Managing infants who cry excessively in the first few months of life
Cite this as: BMJ 2011;343:d7772
- Continuing medical education
- Child and adolescent psychiatry
- Child and adolescent psychiatry (paedatrics)
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There has been a trend to inappropriate diagnosis of lactase insufficiency or lactose intolerance in unsettled babies in the first weeks and months of life, accompanied by treatment with either lactase or a lactose-free formula.1 While a decline in lactase-specific activity commonly occurs as early as 3-5 years of age in humans, congenital lactase deficiency is extremely rare. Babies may, however, acquire a transient, secondary lactose intolerance resulting from damage to the intestinal villi, most commonly due to gastroenteritis or cow’s milk allergy. In formula-fed infants, secondary lactose intolerance may respond to lactose-free formula (although babies with cow’s milk allergy who are mistakenly diagnosed with lactose intolerance could experience perpetuation of their gut lesion if the lactose-free formula contains cow’s milk protein). Weaning is not indicated in breastfed babies with secondary lactose intolerance, although a cow’s milk allergy maternal elimination diet may have a role. Functional lactose overload should not be confused with either congenital lactase insufficiency, or secondary lactose intolerance. Functional lactose overload does not result from abnormality of either the mother’s milk or the infant’s lactase production, but is a common breastfeeding management problem.
Signs of functional lactose overload occur in a baby when breastfeeds consistently contain inadequate amounts of fat. When the lipid fraction of a breastfeed reaches the stomach, high levels of plasma cholecystokinin are triggered, resulting in feelings of satiety. Lipid also slows down milk transit through the intestine. A breastfeed that has too little “cream” results in both poor satiety, and rapid gut transit without time for the milk to be properly digested by the existing lactase so that lactose ferments in the colon, causing low-grade inflammation and crying.2
The volume and constitution of breastmilk, including the relative lipid concentration, is dynamic, and dependent on the way each unique mother-baby pair manage their feeding. The best way to ensure breastfeeding homeostasis is to encourage cue-based feeding, which may be very frequent in the first weeks. These very frequent feeds in the first days postpartum–“if the baby isn’t sleeping, it’s feeding”–prime the breasts for good supply in the weeks and months to come, and prevent engorgement and mastitis. Cue-based feeding trains the breast to meet each baby’s unique and variable need. Some examples of breastfeeding management advice that limit the transfer of low-volume, cream-rich milk are:
1. Don’t allow “comfort suckling” (when the baby makes frequent rhythmic flutter-like sucks and only periodic swallows toward the end of a feed).
2. Only allow “ten minutes a side”–or similar instructions to limit the feed
3. Always offer the fuller side first
4. Always feed from both sides
These instructions create other feeding difficulties that may entrench crying behaviours, in addition to functional lactose overload. For example, they ensure that the factors underlying excessively long feeds remain unidentified.
Babies who do not achieve good satiety due to inadequate lipid intake may quickly want more milk. In older breastfed babies, this can result in a cycle of overproduction. The baby feeds very frequently, stimulating the breast to produce more milk, yet still receives inadequate “cream”. Because a breastpump acts as a vacuum but does not extract much of the low volume, lipid-rich milk, babies receiving significant amounts of expressed breastmilk may also develop functional lactose overload.
Optimal management of functional lactose overload is more likely to be achieved through individual assessment and management by a feeding expert, rather than through a “one-size-fits-all” solution. Certainly mothers should be encouraged to offer cue-based care and be informed of the importance of the creamy “dessert”. They should also be encouraged to pay attention to breast comfort as they decide which breast to offer first, without adhering to any particular rule. They can be reassured that the cluster feeds so commonly required by babies in the evenings are usually low-volume high lipid feeds that result in good satiety and help with sleep. Properly taught breast massage may have a role, to help mobilise the lipid fraction. Simplistic instructions to feed only from the one breast over a stipulated period of time can result in other problems e.g. inadequate supply or mastitis. In older babies with functional lactose overload and high maternal supply, a range of strategies may be advised, including pumping once or twice a day to “empty” the breasts, and feeding the baby expressed breastmilk on occasions to allow the breasts to be fuller than usual until the supply settles. Again, other problems may arise if this management is not individually tailored to fit the mother and baby’s situation.3
Functional lactose overload is just one of a range of feeding difficulties that remain unidentified and unmanaged in (both breastfeeding and non-breastfeeding) crying babies. In the same way a clinician refers to a physiotherapist once a musculoskeletal problem has been identified in order to optimise outcomes, referral to an appropriately qualified feeding expert should occur, if at all possible, when indicators of feeding difficulty emerge.
1. Douglas P, Hiscock H. The unsettled baby: Crying out for an integrated, multidisciplinary, primary care intervention. Med J Aust. 2010; 193: 533-536.
