Irritable baby Flashcards
Important features on history for presentation of irritable/unsettled baby
Antenatal and birth history
Time course of issue - gradual vs. acute - exclude serious infection, organic cause
Crying - duration, frequency, pattern, day vs. night, what they do to manage
Sleep hx - number of hours, pattern
Feeding - what, how long BF, how much and frequency, solids (timing of introduction, what), behavioural issues with feeding/eating, irritable after feeds or settles with feeds, any problems with feeding/BF
Bowels - frequency of stools, mucus, blood, frothiness, greasiness, smell, pale, consistency, relationship to feeds/eating, ulceration around anus
Vomiting - nature of vomit - bile, blood, milk. Relationship to meals, seems well or irritable between, still hungry
Urine - any issues? decreased wet nappies
Weight, growth & development
Hx eczema, rash, allergies/atopy
Vaccinations
FHx - atopy, coeliac, IBD
MATERNAL MENTAL HEALTH SCREEN
- mood
- supports
- shaking the baby
DDx for irritable baby
If acute/change from previously settled baby - exclude serious cause - infection, surgical abdo etc
Normal behaviour
- Parent’s with unrealistic expectations, limited knowledge, MH issues
Chronic organic
- Reflux
- Cow’s milk protein allergy
- Lactose overload/malabsorption
- Coeliac disease
Management strategies for irritable baby who is clinically well
- Reassurance
- Parental education
- Normal crying
- Normal bowels, vomiting
- Normal sleeping - Behavioural strategies
- Controlled crying
- Camp out method - Screen and monitor maternal/parental MH
Definition of colic
Crying for >3 hours, >3 days a week, >3 months with no medical cause
90% inconsolable crying has no medical cause
What Ix can be considered if clinically indicated?
Urine MCS - exclude UTI as cause
Stool sample - reducing sugars or pH<5 suggestive of lactose overload/malabsorption
Coeliac disease screen - Anti-tTG (Tissue transglutimase antibody), follow up with gastroscopy + biopsy
What are the clinical features of reflux in an infant?
Regular vomiting after feeds (>4/day)
Issues with feeding - back swallowing, coughing/choking, food refusal
Generally doesn’t affect weight/growth but if severe can be a cause of FTT
Can be associated with respiratory symptoms (aspiration) - cough, wheeze, apnoeas
Typically starts 1-2 weeks after milk comes in if breast feeding
What are Rx options for likely GORD in an infant?
- Exclude other causes of vomiting - infection (esp. UTI), vomiting
- Generally no investigations
- Reassure it is a benign and self-limiting condition
- Milk thickeners (add to formula or expressed breast milk)
- Advise smaller, regular feeds
- Prone positioning after feeds if being closely monitored and baby is awake
- consider trial of hydrolysed formula
- PPIs and H2-antagonists can be used
What are the clinical features of cow’s/soy milk protein allergy?
Two chronic types - proctolitis, enteropathy
Non-IgE (delayed) food mediated allergy
Enteropathy - chronic diarrhoea, vomiting ++, irritability and FTT. Typically only formula (not BF infants)
Proctolitis - blood in stools, generally well with no weight gain, can occur in BF and formula fed infants
Typically resolves after 18-24 months
What are the Rx options for cow’s/soy milk protein allergy?
Trial hydrolysed formula - improvement in symptoms confirms likely diagnosis
If BF - elimination diet for mother
What are the clinical features of lactose overload/malabsorption?
Frothy, watery diarrhoea
Excoriation/ulceration of perianal area
Food refusal
Rare - may be functional (overload due to foremilk ++) or secondary due to infection/mucosal injury from milk protein allergy
What are management options for lactose overload/malabsorption?
- Diagnosis confirmed with stool sample (reducing sugars, pH<5) and response to feed changes
- If breast feeding - block feed to decrease foremilk consumption (has the most lactose)
- If formula trial lactose-free formula
How can you describe normal infant crying to a parent?
PURPLE
- Peak of crying - usually settled in hospital and first 1-2 weeks, then from 2 weeks - 3/4m will become increasingly unsettled with peak at 6-8w
- Unexpected - may be no reason for crying, start/stop suddenly
- Resist soothing - may be unconsolable
- Pain like expression - may look like they’re in pain but generally they’re not
- Long lasting - average, low and high criers - on average cry ~3hrs/day and can cry up to 5-6hr/day
- Evening - tends to be worse in the afternoon/evening
What are normal feeding and bowel habits to explain to parents?
Feeding
- Normal to wake for feeds ~2-3 hours
- Normal to have small vomits (posits) after feeds - usually not painful or resulting in weight loss
Sleeping
- Normally 16-17 hours/day - 7 during day, 9 overnight
- Have light and deep cycles - may open eyes, jerk etc - need to settle back to sleep
- Self-soothing/settling is a learned skill
- Structure, routine, predictability of cues and settling techniques are important in child learning to self-sooth
