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SA: Hello, and welcome to Master the MRCPCH. In this series, we tap into the expertise here at Great Ormond Street Hospital to give you an overview of a topic on the RCPCH exam curriculum. So whether you're revising for an exam or just brushing up on a need to know topic hopefully this podcast can give you the information that you need.
I'm Dr. Sarah Ahmed, a paediatric registrar and the current digital learning education fellow here at GOSH.
In today's episode, we're going to be talking with Dr. Alexis Bouvier, a consultant in general paediatrics at Great Ormond Street Hospital. We're going to be talking about how to approach the crying baby, covering common conditions that may cause crying and what to do if you're not quite sure what's going on.
Alexis, thank you for coming back to talk to us about an approach to the crying baby.
AB: Nice to be back.
SA: So what would you like people to get out of listening to this podcast?
AB: At the risk of sounding like a broken record from some of my recent ones – an approach to the problem, rather than just automatically worrying or not worrying, because babies and infants cry a lot, most of the time for generally benign reasons, but there are some red flags that would warrant you to look closer or think again. And hopefully we'll cover all of that today.
SA: Yes, absolutely. And like you said, this is an approach. We're not going to go into specific detail about specific conditions, although we will mention them, but this is a way of approaching that baby that you see in A&E whose parents says that they've been crying inconsolably for X number of hours.
So when should you be worried and when is it just normal baby crying?
AB: So the first bit I'd pick up on that presenting complaint of inconsolable crying would be, do I believe it to be inconsolable? Cause that's a common word that we hear, especially from parents, understandably. But from a medical perspective, and this may have come up in previous podcasts, there's a difference between what's consolable or in an older infant, distractible, what is miserable, clingy, not wanting to do much, et cetera.
And then what is irritable? When we talk about a baby being irritable, we're effectively thinking about meningism. In neonatal or infant meningitis, whether bacterial or viral, you may find that any attempt to touch or examine the child will set them off. They might be jittery, they're crying, they often be high pitched or of a different nature, for example. They may also look otherwise non specifically unwell. For example, increased work of breathing, lethargic rather than crying, etc. And of course, always check their anterior fontanelle to make sure it's neither tense nor bulging, either of which might be suggestive of raised intracranial pressure. If I or the nurses or any other doctor are able to settle down a crying child, then in my mind, I probably wouldn't call that child inconsolable. Now that's not to say that they haven't been crying for ages at home and that parents are worried and that parents’ anxiety levels have gone up. All of that is completely normal. But if I am able to settle down a crying child, my level of anxiety starts to come down because I think it's less likely that there's something nasty going on underneath.
Outside of that differentiation, I would be looking to see if parents, if I either hear a weak or particularly high pitched cry, or perhaps more usefully, if parents tell us that their baby's cry is different or not their normal cry. All babies sound slightly different to all other babies. But your baby, as it were, for parents, will have their cry. And parents are generally pretty good at saying, I know they cry every so often for whatever, but this is different. This sounds different. Listen to that.
And then the other bits, the other bit I would be worried about is if there was any abnormal examination that's suggestive of a more concerning underlying organic problem triggering this crying. So looking at the abdomen, is it distended? Is it tender? Is it hard? Is it discoloured? Do they have an incarcerated strangulated hernia, for example. Do they have tender or swollen or hot red limbs or joints from an infection or from a fracture? Or an injury? Do they have bruising? Are they pale, mottled, cool peripherally, suggestive of them being systemically unwell, thinking about something like sepsis, for example? Do they have a fever, thinking about something like infection? Are they working particularly hard with their breathing? Are they having poor pulses, poor capillary refill time, super sweaty, thinking about something like their heart, thinking about something like their chest? Are they floppy or stiff or jittery or have an unusual fontanelle suggestive of something neurological? If your examination is off, if there's something that the parents tell you in the history or if it's something that doesn't make sense in the history, because we have to consider things like NAI in the consistently crying babies. Or if the baby is truly inconsolable and moving towards irritable, those would be the crying situations that I would be more concerned about.
SA: I think you've raised some really important points there especially around parental anxiety. And we've talked about this before. It can be really difficult to hear your baby cry and to not be able to comfort them whether or not they're quote unquote, genuinely inconsolable or not. But I specifically like what you said about what's abnormal. So is there just something a little bit off in the history or in the examination that you're doing?
So bearing that in mind, how should you go about managing a baby that's been brought in with these concerns about crying?