2. Evans K, Evans R, Simmer K. Effect of the method of breastfeeding on breast engorgement, mastitis and infantile colic. Acta Paediatr. 1995; 84: 849-852.
3. Smillie CM, Campbell SH, Iwinski S. Hyperlactation: How 'left brained' rules for breastfeeding can wreak havoc with a natural process. Newborn and Infant Nursing Reviews. 2005; 5: 49-58.
Competing interests: None declared
The University of Queensland, UQ Health Care, 20 Cornwall Street, Annerley, Brisbane Australia 4105
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Douglas and Hill1 wrote an interesting review article on cry babies in terms of aetiology , continuity after a critical age and small proportion of mental health problems late on in life. They dispelled the myth of reflux and colic as explanation for the crying infant, but that can also be the case. Many physical problems2 such as lactose intolerance have been found as aetiological factors for excessive crying. The authors linked the excessive crying to sensory integration deficits stemming from inadequate sensory stimulation preterm and term babies. Their review supposed that this can induce developmental disorders, which in terms of the hierarchical development of the brain, can affect i.e. development of the higher cortical functions, which are based on a platform of sensory integration3
A link with depressed mothers has been found and attachment issues. This can have an effect on adequate (sensory) stimulation. However, a child with sensory integration problems will respond negatively or even aversively to the interaction with the carer which can result in recursive traumatising interactions4 with risks of abuse.
There is also a bit of a chicken and egg question; On retrospect, from the developmental history at a mental health assessment crying in infancy is not uncommonly solely appraised as an early ADHD sign. Perry explains this by an overstimulated adrenergic systems causing symptoms of hyperactivity, impulsivity and distractibility. ADHD features can occur in attachment disorders. Bioscientist6,7 have found evidence of a dysregulation of cortisol by the hypothalomo axis , at pre-gestational distress on the offspring. This also results in a hyperactive adrenergic system.
Psychoanalysts and psychotraumatologist speak about the fight, flight freeze reaction of the infant. Crying can be form of a post traumatic stress reaction8 which can also be induced by medical illness or interventions. Post traumatic stress in infant9 has a profound negative impact on the pituitary hypothalamo pituitary axis and early brain development.
Depending on specialism there appears to be a physical and developmental dichotomy in the theories of a cry baby based on different type of research i.e. cross sectional studies versus case studies10
All these theories acknowledge the distress features11 Poole. It is when the stress persists for a longer period of time the hypothalamo axis gets recalibrated. Many researchers conclude that early exposure to stress predicts future deficits in mood regulation.
Douglas and Hill acknowledge the recursive repercussion of distress on parents, by the crying baby, a mutually traumatising vicious circle resulting in sustained sub-optimum interactions which undermine brain development further. Feeding and eye contact have an organising function on the brain and children with problems in those area, i.e. pre-autism babies or infants with severe eczema will be compromised.
Treatments consist of reducing the distress on parents by helping them to feel less guilty and inadequate have been made available. Physical contact is also recommended and wrapping has been used , which is a tactile sensory integration intervention. Results of these interventions have not been extensively studied.It has been established that skin contact has got soothing properties, which are compromised by therefore sensory integration problems. Under-stimulation can induce sensory integration problems. Sensory integration problems have been implicated in hyperactivity behaviours to compensate for the internal under-stimulation. Wrapping a form of deep tactile stimulation has been shown affective in certain cases.
Many years later, at a CAMHS clinic parents tend to state that no help had been on offer.
Clearly chronic excessive crying whether due to physical, developmental or trauma related distress is a future mental health concern, with recursive repercussions on family life and risks of abuse. Investments need to be made in research interventions to address this matter at an earliest stage.
2. Fahimi,D et al. Excessive crying of infancy; a report of 200 cases Iran Journal of Paediatrics 2007 17; 3: 222-226
3. Perspectives on Sensory Processing Disorder: A Call for Translational Research Lucy J. Miller, D. Nielsen et al Frontiers in integrative brain science 2009 September
4. Reijneveld SA, Brugman E, Hirasing RA.Excessive infant crying: The impact of varying definitions. Pediatrics. 2001; 108(4):893-4.
5. Singer JI, Rosenberg NM. A fatal case of colic. Pediatr Emerg Care. 1992;8(3):171
6. Rice F, Jones I, Thapar A. The impact of gestational stress and prenatal growth on emotional problems in offspring: A review. Acta Psychiatr Scand 2007; 115: 171-183.
