Crying Baby

Differential Diagnosis

Common Diagnoses

  • Normal
  • Colic
  • Constipation
  • Teething
  • Viral Illness

Occasional Diagnoses

Rare Diagnoses

  • Non-Accidental Injury
  • Mastoiditis
  • Meningitis, Encephalitis
  • Septicaemia and sepsis
  • Bowel Obstruction including Intussusception and Strangulated Hernia
  • Appendicitis
  • Osteomyelitis
  • Testicular torsion
  • Undiagnosed Birth Injury, e.g. Fractured Clavicle
  • Congenital Disorders, e.g. Hirschprung’s Disease, Pyloric Stenosis

Ready Reckoner

Key distinguishing features of the most common diagnoses

NormalColicConstipationTeethingViral Illness
Reduced FeedingNoPossiblePossiblePossibleYes
DroolingNoNoNoYesPossible
Straining at StoolNoNoYesNoNo
FeverNoNoNoPossibleYes
Recurrent Bouts of CryingPossibleYesPossiblePossibleNo

Possible Investigations

Likely:None other than those performed after admission.

Possible:Swab of any obvious discharge.

Small Print:See hospital investigations.

  • Other than a swab for obvious discharge (e.g. in otitis externa), no investigations are appropriate in general practice – if no obvious cause is found and the baby continues to be distressed, admission for observation and investigation is mandatory.
  • Secondary care investigations are likely to include urinalysis, MSU for bacteriology, bloods for FBC, ESR, glucose, U&E, and many others depending on the indication (e.g. CXR, AXR, lumbar puncture, blood gases).

Top Tips

  • Babies cry on average for 1½ to 2 hours per day. Some normal babies cry more than this or for long periods for no apparent reason.
  • Remain calm and sensitive. Parents of a crying baby are often distraught, and whatever your perception of the seriousness or not of the situation, make a thorough assessment and make sure the parents understand you are taking them seriously.
  • Always explain your findings and advice clearly, and make sure the parents understand you. Write things down for them if necessary. Your patient depends completely on your communication skills.
  • Remember the obvious – babies may cry because of tiredness, hunger, wind after feeds, boredom, and uncomfortably full nappies. Never assume that parenting skills are 100%, and do explore baby care issues that may seem to be too obvious to ask about.
  • Babies may be unsettled and cry more than normal for a day or two after immunisation. If a baby is crying excessively for longer than 48 hours after immunisation, it is unsafe to diagnose immunisation as the cause without clinical assessment.
  • Telephone advice calls may be handled with careful triage and advice alone, providing there is always a fall back plan for the parents to call back or seek further advice if things do not settle rapidly. There is no substitute for a hands-on clinical assessment, and if in the slightest doubt, always see the baby as soon as possible.
  • Observe in the most general way how a baby handles during examination. Irritability on handling is a very important general sign. Regardless of other examination findings, this alone can be a reason to refer for paediatric assessment.
  • There is no clear physiological reason why babies should develop a fever during teething, but there is no doubt this happens in some babies, in spite of traditional medical teaching to the contrary. A fever is never high if due to teething alone. The fever of teething is usually very short-lived – less than 24 hours – while a fever caused by a viral infection can go on for several days.
  • Babies cannot tell us what’s wrong, but they can tell us something’s wrong. If in any doubt about the diagnosis, seek a second opinion or a paediatric assessment. Always follow your sixth sense, intuition or personal alarm bells. Thoughtful and experienced paediatricians will respect your feeling on this, so do not worry if you can’t justify your referral on textbook clinical criteria.

Red Flags

  • Be aware of the possibility of non-accidental injury as a cause for the baby crying. If you detect unusual anxiety, or unusual emotional detachment from the calling parent, make sure you see the baby and examine it thoroughly.
  • A baby that has been crying a lot and goes on to become lethargic (as opposed to a normal calm state) is probably very ill. Even if you are unsure of the diagnosis, follow your intuition and arrange a paediatric opinion.
  • A constantly bulging fontanelle is always an indication for immediate paediatric referral.
  • Be sure to observe and note the general muscular tone of a crying baby. Constant stiffness or floppiness are ominous signs and immediate referral is indicated.

Published: 2nd August 2022 Updated: 10th April 2024

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Based on the best-selling book Symptom Sorter. Pulse Reference is designed to help GPs make sense of patient presentations. It analyses a multitude of symptoms commonly seen in primary care and for each presents differentials, distinguishing features, possible investigations and key points. It also provides guides on managing more than 350 conditions. The perspective is very much grass roots primary care, informed by the latest evidence and guidance.

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Disclaimer

Pulse Reference is based on the best-selling book Symptom Sorter. The experts behind Pulse Reference are Dr Keith Hopcroft who is the co-author of Symptom Sorter, a GP in Essex and Pulse’s editorial advisor and Dr Poppy Freeman, a GP in Camden and also a clinical advisor to Pulse. This website is for clinical guidance only and cannot give definitive diagnostic information. Practitioners should work within the limits of their individual professional practice, seek guidance when necessary and refer appropriately.