Cry duration differs by culture and infant care practices. For example, !Kung San hunter−gatherer infants, who are continuously carried and fed four times per hour, cry 50% less than infants in the United States. Crying may also relate to health status. Premature infants cry little before 40 weeks gestational age but tend to cry more than term infants at 6 weeks’ corrected age. Crying behavior in former premature infants also may be influenced by ongoing medical conditions, such as bronchopulmonary dysplasia, visual impairments, and feed-
Colic often is diagnosed using Wessel’s rule of threes—crying for more than 3 hours per day, at least 3 days per week, for more than 3 weeks. The limitations of this definition include the lack of specificity of the word crying (e.g., does this include fussing?) and the necessity to wait 3 weeks to make a diagnosis in an infant who has excessive crying. Colicky crying is often described as paroxysmal and may be characterized by facial grimacing, leg flexion, and passing flatus.
Fewer than 5% of infants evaluated for excessive crying have an organic etiology. Because the etiology of colic is unknown, this syndrome may represent the extreme of the normal phenomenon of infant crying. Nonetheless evaluation of infants with excessive crying is warranted.
Cumulative incidence rates of colic vary from 5% to 19% in different studies. Girls and boys are affected equally. Studies vary byhow colic is defined and by data collection methodology, suchas maintaining a cry diary or actual recording of infant vocalizations. Concern about infant crying also varies by culture, andthis may influence what is recorded as crying or fussing.
ing disorders. The duration of crying is often modifiable by caregiving strategies.
Frequency of crying is less variable than duration of crying. At 6 weeks of age, the mean frequency of combined crying and fussing is 10 episodes in 24 hours. Diurnal variation in crying is the norm, with crying concentrated in the late afternoon and evening.
The intensity of infant crying varies, with descriptionsranging from fussing to screaming. An intense infant cry(pitch and loudness) is more likely to elicit concern or evenalarm from parents and caregivers than an infant who fretsmore quietly. Pain cries of newborns are remarkably loud:80 dB at a distance of 30.5 cm from the infant’s mouth. Although pain cries have a higher frequency than hungercries, when not attended to for a protracted period, hungercries become acoustically similar to pain cries. Fortunatelymost infant crying is of a lesser intensity, consistent withfussing.
Hours of fussing per day
Figure 11-1 Distribution of total crying time among 80 infants studied from 2 to 12 weeks of age. Data derived from daily crying diaries recorded by mothers. (From Brazelton TB: Crying in infancy. Pediatrics 29:582, 1962.)
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The clinician who evaluates a crying infant must differentiate serious disease from colic, which has no identifiable etiology. The history includes a description of the crying, including duration, frequency, intensity, and modifiability. Associated symptoms, such as leg flexion, facial grimacing, vomiting, or back arching, should be identified. Other important historical clues include the onset, diurnal pattern, any changes in quality, and triggers or activities that relieve crying. A review of systems can identify or eliminate other serious illnesses. Medical history also is important because infants with perinatal problems are at increased risk for neurologic causes of crying. Attention to the feeding history can reveal feeding-related problems, including hunger, air swallowing (worsened by crying), gastroesophageal reflux, and food intolerance. Questions concerning the family’s ability to handle the stress of the infant’s crying and their knowledge of infant soothing strategies assist the clinician in assessing risk for parental mental health comorbidities and developing an intervention plan suitable for the family.