7. Essex M. Klein M. Cho E. Kalin N. Maternal stress beginning in Infancy may sensitise children to later stress exposure: effects on cortisol and behaviour Biological Psychiatry 52; 776-84
8. Feldman R Vengrover Posttraumatic stress disorder in infants and young children exposed to war-related trauma A Journal of the American Academy of Child & Adolescent Psychiatry July 2011; 50: 645-658,
9. Perry, B. “Incubated in Terror: Neurodevelopmental Factors in the Cycle of Violence,” Children in a Violent Society, 1997 Guilford Press, New York
10. Reijneveld SA, Brugman E, Hirasing RA. Excessive infant crying: the impact of varying definitions. Pediatrics. 2001 Oct;108(4):893-7.
11. Poole SR. unexplained, excessive crying. Pediatr.1991;88(3):450-5 4
Competing interests: None declared
CAMHS, The Town House
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Babies’ Cry For Help
The paper on Managing infants who cry excessively in the first few months of life by Douglas and Hill considers excessive crying as benign and frequent vomiting a normal phenomenon.1 This is misleading and inaccurate. The paper also contradicts itself by suggesting that frequent crying with refusal to feed and back arching does not merit treatment and at the same time suggests assessment by a feeding expert. The statement that the disease states which may cause excessive vomiting as pyloric stenosis, are uncommon is untrue. Pyloric stenosis is the most common cause of gastric outlet obstruction in infants and its prevalence ranges from 2.5-4 cases per 1000 live births.2
Babies cry when they are uncomfortable, hungry, thirsty or in discomfort or pain and signal their need to the carer. Brief cry of a term infant at birth, while an expression of uncomfortable new environment, also serves to help the infant in its extrauterine circulatory adaptation. The expert consensus statement that gastro-oesophageal reflux is not the cause of persistent crying is not backed by any scientific evidence.3
Population based studies of infant crying behaviour have limitations of having included both healthy and symptomatic infants.4 Feed regurgitation or posseting is normal in early infancy. Vomiting is an abnormal symptom and connotes underlying feeding. gastro-intestinal or systemic disorder; vomiting is an active process and is associated with autonomic symptoms like sweating, colour changes and includes neuro-behavioural and/or circulatory changes.4 In a series of 46 infants who presented to our feeding clinic with the main symptom of persistent feed related crying, significant gastro-oesophageal reflux was demonstrated in 34 (74%) infants on isotope scan.5,6
A persistently crying baby who is refusing feeds is a source of great distress to the parents and causes considerable loss of parental sleep; many parents feel that the magnitude and severity of the reflux symptoms and its impact on the family are not fully appreciated by the health professionals.6 Persistent crying is abnormal and merits detailed assessment by a multidisciplinary team comprising of a paediatrician, speech and language therapist and a dietician.
Douglas P, Hill P. Managing infants who cry excessively in the first few months of life. BMJ 2011; 343:1265-1269.
Schechter R, Torfs CP, Bateson TF.
The epidemiology of infantile hypertrophic pyloric stenosis
Paediatric and Perinatal Epidemiology 1997;11 (4): 407-427
Sherman PM, Hassall E, Fagundes-Neto U et al.
A global, evidence-based consensus on the definition of gastroesophageal reflux disease in the pediatric population. Am J Gastroenterol. 2009;104(5):1278-95.
Nelson SP, Chen EH, Synair GM et al. Prevalence of symptoms of Gastroesophageal reflux disease during infancy; a paediatric practice based survey. Arch Pediatr Adolesc Med 1997; 151: 569-572
Mir, Nisar. Presentation and Diagnosis of Gastro-oesophageal Reflux in babies.
MIMS Advances. Infant Nutrition 2005;4:1-4
Mir, Nisar. Diagnosis of gastro-oesophageal reflux in infants (unpublished data)
Mir NA. Epidemic of gastro-oesophageal reflux in young infants. (Letter)
Managing gastro-oesophageal reflux in infants. 341:doi:10.1136/bmj.c4420
Competing interests: None declared
Warrington & Halton Hospitals NHS Foundation Trust, Warrington Hospital Lovely Lane Warrington WA5 1QG
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The authors recommend referral of "a new mother who seems to be depressed or has a high EPDS score to perinatal and infant mental health experts" (p4) but such resources are too often absent, even though there is good evidence of effective interventions (Barlow et al 2010). A greater integration of perinatal mental health with neonatal paediatrics is necessary to manage these cases in a truly multidisciplinary way.
Barlow J, McMillan AS, Kirkpatrick S, Gate D, Barnes J, Smith M. Health-led interventions in the early years to enhance infant and maternal mental health: A review of reviews. Child and Adolescent Mental Health 2010;15:178-185. doi: 10.1111/j.1475-3588.2010.00570.x
Competing interests: None declared
Whittington Hospital, London N19 5NF
I just wanted to re-iterate the fact that many health professionals are unaware of their knowledge deficits regarding the identification and management of (infant) feeding problems.
