to try and see if teething is indeed the cause. Colic is still a plausible explanation for the baby’s distress, even though colic mixture has been tried (bear in mind, however, that there is a lack of evidence for the efficacy of colic preparations).
You ask Rob and Louise whether they have noticed if the baby shows any facial flushing and draws up her legs when she is crying, and if they have seen her chewing or biting things. They tell you they have not noticed these symptoms.
In colic, facial flushing and drawing up the legs are common symptoms. In the absence of these and the fact that the symptoms are relatively recent in onset, colic seems unlikely. One would expect May to be chewing and biting at objects if teething is the cause. However, absence of this behaviour does not rule out teething.
Almost all children will see their first tooth erupt from four to 10 months of age, with roughly one tooth emerging every month. A full complement of 20 deciduous (baby) teeth is almost always present by 30 months. Teething is uncomfortable and painful for most infants, and can be a very distressing experience for parents.
On balance, the signs and symptoms are pointing more to the start of teething. However, to ensure more unlikely diagnoses are not the cause, you ask if she is putting on weight. Her parents tell you that the health visitor came last week and said the baby was fine and of expected weight. This helps to rule out GORD and intolerance.
Red flags
As the baby’s crying was not sudden in onset and she is not experiencing any other symptoms, there is no cause for concern.
Management
Chewing objects is normal behaviour when teeth start to emerge, so you can advise the parents that if May starts to do this, she may get some relief from chewing on hard objects such as teething rings. These can be cooled first to help soothe the baby’s gums. Once she is past six months of age, they could give her healthy things to chew (e.g. raw fruit, vegetables). Proprietary biscuits and rusks can contain sugar are best avoided.
Teething gels (e.g. Bonjela Junior, Calgel, Anbesol) containing lidocaine can be given from five months of age. Paracetamol or ibuprofen can also be offered to manage discomfort and pain if the above measures fail to control symptoms.
Safety netting
You tell the parents that baby May has started teething and they should stop using the colic mixture. You explain that it is likely that as each tooth comes through, she will be irritable and cry more – but this is normal and there is nothing to worry about.
Check your knowledge of babies crying by answering these multiple choice questions:
1. Excessive crying accompanied by vomiting and a swollen abdomen might indicate which ONE of the following conditions in infants?
a. Colic
b. Intussusception (where the bowel ‘telescopes’ in on itself)
c. Lactose intolerance
d. Sepsis
e. Urinary tract infection
2. Which ONE of the following conditions is most likely if the infant is excessively crying, shows signs of fever and is irritable?
a. Colic
b. Hunger
c. Infection
d. Teething
e. Sepsis
3. Which ONE of the following GI conditions is most likely to cause excessive crying in infants?
a. Colic
b. Constipation
c. Gastroenteritis
d. Gastro-oesophageal reflux disease
e. None of the above
4. Which ONE of the following is most likely to be a symptom of colic?
a. Crying for less than 30 minutes at a time
b.Crying that is consistent and predictable, often at the same time each day
c. Crying that stops immediately when the baby is held
d. Crying only when the baby is tired
e. None of the above
5. Which ONE of the following options should indicate to parents that teething is NOT the cause of their infant’s symptoms?
a. When the baby is chewing on objects
b. When the baby is drooling more than normal
c. When the baby has GI symptoms
d. When the baby is irritable
e. When the baby has swollen gums
Answers: 1.b 2.c 3.a 4.b 5.c
In Learning
This is your ultimate guide to pharmacy learning. Here you can find modules, articles, scenarios and more to improve your knowledge and support your learning in the pharmacy.