How should a 2‑month‑old infant with continuous crying be evaluated and managed?

Evaluation and Management of Incessant Crying in a 2-Month-Old Infant

Immediately exclude serious organic causes before attributing crying to normal developmental patterns or benign colic, as this is the peak age for both physiological crying and life-threatening conditions including abusive head trauma, metabolic emergencies, and incomplete Kawasaki disease. 1, 2

Critical Context: This is a High-Risk Age

• Crying peaks between 2-4 months of age, making this infant at the apex of normal developmental crying. 2, 3
• This is simultaneously the peak age for abusive head trauma, with crying being the most common trigger—almost 6% of parents admit to smothering, slapping, or shaking their infant at least once because of crying. 2, 3
• Almost all parents of infants who suffered abusive head trauma had previously sought help from their physician for crying, making this visit a critical intervention point. 2

Step 1: Exclude Life-Threatening Organic Causes First

Immediate Laboratory Testing Required

• Obtain serum glucose, calcium, and magnesium immediately—hypoglycemia, hypocalcemia, and hypomagnesemia are common, easily reversible causes of excessive crying and jitteriness. 1, 2

Red-Flag History and Physical Examination

• Assess for bilious vomiting, gastrointestinal bleeding, fever, lethargy, hepatosplenomegaly, or abdominal tenderness/distension—any of these mandate urgent workup. 2, 3
• Examine carefully for fractures or trauma, particularly unexplained bruising, as this is peak age for abusive head trauma. 1, 2
• Obtain comprehensive maternal drug history—neonatal withdrawal has increased 10-fold, with opioids causing withdrawal in 55-94% of exposed neonates (onset 24-72 hours but may be delayed 5-7 days), SSRIs causing tremors and irritability, and barbiturates causing severe tremors (onset within 24 hours or delayed 10-14 days). 2
• If fever is present, consider incomplete Kawasaki disease, particularly as infants <6 months are at highest risk for coronary artery abnormalities. 1

Abuse Screening Elements

• Document who witnessed the crying, the setting, infant's position, muscle tone changes, breathing patterns, color changes, and level of responsiveness. 2
• Multiple, evolving, or contradictory accounts are red flags for caregiver-inflicted injury. 2
• Reports inconsistent with developmental capabilities warrant heightened suspicion. 2

Step 2: Evaluate for Common Benign Organic Causes

Cow's Milk Protein Intolerance

• Consider cow's milk protein intolerance if irritability is accompanied by poor feeding or intermittent symptoms—initiate a 2-4 week trial of maternal dietary elimination (milk and eggs) in breastfed infants or switch to extensively hydrolyzed formula in formula-fed infants. 1, 3
• Feeding difficulties are significantly associated with pathological gastroesophageal reflux (p=0.02). 4

Gastroesophageal Reflux

• Regurgitation more than 5 times daily has 70.9% specificity for pathological reflux, though positive predictive value is only 22.2%. 4
• In the absence of frequent regurgitation (>5 times daily) or feeding difficulties, pathological GOR is unlikely (negative predictive value 87-90%). 4
• Never prescribe proton pump inhibitors—they are ineffective for uncomplicated reflux and carry significant risks including pneumonia and gastroenteritis. 1, 3

Environmental Triggers

• Assess for uncomfortable temperature, need for repositioning, teething discomfort, and wet or soiled diaper. 2

Step 3: Management of Normal Developmental Crying (After Exclusion of Organic Causes)

Immediate Parental Safety Counseling (Critical)

• Counsel parents explicitly that it is safe to put the baby down in a safe place and take a break if overwhelmed—this is mandatory anticipatory guidance at this peak-risk age. 2, 3
• Implement the Period of PURPLE Crying education program to improve mothers' knowledge about crying and behavioral responses. 2

Soothing Techniques

• Use gentle motion, rhythmic movement, and white noise to calm the overstimulated infant. 2, 3
• Avoid overstimulation from excessive tactile, visual, auditory, and kinesthetic stimuli. 2, 3
• Parents should remain calm and serve as an "emotional container" for the infant's strong emotions. 2, 3

Establishing Routines

• Establish protective routines using visual and verbal cues for mealtimes and sleep times. 2, 3
• Implement 10-30 minutes of child-directed play ("time-in") to strengthen parent-child connection. 3

Probiotic Consideration (Limited Evidence)

• Lactobacillus reuteri (DSM 17938) may reduce crying by approximately 65 minutes per day in breastfed infants, though evidence is insufficient for routine use. 3

Common Pitfalls to Avoid

• Never dismiss prolonged fever with irritability as viral illness without considering incomplete Kawasaki disease, especially in infants <6 months. 1
• Never attribute all crying to normal development without excluding metabolic derangements—these are easily correctable. 1
• Recognize that adults who are socially isolated may lack standards for comparison or resources, which exacerbates stress and increases abuse risk. 2
• Understand that repeated stress without adequate support makes children progressively more vulnerable to future stressors, not more resilient. 3
• Avoid dicyclomine (not recommended <6 months) and simethicone (no proven efficacy). 5