AB: So I'm going to pick up on something you said about the parental anxiety. First of all, be sympathetic. Parents generally don't bring their child in after five minutes of crying. They bring him in after hours of crying. Especially when you're getting into the picture of colic, which is generally defined as crying for more than three hours a day for more than three days a week for more than a week in a child who's otherwise well. But this is just that it's, it's crying all the time. Why was it still crying all the time? And understandably, parents are going to get stressed. Parents are going to get tired. Parents patience for the child and for each other is going to be affected and especially in things like colic, where there's no magic bullet, although some children seem to react to things like gripe water or infacol or other medicines like that, there's not the best evidence around them. Often you just have to ride through it. And find what might work for your baby. Is it that they like being rocked? Is it that they like being driven around for example, some of it, some of the common ones, whilst just trying to do all the basics. So, thinking, could it be reflux? Make sure that you're positioning them appropriately during and after a feed, winding them, trying to avoid them getting too gassy. Is it a nappy? Making sure you're checking. Is it constipation? And on our part, thinking about things like, is it cow's milk protein for example, is it an undiagnosed UTI that might be causing it to go on. But this could go on for months, usually for should be sorted by three, four months old, but you can understand how parents are going to be anxious and stressed when they come in with a child who's been crying that long or that frequently. But again, part of your job, to manage that anxiety professionally is to thoroughly assess the child with a proper MOT. And whilst it's super important to strip down and document appropriately for all children, crying babies is the most important patient cohort to strip down fully and document having done so. That's because we're looking for things like bruises, and their joints and their skin. And if you haven't stripped down the child and that child comes back in tomorrow or a few days later with a big bruise, or not moving X limb or having a deformity that it turns out to be a fracture, how can you tell whether that had been there or has happened since? And actually that can be as simplistic as birthmarks like, um, congenital dermo melanocytosis or blue spots. Though it would be really unfortunate for parents to be accused of bruises in a child that's got blue spots, just because you didn't look at it and be able to document it at the time. So really check out your child, including stripping them down, nappy on, all the clothes off, open the nappy and then nappy back on. And that can be done quite quickly. And if you make that part of your routine spiel of practice, then parents aren't going to sound like you're suspecting them or treating their child any differently than you would do.
And once you've been able to take a full history and a full examination, that should give you a good impression of, is there something concerning going on medically or otherwise, and therefore, what do you potentially need to do about it?
SA: So what are some of the common causes of what you might call benign crying, or some of the things that you're looking for when you're examining these babies?
AB: So, simple things being simple, how's their feeding? Is it that they're just not quite getting enough? For example, if they’re bottle fed you can just calculate that in mils per kilo per day. Are they being overfed for example, and then they're vomiting or being refluxy from that. Are they being fed appropriately but are being refluxy; discomfort during feeds around feeds, vomiting after feeds back arching, maybe going red in the face, for example? Are they coming out with diarrhoea or eczema type rashes whilst being milk fed, that might suggest something like cow's milk protein. We've kind of touched on infections, so fever and just sort of a baby who's not examining well from a cardiovascular perspective or general systemic perspective.
And we've touched on an NAI. So, but from an examination perspective, if you can find anything, but also from a history perspective, if there's signs often bruises or musculoskeletal stuff that doesn't fit. i.e. there's no history of how they might have had these marks or what parents say doesn't fit to your mind with what you can see in front of you. Or if there's a vibe, and I sort of pause and put that in inverted commas because we all get vibes every so often and with experience, we tend to get better at determining which vibes we need to be worried about. And it's not just socioeconomic, it's not just whether the parents are polite to you or not, it's not just if there's a language barrier and something's getting lost in translation. Eventually you'll develop more and more of a spider sense of, is it the way that they're looking at you or not looking at you when they're talking to you? Is it how they, what questions they answer or how they're not answering, for example. If in doubt, seek senior review. Crying babies are definitely something that I would expect, if you're an SHO, your registrar should be saying, absolutely, I'll come and come and check out. And if you're a registrar, absolutely, your consultant should be happy to pop down even if just to give you reassurance that you're doing the right thing and that there's nothing else that you need to be considering.
Other common things to think about because they sometimes might get missed – UTIs in babies. They don't tell us that they've got a burning, stinging dysuria sensation. They just cry. So think about things like doing a urine dip, but if you are going to do that, do it properly, which is the boring watch and wait with a pot by parents, not a cotton wool ball in the nappy.
