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The Unsettled Infant – An Update

23 May 2007 7:48 AM -
  • 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)