My 1 year old son was diagnosed with a ‘posterior tongue-tie’ when he was 5 weeks old. I had already been told by many health care professionals, including two midwives and a breastfeeding counsellor, that he was ‘definitely not tongue-tied’. He was always able to stick his tongue out, and his tongue was not classically heart shaped. I myself could not see a visible tongue-tie.
Our problems started from birth, including poor latch, slipping off the breast, lengthy frequent feeds (60-90 mins) sore nipples, poor weight gain, crying/ screaming and generally being unsettled between feeds. He was initially thought to have gastro-oesophageal reflux and started on gaviscon.
I sought help from a breast-feeding drop-in clinic, and having done some of my own research on tongue-tie I asked a breastfeeding counsellor if they would check for a posterior tongue-tie. This particular breastfeeding counsellor actually palpated for the tie by sweeping her little finger along the floor of the mouth. She described the frenulum as ‘very tight indeed’. It was divided very promptly at the tongue-tie clinic at Kings College Hospital. Posterior tongue-tie is simply a shortened, tight frenulum, tethering the posterior aspect of the tongue to the floor of the mouth. Posterior tongue-ties and similarly sub-mucosal tongue-ties must be palpated for, as they are not clearly visible and are easily missed.
Having come across classic anterior tongue-tie in infants during my clinical practice, I had never come across the term ‘posterior tongue-tie’. None of the midwives that were involved in my care, nor my GP or health visitor had ever heard of it either. My GP colleagues had also never heard of this clinical entity.
It is extremely worrying that knowledge about tongue-tie is so severely lacking. Depending on the diagnostic criteria used, it is thought the prevalence of tongue tie is between 4-10% of newborns.1 Of the 8 babies in my NCT group, 5 were tongue-tied, 3 posterior and 2 anterior. Again the diagnoses were made at a late stage, resulting in feeding difficulties, problems attaching the baby to the breast and maintaining the latch, fussy hungry babies, lengthy feeds and nipple soreness. Milk supply was also adversely affected since the babies were unable to withdraw milk effectively in the early weeks. Interestingly, the mothers of the babies who had the anterior tongue-ties were told by their GP’s and health visitors on several occasions, that their babies were not tongue-tied. Luckily these mothers persevered and sought help from trained breastfeeding counsellors who eventually made the diagnosis.
It is all very well advising health care professionals to check for tongue-tie, but I believe that most health care professionals who will have contact with the mother and baby at this early stage, will not be aware of what exactly to look for. Healthcare professionals need appropriate training in how to assess for tongue-tie. If in doubt they need to refer to a professional who does know, e.g. a lactation consultant, tongue-tie or infant feeding specialist. The information in Box 1 – taking a feeding history, is very useful, as answering yes to any of these questions should alert the healthcare professional that there is a problem which needs expert assessment.
Unfortunately as GP’s we often do not usually see the mother and baby until the 6-8 week check. If there have been feeding difficulties as a result of an undiagnosed tongue-tie, the chances are that the mother has given up breast-feeding, or is having to supplement with formula owing to nipple soreness, failure of the infant to gain sufficient weight, or a dwindling milk supply. Parents or prospective parents need to be made aware of where and how to seek help with feeding at an early stage, preferably antenatally.
Detecting a tongue-tie early and making a timely referral to an appropriate specialist (i.e. a paediatric surgeon) has the potential to make a huge impact on the short and long term health of both babies and mothers alike.
Information about tongue-tie and support with breastfeeding:
Baby Friendly Initiative
Lactation Consultants of Great Britain
La Leche League International
The breastfeeding network
Association of breastfeeding mothers:
1. Prevalence, diagnosis, and treatment of ankyloglossia: methodologic review.
Segal LM, Stephenson R, Dawes M, Feldman P
Can Fam Physician. 2007;53(6):1027.
Competing interests: None declared
Much Hadham Health Centre, Ash Meadow, Much Hadham, Herts. SG10 6DE
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Although both the original article, by Douglas and Hill, and the editorial made for interesting reading I found their lack of information on one subject very difficult.
Functional lactose overload is frequently referred to as an alternative title for lactase insufficiency, a pathology many paediatricians are at least aware of. That title is thought to describe a problem with the digestion and absorption of the breast milk. The article describes a problem with the constituents of the breast milk, something that is not widely taught.
If that is to be generally accepted as true I would suggest more education is needed. Just saying it exists and the suggesting all such patients are referred to an "international board certified lactation consultant" is not suitable for an article that is "aimed at paediatricians".
Why keep the treatment (if there is one), or the advice, from us?
Competing interests: None declared