Evaluation and Management of Uncontrollable Crying in Infants

Normal Developmental Context

Crying begins in the first month of life and increases progressively until peaking between 2-4 months of age, making a 2-week-old infant at the early phase of this normal developmental curve 1
Understanding this timeline is critical because crying is the most common trigger of abusive head trauma, and almost all parents of infants who suffered abusive head trauma had previously sought help from their physician for their infant's crying 2

The American Academy of Pediatrics specifies concerning features that mandate workup, including bilious vomiting, gastrointestinal bleeding, fever, lethargy, hepatosplenomegaly, and abdominal tenderness or distension 1
Perform serum glucose, calcium, and magnesium testing immediately, as hypoglycemia, hypocalcemia, and hypomagnesemia are common provoked causes of excessive crying and jitteriness that require immediate reversal 3
Fractures or other trauma should be considered as a potential cause, particularly given that this is the peak age for abusive head trauma risk 1, 3
Obtain a comprehensive maternal drug history, as neonatal withdrawal has increased 10-fold in recent years, with opioids causing withdrawal in 55-94% of exposed neonates, SSRIs presenting with tremors, irritability, and jitteriness, and benzodiazepines causing tremors and jitteriness 3

This is the peak age for abusive head trauma risk, with crying being the most common trigger, and almost 6% of parents of 6-month-old infants admit to smothering, slapping, or shaking their infant at least once because of crying 1
Counsel parents explicitly that it's safe to put the baby down in a safe place and take a break if overwhelmed, and implement the Period of PURPLE Crying education program to improve mothers' knowledge about crying and behavioral responses 1, 2

Gentle motion, rhythmic movement, and white noise can calm the overstimulated infant, and parents should avoid overstimulation from excessive tactile, visual, auditory, and kinesthetic stimuli 1
Parents should remain calm and serve as an "emotional container" for the infant's strong emotions, and establish protective routines using visual and verbal cues for mealtimes and sleep times 1, 2

Never use proton pump inhibitors—they are ineffective and carry risks including pneumonia and gastroenteritis, and recognize that repeated stress without adequate support makes children progressively more vulnerable to future stressors, not more resilient 1, 2
Adults who are socially isolated may lack standards for comparison of their child's behaviors or resources for themselves, which can exacerbate stress and increase risk for abuse 4

Opioid exposure during pregnancy leads to neonatal withdrawal in approximately 55 %–94 % of exposed infants; symptoms typically begin 24–72 hours after birth but may be delayed up to 5–7 days or longer. (American Academy of Pediatrics) 5
Maternal use of barbiturates can cause severe neonatal tremors, with onset either within the first 24 hours of life or delayed up to 10–14 days. (American Academy of Pediatrics) 5

Common environmental factors that can provoke excessive crying in infants include uncomfortable temperature, the need for repositioning, teething discomfort, and a wet or soiled diaper. (Intensive Care Medicine Society) 6

The American Academy of Pediatrics recommends that clinicians systematically inquire about who witnessed the crying episode, the setting, the infant’s position, and state to contextualize the event. 7
Clinicians should document muscle tone changes, breathing patterns, color changes, and level of responsiveness during crying episodes to identify possible neurologic or respiratory contributors. 7
The duration of each crying episode and the interventions that successfully terminate crying (e.g., feeding, soothing) should be recorded to guide management decisions. 7
A recent history of fever, upper‑respiratory symptoms, vomiting, diarrhea, or reduced oral intake must be explored, as intercurrent illness can precipitate excessive crying. 7

The presence of multiple, evolving, or contradictory accounts of the crying episode is a red‑flag for potential caregiver‑inflicted injury and should prompt further evaluation. 7
Reports that are inconsistent with the infant’s developmental capabilities (e.g., crying patterns that exceed expected motor or communicative milestones) warrant heightened suspicion for abuse. 7
Unexplained bruising noted on physical examination or reported by caregivers should be considered a concerning historical feature suggestive of possible maltreatment. 7