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Crying baby: sorting out the symptoms

Every day GPs face symptoms which they have to make sense of. GPs Dr Keith Hopcroft and Dr Vincent Forte kick off their new series which looks at some common presentations and offers guidance on likely causes, how to come to sensible conclusions and when alarm bells should ring.

Every day GPs face symptoms which they have to make sense of. GPs Dr Keith Hopcroft and Dr Vincent Forte kick off their new series which looks at some common presentations and offers guidance on likely causes, how to come to sensible conclusions and when alarm bells should ring.

The GP overview

This is a very frequent reason for an out-of-hours call. A baby's cry is almost impossible for parents to ignore. When crying continues unabated in spite of all that parents can do to settle an infant, parental distress sets in and they will turn to you for answers and a solution.

Differential diagnosis

Common

• normal

• colic

• constipation

• teething

• viral illness

Occasional

• otitis media or externa

• severe nappy rash or inflamed foreskin

• gastroenteritis

• UTI

• after immunisation

• respiratory distress – severe bronchiolitis, chest infection, croupy cough

Rare

• non-accidental injury

• mastoiditis

• meningitis, encephalitis

• septicaemia

• bowel obstruction including intussusception and strangulated hernia

• appendicitis

• osteomyelitis

• testicular torsion

• undiagnosed birth injury, such as a fractured clavicle

• congenital disorders, such as Hirschprung's disease or pyloric stenosis

Possible investigations

Likely None, other than those performed after admission.

Possible Swab of any obvious discharge.

Small print See hospital investigations (below).

• Other than a swab for obvious discharge – for example in otitis externa – no investigations are appropriate in general practice. If no obvious cause is found and the baby continues to be distressed, admission for observation and investigation is mandatory.

• Secondary care investigations are likely to include urinalysis, MSU for bacteriology, bloods for FBC, ESR, glucose, U&Es and many others depending on the indication – such as CXR, AXR, lumbar puncture, blood gases.

Top tips

• Babies cry on average for one-and-a-half to two hours per day. Some normal babies cry more than this or for long periods for no apparent reason.

• Remain calm and sensitive. Parents of a crying baby are often distraught, and whatever your perception of the seriousness or not of the situation, make a thorough assessment and make sure the parents understand you are taking them seriously.

• Always explain your findings and advice clearly, and make sure the parents understand you. Write things down for them if necessary. Your patients depend completely on your communication skills.

• Remember the obvious – babies may cry because of tiredness, hunger, wind after feeds, boredom, and uncomfortably full nappies. Never assume that parenting skills are 100%, and do explore baby care issues that may seem to be too obvious to ask about.

• Babies may be unsettled and cry more for a day or two after immunisation.

• If a baby is crying excessively for longer than 48 hours after immunisation, it is unsafe to diagnose immunisation as the cause without clinical assessment.

• Telephone advice calls may be handled with careful triage and advice alone, providing there is always a fallback plan for the parents to call back or seek further advice if things do not settle rapidly. There is no substitute for a hands-on clinical assessment and, if in the slightest doubt, always see the baby as soon as possible.

• Observe in the most general way how a baby handles during examination. Irritability on handling is a very important general sign. Regardless of other findings, this alone can be a reason to refer for paediatric assessment.

• There is no clear physiological reason why babies should develop a fever during teething, but there is no doubt this happens in some babies, in spite of traditional medical teaching to the contrary. A fever is never high if caused by teething alone. The fever of teething is usually very short-lived – less than 24 hours – whereas a fever caused by a viral infection can go on for several days.

• Babies cannot tell us what's wrong, but they can tell us something's wrong. If in any doubt about the diagnosis, seek a second opinion or a paediatric assessment. Always follow your sixth sense, intuition or personal alarm bells. Thoughtful and experienced paediatricians will respect your feeling on this, so do not worry if you can't justify your referral on textbook clinical criteria.

Dr Keith Hopcroft is a GP in Basildon, Essex

Dr Vincent Forte is a GP in Gorleston, Norfolk

Red flags Red flags

• Be aware of the possibility of non-accidental injury as a cause for the baby crying. If you detect unusual anxiety or unusual emotional detachment from the calling parent, make sure you see the baby and examine it thoroughly.

• A baby that has been crying a lot and goes on to become lethargic – as opposed to a normal calm state – is probably very ill. Even if you are unsure of the diagnosis, follow your intuition and arrange a paediatric opinion.

• A constantly bulging fontanelle is always an indication for immediate paediatric referral.

• Be sure to observe the general muscular tone of a crying baby. Constant stiffness or floppiness are ominous signs and immediate referral is indicated.

Crying baby

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