Strangulated hernias and testicular torsion are other things to consider. So again, once you've stripped your baby down, have a good feel around their groin and their abdomen to make sure that there are no lumps and bumps. Especially if anything looks asymmetrical, feels tense or hard, appears to be tender. i.e. causing them to cry more when you touch it or has discolouration, these features might suggest a bad umbilical, femoral or inguinal hernia or testicular torsion, with the femoral and inguinal hernias and testicular torsion especially being the ones that might get missed in babies.
Hair tourniquets don't happen very often, but can definitely get missed when they do. Often around the toes more than the fingers and they can get wrapped around really, really tightly and start to cause discoloration and, and swelling and uh, eventually potentially vascular damage to that part of the digit. So if you have a baby with no obvious reason on examination for their ongoing crying, CHECK AGAIN. You may have missed something.
And don't forget about immunizations. Somebody's jabbed them with a needle to purposefully set off their immune system, which is likely going to cause some inflammation. Whether local, for example, a sore, red or swollen vaccination site, or system specific, for example, gut pain after oral rotavirus immunization, either of which is not unexpected to cause a child to cry.
SA: So once you've seen this baby in A&E, you've done your full MOT, you've taken a really good history. Let's say the baby is still crying or you've got a vibe or a sense that something else might be off, but you can't quite put your finger on it. How would you go about managing that child?
AB: That probably fits into one of two categories. Either that's the baby you're not worried about, but parents are unable to be reassured enough to go home. And if you still can't reassure them with a little bit more time and observations, some repeat numbers, showing them sort of stats and things that are normal. Or if your senior review, for example uh, is also unsuccessful at reassuring them out of the door, then sometimes in DGHs and such like, we admit them for a few hours overnight, or depending on how your A&E works, you might have a short stay ward or clinical decision unit or a short stay unit, whatever they want to call it, where you can just keep an eye on them for a little bit longer, perhaps even just for parents to get a couple of hours sleep. And then when they've woken up, feeling a little bit more refreshed, and seeing that for another few hours, nothing bad has happened, they will generally, in my experience, be ready to go home.
Related to this is that sometimes you may even find through sensitive questioning and experience gained from talking to more and more parents, that the problem is less the normally in inverted commas crying baby, but the potential postnatal depression in the mother. At this point, I think it's important to remind listeners, but if you're ever concerned or unsure about a caregiver's mental health, please seek senior support from within your team of how to manage this, in terms of helping the parents, but also about considering the overall safety for the child.
The other one is if parents are not worried and you are worried. Um, that's often when you're starting to have vibes about non accidental injury or inflicted injury or child abuse, call it what you will. But not automatically. That can be medically. Sometimes you can be medically worried about a child and try and explain it. I'm worried that their heart rate is doing this or their breathing is doing this or their weight or their feeding or their hydration or their, whichever element of the history or examination has made you professionally concerned including investigations as appropriate or necessary. And sometimes you, parents will be like, no, no, no, it's fine. I want to go home. And if, for either a medical reason, you think the baby is not safe to go home, or for a child protection reason, you think the baby is not safe to go home, then you should be escalating that to your registrar, to your consultant as necessary and determining how much you're going to fight this parent to keep this child.
So effectively either you're happy and the parents are happy, in which case, reassurance, safety net advice, red flags. The parents are happy and you're not, in which case escalate. Or you're happy and the parents are unable to be adequately reassured within the magic four hours of A&E, for example in which case you often end up just sitting on those for a little bit longer in some area of your hospital until they're happy to go home.
SA: Yeah, never underestimate the power that six hours of observation in quieter side room or quieter part of the hospital. It can work miracles sometimes.
Ab: And these are often the ones that will be admitted on a night shift and discharged before the morning handover. Consultant might not even ever find out about them and that'd be absolutely fine. You've kept an eye on them. You've made sure nothing bad has happened. The parents have seen that nothing bad has happened. Everybody wins.
SA: And that's reassurance for the parents, but also for you as well, because sometimes you don't have an answer and it is better for everyone just to keep them a little bit to see that nothing does develop. It can be a little bit hard to convince people to admit those children, but your spidey sense and your clinical reasoning is extremely important and you should listen to that voice in your gut that's telling you to do something.
AB: I couldn't agree more. If you're not sure, it's important to be able to be brave enough to tell parents, I think something, I'm just not quite happy. Even if I'm not quite sure why I'd like to keep an eye on them for a little bit longer. Please don't be afraid to say that. You need the parents on side with you.
