No single event in my lifetime has transformed the practice of pediatrics more than the novel coronavirus (COVID-19) pandemic. Since the time of Hippocrates, the medical encounter has been an in-person experience. I walk into a room, shake your hand, sit close by and listen to your concerns. Then I lean over your baby, conduct a thorough exam (playing with her, tickling her, smiling close to her face) and sit back down to talk about what we think is going on and agreeing on a plan.
Now we have the SARS-CoV-2 virus, and suddenly we are avoiding close interactions “like the plague,” a phrase I enjoyed more when it was a figure of speech. All over the world, pediatricians like me and their patients are asking themselves, “Do I really need an office visit for that?” Fortunately, this crisis arrives just as remote visits (telemedicine) are gaining widespread acceptance.
Today I want to look at one of the most common complaints we address for new parents — infant tummy trouble — and consider what you can do at home, when to contact your doctor, and when you might have to brave an office visit. There’s enough here for two blogs, so this will be Part One.
First, the usual disclaimer: here I’m talking about fussy infants in general, but I don’t know your fussy infant. As always, if you’re concerned about a health issue with your baby, please contact your doctor’s office.
Newborns cry a lot, especially between the ages of 2 weeks and 2 months. Some people who may not have been home with newborns before are now learning just how much they cry. We smile a bit at that idea, but pediatricians are also concerned that frustrated, anxious parents with nowhere to turn for relief with be more prone to child abuse than in the past. Anything we can do to help with this frustration may literally save lives!
Around 1 in 6 families consult a healthcare provider about infant crying. While the vast majority of this fussiness is normal, inconsolable crying (crying that does not resolve with feeding, sleep, diaper changes, rocking) can be a sign of serious illnesses such as meningitis or twisted intestines. Most cases, however, fall under the heading of “colic,” an ancient term that we have come to define as crying in the newborn period that lasts more than 3 hours a day more than 3 days a week.
Colic often strikes at the same time every day, usually in the evening, and then goes away as suddenly as it came on. Except for when they’re crying, colicky babies feed, gain weight and develop normally. Colic never comes with fever (rectal temperature of 100.4℉ or more), weakness, or blue/pale skin, all signs of serious illness that should prompt an immediate call to your baby’s doctor.
For most of my career colic was one of the great mysteries of pediatrics: no one knew what caused it or what to do about it. Folk remedies flourished; they made as much sense as anything we doctors had to offer. I recommended swaddling, an ounce of chamomile tea and long car trips, whatever was safe and might help.
Now, however, clues are starting to point to both a cause for the fussiness, spitting, and hard stools that afflict so many infants and toward a low-risk solution that many parents and doctors can embrace: intestinal bacteria(the microbiome) and prebiotics, the substances that feed them (human milk oligosaccharides or HMO’s). The next blog is going to explore these issues in greater detail, but first let’s talk about when to call the doctor and when you might have to go in for a visit.
Crying that you can console and that lasts less than 3 hours less than 3 days a week is normal, especially if feeds and bowel movements are normal. Spitting up with feeds occurs to some extent in nearly all newborns. Breast milk or formula coming from the mouth and even the nose is to be expected, even if curds are visible.
Spitting worries us when it shoots forcefully from the mouth (projectile vomiting), is green-yellow in color (may contain bile) or contains fresh blood or old blood that looks like coffee grounds. If feeds seem painful to your infant — she is arching or crying with feeding — she may have a protein allergy or a concerning degree of reflux. Poop concerns us when it is very hard (like marbles or balls), is very watery and frequent, or contains visible blood or mucous. Any of these observations should prompt you to call your baby’s doctor about a possible visit, even after hours.
(Inconsolable crying pro tip: if the crying started recently and seems unusual, carefully check each finger and toe to make sure a hair isn’t wrapped around it causing a painful “hair tourniquet.”)
Normal growth reassures us as well. Most pediatric offices are still scheduling routine well child exams for infants, but in some places mothers of newborns are going home with baby scales and tape measures so they can call growth figures in and skip a visit. Most adult scales are not precise enough to measure the ounces that can make the difference between normal and abnormal growth in the first few months of life. Your baby’s doctor will plot her weight, length and head circumference on standard charts to confirm that she is growing well.
If growth is good, feeds are normal, and none of the above “red flag” signs is present, then by all means call your baby’s doctor if you’re worried, but in the next post we’ll consider some things you might try to prevent and treat crying, spitting, and hard stools.
*#Sponsored Dr. David Hill is a paid consultant to Gerber.