By Barbara Howard, MD
All babies cry, of course, but some babies cry a lot.
In the old days, these babies were labeled “colicky.” These days, they're often labeled GER (gastroesophageal reflux, basically “spitting up”) babies, or they may be diagnosed with the more specific condition, GERD (gastroesophageal reflux disease), many times without good reason.
As in times past, the vast majority of these crying infants are not ill, but perhaps suffering from overstimulation or an immature digestive system. A rare few will have real pathology: true GERD, allergies, or even a volvulus of the bowel.
Keep in mind that although your level of concern may be low as you rule out things like otitis, parents’ level of concern is off the charts. Faced with a screaming baby under 2 months of age, new parents are thinking, “Will our child survive?” In what has been referred to as the fourth trimester, the baby is part of the mother psychologically; her inability to comfort her infant is emotionally devastating.
The baby is inconsolable, there is no quick fix, and your relationship with a new family is on the line. A crying infant, then, represents both a golden opportunity and a time-consuming burden.
What's more, the stakes couldn't be higher because a third of child abuse occurs in the first 6 months of life. Why on earth would parents vigorously shake a defenseless newborn or hurl a baby against a wall? Because the parents are exhausted, and the baby won't stop crying despite traditional interventions: breastfeeding or bottle feeding, a new diaper, rocking, and cradling.
Often, pediatricians grasp at a solution that's quick to implement, advising a switch of formulas or worse, suggesting that a breastfeeding mother switch to formula. Unless the baby has real diarrhea, real vomiting (not “spitting up), a rash, or hives, I'd recommend against this option, which in fact is not a benign intervention.
One study found that when infant formulas are switched, years later parents are more likely to falsely believe their child has gastrointestinal disease. By the time these children are in preschool, they are statistically more likely to be overprotected by their parents.
What's more, right from the start, you will have established a precedent leading to the slippery slope of non-evidence-based medicine. These parents will come to expect that when there is a problem, you're going to write a prescription. And because of a placebo effect for any intervention of about 40% plus the time-limited nature of crying, they're quite likely to believe the medical solution worked, and come to depend on your signature on the next script as well.
A better alternative is to undertake a systematic overview of the problem, just as you would with a medically urgent symptom. No matter how smart you are, or how many years you've been treating healthy crying babies, do a careful physical examination. You may find real pathology and surprise yourself, but more importantly, you're being watched. Desperate parents are studying you to decide whether you are taking seriously their baby's obvious distress and their profound concern.
Next, of course, take an equally thorough history.
Look for patterns. How old is this baby? (Colic is technically defined as crying for at least 3 hours a day, at least 3 days a week, starting before 3 months of age post-term.) The onset of developmentally normal crying is usually at 2 weeks and the peak of 2 3/4 hours per day of crying is at 6–8 weeks post term. Importantly, does this inconsolable crying occur during one part of the day, in contrast to hours spent as a happy, engaged, easily soothed baby?
This last point is critical to elicit because it establishes evidence that formula or breast milk is not the problem. Presumably, the baby consumes the same food throughout the day and digests it fine most of the time.
Occasionally, underfeeding (especially in a baby younger than 2 weeks of age and breast fed) or overfeeding (marked by lots of spitting-up) can be the source of the excessive crying.
Obtain a specific history of the worst crying day ever. If that day included a trip to the store, a baby shower with 15 people, and a long play session with new toys, the ensuing discussion of ove