The unsettled infant

Chris Elliot speaks to Karly Casamento about the unsettled infant. A crying baby is a common presentation to General Practice and Emergency Departments and can be very distressing for the parents. In this podcast, Karly and Chris chat about how to assess an unsettled infant. They talk about red flags and differential diagnoses, what is normal infant behaviour, when it’s time to refer, and how to reassure parents.

Summary Writer:  Lucy Coles

Script Writer:  Karly Casamento

Editor:   Karly Casamento

Interviewer:  Chris Elliot

Interviewee:  Karly Casamento

About Dr Karly Casamento

Karly Casamento is an Advanced Trainee in General Paediatrics based out of Sydney Children’s Hospital, Randwick. She is passionate about anything to do with the health of babies and children and is committed to improving Junior Medical Officer education, mental health and wellbeing. Karly is currently undertaking a research project on virtual learning environments with the University of New South Wales. She dedicates most of her time to chasing around her two energetic young boys and trying to get them to bed on time.

About Dr Chris Elliot

Chris is a Consultant Paediatrician who works in a teaching hospital in Sydney and in private rooms. As well as clinical medicine he is enthusiastic about health communication and teaching. Chris is a Conjoint Lecturer for the University of New South Wales and writes the occasional article on child health for mainstream media. He also teaches Advanced Paediatric Life Support and sits on the Editorial Board of the Journal of Paediatrics and Child Health. Chris completed his Internship at Bankstown Hospital and Paediatric training through the Sydney Children’s Hospitals Network. On the days when he is not at work he enjoys playing with his children, and also when they play by themselves.

The Unsettled Infant

With Dr Karly Casamento, Advanced Trainee in General Paediatrics at Sydney Children’s Hospital in Randwick, New South Wales, Australia

Introduction

A crying infant is incredibly distressing for parents and a common cause for presentation to general practices and emergency departments. This podcast explains the considerations in assessing an unsettled infant: how to tell red flags from normal infant behaviour, when to refer, and how to reassure parents.

Case

A 6 week old boy is brought to the Emergency Department by his parents due to persistent crying.

  • Life-threatening:
    • serious bacterial infection
    • neurological disorders
    • congenital cardiac disease
    • metabolic disease, non-accidental injury
  • Normal crying: it is normal for babies to cry for up to 4-5 hours per day, peaking at around 6 weeks of age.
  • Babies also commonly appear distressed by strange sensations, e.g. when passing wind or stool.
  • History:
    • Weight gain and feeding are reassuring if normal.
      • Feeding pattern: as a rule of thumb, normal is 120-180 mL/kg in bottle-fed babies, stretching 3-4 hours between feeds and with one wet nappy per feed.
    • Vomiting: possets and reflux are normal and best managed simply, e.g. holding upright after feeds.
    • Stool colour: anything but black or red (blood) or white (biliary disorders) is normal. Normal stool does not contain mucus.
    • Pattern of crying: concerning if crying does not settle with feeds.
    • Fevers
  • Examination:
    • Weight, length and head circumference.
      • Demonstrating normal growth can be very reassuring to parents.
      • Growth below expected may indicate an underlying medical cause for presentation.
    • Tone and development: at 6 weeks, a baby should start to smile, lift the head, and fix and follow.
    • Check for hair wrapped around fingers or toes, which can act like a tourniquet.
  • Red flags:
    • Fever, defined as temperature of 38.0 degrees or higher
    • Evidence of non-accidental injury
    • Social issues:
      • postnatal depression
      • domestic violence
      • drug use
      • mental health problems
  • Large head circumference or bulging fontanelles
  • Hepatomegaly or jaundice
  • Dysmorphic features
  • No investigations are required if the history and exam are reassuring.
  • Consider testing for occult urinary tract infection.
  • If no concerns following assessment: reassure parents, provide education (e.g. purplecrying.info website) and follow-up plans (GP, Child and Family Health Nurse, General Paediatrician).
  • Always contact paediatrics if at all concerned. Babies are sometimes admitted for overnight observation because of parental concern alone.
  • Safety netting: explain to parents that babies can change very quickly and they are always welcome to return if any new symptoms develop or they have further concerns.
  • The unsettled infant is a common presentation which is usually benign. Thorough assessment for concerning causes is required, followed by reassurance and education for the parents.
  • Do not hesitate to discuss any concerns with Paediatrics and remember that parental concern should be taken seriously.

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Tags: #babies,#bacterial infection,#communication,#congenital cardiac disease,#crying baby,#crying infant,#differential diagnosis,#dysmorphic features,#fever,#infant behaviour,#metabolic disease,#neurological disorders,#non-accidental injury,#occult urinary tract infection,#paediatrics,#parenthood,#reassuring parents,#the period of purple crying,#unsettled infant

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1 Comment

  1. Prakash

    August 25, 2022 at 9:11 am

    Wonderful talk

    Reply

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