The Unsettled Infant – An Update

23 May 07

•Unsettled infants are predominately <6mths of age
•Crying is a normal response
•Crying increases from birth and peaks at 6-8 weeks
•Average duration 30-180mins per day, concentrated in evenings
•Usually subsides by 3-4 months

Persistent crying = more than 3 hours/day, 3 days a week for 3 consecutive weeks

Often classified as ‘colic' – occurs in 20% of babies

NON-ORGANIC CAUSES (>90% OF CASES)

TIREDNESS

unsettled, clenched fists, jerking movements of arms and legs
parents should be encouraged anØd assisted in keeping a strict routine, self-settling techniques (e.g. ‘controlled settling' techniques).

HUNGER

frequent (<2hrly) feeding, poor settling after feeds, poor weight gain (normal 150-200g/week).
review maternal supply, feeding technique, feeding routine. Lactation consultant if reqd or available.

COLIC

unexplained paroxysms of irritability, fussing or crying for 3:3:3
often late afternoon and evening (when everyone is tired and cranky !)
significantly improved by 3-4 months
incidence 5-19% depending on study and parameters

MATERNAL ANXIETY/DEPRESSION

the importance of the ‘mother:baby dyad'
screen mother for biopsychosocial risks for PND and anxiety disorders
explain the dyad concept to parents.

INABILITY TO SELF-SOOTHE

INFANT TEMPERAMENT

familial/genomic influences

ORGANIC CAUSES (<10% OF CASES)

GASTRO-OESOPHAGEAL REFLUX DISEASE

tends to be over-diagnosed, especially children < 3 mths old
presents with vomiting, regurgitation, excessive crying & irritability, persisting after 3 months of age
food refusal, feeding difficulties, blood in vomit, poor weight gain
persistent cough or wheeze, apnoea episodes
strong family history of allergy – consider food allergy and eosinophilicØ oesophagitis
trial of PPI acid suppression therapy (Losec/Zoton)

FOOD PROTEIN SENSITIVITIES (DAIRY, GOAT, SOY)

cow's milk allergy affects 2% of infants under 2 years. 80% resolve by age 5 yrs
often over-diagnosed or mis-diagnosed
often confused with lactose intolerance by parents and health professionals
wide range of presenting symptoms, including anaphylaxis/angioedema/urticaria, eczema, colic, reflux disease and oesophagitis, proctocolitis & enterocolitis (bloody diarrhoea)
<6mths – dietary elimination and rechallenge
>6mths – RAST blood testing, skin prick testing

LACTOSE INTOLERANCE

primary lactose intolerance is rare
over-diagnosed by parents, health professionals and complementary medicine practitioners
most commonly transient, relative lactase deficiency (due to excellent maternal supply – lactose overload)
fussiness, excessive crying, flatulence, frequent explosive watery stools, perianal excoriation
Stool for reducing substances most common diagnostic test
Small bowel biopsy – gold standard for diagnosis
Could use Lactase drops 12-24 hours prior to breast feeding. Soy or lactose-free formulae in bottle fed babies.

EOSINOPHILIC OESOPHAGITIS

related to severe food protein sensitivity
usually overlaps with reflux disease in babies with obvious personal or family histories of allergy
diagnosed by endoscopy and biopsy
treat with dietary elimination of proteins in question (defined by RAST or SPT), combined with PPI acid suppression
usually co-managed with paed or paed gastro

OTHER CONSIDERATIONS

infection (UTI, meningitis, otitis media, viral illness, oral thrush)
neurological causes (cerebral palsy, developmental delay, hydrocephalus)
withdrawal of illicit drugs (babies of heroin-addicted mothers)
surgical reasons (incarcerated hernia, volvulus – bile stained vomiting)

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