* Approved by CPG Committee; PIC endorsement pending

See also

Gastrooesophageal reflux disease in infants 

Non-IgE mediated food allergy 

Slow weight gain 

Child abuse 

Recognition of the seriously unwell neonate and young infant

Key points

1. Crying is a normal part of infant communication and reflects a range of physical, emotional and developmental needs, which can vary in frequency and intensity over time
2. Assessment aims to exclude medical conditions, inflicted injury or parental mental health concerns
3. Management focuses on education, reassurance and shared decision making to develop a supportive and individualised approach
4. Avoid medications due to limited evidence of benefit and potential for harm

Background

• Crying typically peaks at 6-8 weeks of age, averaging 2-3 hours/day
• Families often receive diverse and conflicting advice, which can be challenging to navigate
• A range of settling approaches exist, from structured to flexible, which may complement one another, to suit the individual infant and family
• The term 'infant colic' has traditionally described excessive crying but is now considered unhelpful, as it inaccurately implies an abdominal cause

Assessment

The assessment of a crying or unsettled infant aims to

• Identify red flags and exclude medical/traumatic causes
• Evaluate parental mental health, support systems, and parent-infant interactions
• Determine if crying pattern is developmentally normal and/or related to communication of common infant needs eg hunger, discomfort, sensory input, or need for comfort

History

• Pregnancy and birth history
• Feeding patterns
• Sleep-wake patterns
• Growth and development
• Current strategies, treatments and support services
• Family and social context
• Parental/carer mental health

Examination

Assess for physical signs of illness, injury or pathology contributing to unsettled behaviour

Red flags

• Sudden onset irritability and persistent crying
• Features of an acutely unwell infant. See Recognition of the seriously unwell neonate and young infant
• Faltering growth, feeding difficulties, oral aversion
• Rapid head circumference growth crossing percentiles
• Unexplained injuries
  • Excessive crying is a risk factor for abusive head trauma (previously known as shaken baby syndrome) See Child abuse
• Parental post-natal depression (PND) and social isolation
  • Screen for PND using the Edinburgh Postnatal Depression Scale. See Additional Notes for other languages
  • Concern if score >12 (mothers), >9 (fathers) or any score >1 on question 10 (suicidal thoughts)

Consider if sudden onset crying

• Incarcerated inguinal hernia
• Intussusception
• Raised intracranial pressure
• Accidental or inflicted injury, see Child abuse
• Infection, see Sepsis
• Hair tourniquet
• Corneal foreign body/abrasion, see Acute eye injury

Other causes to consider in assessment

• Inadequate caloric intake, see Slow weight gain
• Non-IgE mediated food allergy
• Gastrooesophageal reflux disease
  • Not a common cause of unexplained crying in otherwise well infants
  • Need to differentiate normal infant physiological reflux from reflux disease
  • No evidence to support the diagnosis of 'silent reflux'
• Functional lactose overload, eg frothy, green stools, perianal excoriation and excess gas
  • May occur with non-IgE mediated food allergy (relative loss of brush border enzymes) or excessive maternal breast milk supply
• Eczema (atopic dermatitis)

Typical infant crying pattern

Babies cry to communicate a broad range of physical, emotional and developmental needs. It is best understood as proximity-seeking communication, the expression of a need for physical and emotional closeness with a caregiver

There is a wide range of unsettled or crying behaviour that is considered typical (in an otherwise well and thriving infant)

• Increases to a peak at 6-8 weeks and improves by 3-4 months (see graph below)
• Often worse in the late afternoon/evening, may last hours, can be resistant to soothing
• Night waking is normal for infants <12 months of age
• Breastfed infants often engage in cluster feeding during growth spurts, particularly in the evening (helps regulate breastmilk supply to meet the infant's changing needs)
• Some babies strain, cry, grunt and go red in the face, before passing soft stools (also known as infant dyschezia). This is a common and self-resolving difficulty in coordinating increased intra-abdominal pressure with relaxation of the pelvic floor required to pass stool

Curves of early infant crying

Management

Investigations

If history and examination is consistent with typical infant crying patterns, no investigations are required

Management approach

Once red flags and medical causes are excluded, parental reassurance and education are essential.

• If screening for postnatal depression raises significant concerns, or there are concerns for the safety of parent and/or infant, urgent mental health assessment and support should be facilitated

Focus is on shared decision making and involvement of a multidisciplinary team eg lactation consultant, child health nurse, GP, paediatrician, perinatal mental health or infant mental health service, and parenting support services

Where possible, allowing time for the following discussion points can be highly effective for the infant and family's care

1. Acknowledge the challenges and validate caregiver concerns
2. Explain that underlying causes have been considered and give reassurance regarding normal examination, growth and development
3. Provide an explanation of typical infant crying patterns and variability. Share resources (eg PURPLE crying) that describe normal crying behaviours as an important form of infant communication
4. Address parental mental health and stress levels, identify protective support systems, provide resources and early referral
5. Offer practical strategies (see below), ongoing support and early follow-up. Encourage caregivers to flexibly explore settling strategies that align with family values and infant developmental stage and temperament

Treatment

Medication, supplements and interventions are often sought by families.  Often these are not indicated, have no evidence and can cause harm

Consider consultation with local paediatric team when

• Medical cause of crying identified or suspected
• Infant clinically unwell
• Concerns for inflicted injury or significant parental mental health concerns

Consider transfer when

• Infant requiring care beyond the comfort level of the hospital
• Parent requiring care beyond the comfort level of the hospital (inpatient mental health support)

For emergency advice and paediatric or neonatal ICU transfers, see Retrieval Services

Consider discharge when

• Medical conditions, inflicted injury, and parental mental health concerns have been excluded or appropriately addressed
• Families have been provided reassurance, education, resources and referral for early ongoing support

Options for ongoing support include

• Maternal and child health nurse, including state based enhanced/extended programs
• General practitioner
• General paediatrician
• Lactation consultant
• Perinatal mental health clinician
• Infant mental health clinician
• Parent and family support services (state specific)
• Early parenting centre for sleep and settling support
• Parent-baby unit when close professional or inpatient mental health support is required

Parent information

• Raising Children Network
• Australian Breastfeeding Association, including a resource on Supporting safer sleep for babies in evacuation centres which provides parents with practical strategies to make all sleep environments safer for their baby
• RCH parent information on Managing Unsettled Babies
• RCH parent information on How do I know if my baby has reflux?
• Parent and Infant Units across Australia

Additional notes

Edinburgh Postnatal Depression Scale in other languages

Practical strategies

*Last updated October 2025