SA: And parents often respond quite well to that as well. I was often scared of saying that because it makes you seem like you're not the know-it-all doctor that you're quote unquote supposed to be. But actually parents respond really well when you admit that, you know, sometimes I just don't know, and I just want to keep an eye on you for a few hours.
So let's wrap up with some quickfire questions. So we ask these at the end of every podcast. So firstly, are there any exam questions that might pop up about a crying baby?
AB: I think in the written or communication, you might get your inconsolable, constantly, recurrently crying baby. And whether through extra information in the written bit or the parents give you in the communication, have to find out that actually this is colic or it's quite possibly reflux or it's quite possibly something else, and therefore what you're going to do about it. And definitely if it's in the communication station, there's going to be a lot of reassurance and probably a lot of why not doing stuff and probably a good few marks about safety netting in that.
Another communication one that could be a written, but it's probably better placed as a communication one, is the query, NAI, non-accidental injury, child abuse vibes. Whether based on something you found usually on examination, plus or minus an inconsistency with the content or the manner of the history. And having to say, I know you want to take your child home and you think everything's fine, but I'm concerned about you know this because that, and therefore there is a process which we have to do that includes social care, that includes police, that includes investigations, and you're not going home. The actor will likely be unhappy about this to varying degrees and your job would be to stick to your guns and explain the mandated process both from a legal, social care perspective and the medical perspective to ensure that the child remains in a place of safety and appropriately investigated and escalated.
Those are probably the main ones that I would see a crying baby coming up, although as we discussed there are lots of other medical or surgical reasons why a baby might be crying, and those could come up probably in, in writtens across any level.
SA: Yeah, absolutely. And we've mentioned NAI a few times and we do have a podcast coming up soon where we talk about NAI and physical abuse in a little bit more detail.
So secondly, are there any resources that you would recommend?
AB: Not as much specifically about crying baby, for crying babies as for some of the other podcasts that we've done because it's so much about the just taking a history and doing an examination. That that's just, I cannot stress that one enough. But otherwise, probably some of your local guidelines around reflux or cow's milk protein, because sometimes the management or at least the immediate management, perhaps milks wise and such differs slightly depending on where you work. Otherwise, if there are any local videos perhaps by your surgeons around how to assess for and look for things like umbilical hernias or hair tourniquets. And actually, from a baseline of safe practice and the core skills, I'd recommend looking at Don't Forget the Bubbles or DFTB, um, which is a website by healthcare professionals for healthcare professionals around paediatrics. And they have various videos or discussion pieces and advisories about crying infants, about reflux, about all kinds of things. Generally A&E targeted but the approach and definitely the, the content as it were. Children present unwell in a ward just as much as they present unwell in A&E. So the approach and the content is applicable across.
SA: Yeah, DFTB is a fantastic resource. And if you haven't already checked it out, then, then do.
And so finally to wrap up, what are your three takeaway learning points?
AB: Number one, please be sympathetic to the parent who's been sitting there with a crying infant. Even if they know that nothing is wrong with their child, they are tired and stressed. And you need to take that into account when they are talking to you and when you are talking to them.
As with most things, a thorough and full history and examination MOT type assessment of a child will generally give you the answers, if only of how worried you should be and why or why not. And within that, please strip down your baby fully, examine them fully, and document that you have done so. That is especially critical in your crying babies but definitely under one year old and it's generally a good practice anyway to examine as much of a child as possible.
And finally whilst most causes of crying are part and parcel of being a baby, your colics, your overfeeding, your nappies, your hungry, et cetera, there are some particular red flags, whether on examination or history, including if the parent thinks something is particularly different about the crying itself, that should warrant you to think again and look again, if necessary.
Can I add one last one?
SA: Of course you can.
AB: And finally, as as Sarah, you mentioned, we are able to keep an eye on children if we're not sure, and professional, observation around professional uncertainty and or parental anxiety is one of the tools that we generally have. And the ability to be able to explain that and pass that across to parents is one of the skills that we should all be pushing to acquire.
SA: Absolutely. Thank you so much, Alexis, for taking the time to talk to us today.
AB: You are most welcome. Pleasure as always.
SA: Thank you for listening to this episode of Master the MRCPCH. We would love to get your feedback on the podcast and any ideas you may have for future episodes. You can find link to the feedback page in the episode description, or email us at
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