4.8: Infant Health

Common Physical Conditions and Issues during Infancy

Infants depend on the adults that care for them to promote and protect their health. Some physical conditions and issues are very common during infancy. Many are normal, and the infant's caregivers can manage them if they occur. The key is learning about and understanding what is normal for the infant and becoming comfortable with their routine.

New parents and caregivers often have questions about such things as:

• Bowel Movements
• Teething
• Spitting Up/Vomiting
• Urination
• Diaper Rash
• Jaundice
• Colic/Purple Crying

Fig 4.8. Infant being diapered.

Image Source: DaddyDiaper. Daddy does the best diapers. Wikimedia Commons.

Bowel Movements

Infants' bowel movements go through many changes in color and consistency, even within the first few days after birth. While the color, consistency, and frequency of stool will vary, hard or dry stools may indicate dehydration and increased frequency of watery stools may indicate diarrhea.

Teething

Although newborns usually have no visible teeth, baby teeth begin to appear generally about 6 months after birth. During the first few years, all 20 baby teeth will push through the gums, and most children will have their full set of these teeth in place by age 3.

An infant's front four teeth usually appear first (two on top, and two on bottom) at about 6 months of age, although some children don't get their first tooth until 12-14 months. As their teeth break through the gums, some infants become fussy, and irritable; lose their appetite; or drool more than usual.

The FDA does not recommend gum-numbing medications with an ingredient called benzocaine because they can cause a potentially fatal condition in young children. Safe forms of relief include a chilled teething ring or gently rubbing the child's gums with a clean finger.

Spitting Up/Vomiting

Spitting up is a common occurrence for young infants and is usually not a sign of a more serious problem. But if an infant is not gaining weight or shows other signs of illness, a health care provider should be consulted.

Urination

Infants urinate as often as every 1 to 3 hours or as infrequently as every 4 to 6 hours. In case of sickness or if the weather is very hot, urine output might drop by half and still be normal. If an infant shows any signs of distress while urinating or if any blood is found in a wet diaper medical care should be sought.

Diaper Rash

A rash on the skin covered by a diaper is quite common. It is usually caused by irritation of the skin from being in contact with stool and urine. It can get worse during bouts of diarrhea. Diaper rash usually can be prevented by frequent diaper changes.

Jaundice

Jaundice can cause an infant's skin, eyes, and mouth to turn a yellowish color. The yellow color is caused by a buildup of bilirubin, a substance that is produced in the body during the normal process of breaking down old red blood cells and forming new ones. Normally the liver removes bilirubin from the body. But, for many infants, in the first few days after birth, the liver is not yet working at its full power. As a result, the level of bilirubin in the blood gets too high, causing the infant's color to become slightly yellow—this is jaundice.

Although jaundice is common and usually not serious, in some cases, high levels of bilirubin could cause brain injury. All infants with jaundice need to be seen by a health care provider. Many infants need no treatment. Their livers start to catch up quickly and begin to remove bilirubin normally, usually within a few days after birth. For some infants, health care providers prescribe phototherapy—a treatment using a special lamp—to help break down the bilirubin in their bodies.

Colic: The Period of PURPLE Crying

Many infants are fussy in the evenings, but if the crying does not stop and gets worse throughout the day or night, it may be caused by colic. Babies may cry inconsolably or scream, extend or pull up their legs, and pass gas. Their stomachs may be enlarged. The crying spells can occur anytime, although they often get worse in the early evening.

It can be confusing and concerning to be told your baby "has colic" because it sounds like it is an illness or a condition that is abnormal. Colic simply means your otherwise healthy baby cries excessively for no apparent reason. Healthcare providers define colic as intense crying for more than three hours a day, at least three days a week, for more than three weeks. Often, there’s nothing you can do to relieve your crying baby.

All babies cry — it’s the way they communicate their needs. But a colicky baby is inconsolable and screams without any obvious cause. The crying usually starts suddenly at about the same time every day, often in the afternoon or evening hours. However, when your baby isn’t crying, they act completely normal.

The Period of PURPLE Crying program is an evidence-based shaken baby syndrome/abusive head trauma (SBS/AHT) prevention program available since 2007.

While colic in babies is harmless and passes quickly, the condition can be frustrating for parents. Dr. Ronald Barr, a developmental pediatrician who has extensively studied infant crying, came up with the phrase the Period of PURPLE Crying. His idea was to explain this phase to parents of new babies so they would know it was normal and they would be encouraged that it would come to an end. The Period of PURPLE Crying usually starts around 2 weeks of age and ends around 3 to 5 months of age. The acronym PURPLE does not mean the baby turns purple while crying but is used as a meaningful and memorable way to describe what parents and their babies are going through. There are other common characteristics of this phase, or period, that all babies go through to some extent.The acronym PURPLE helps parents learn how to care for their crying baby — and themselves — during this time.It is a new way to help parents understand this time in their baby's life, which is a normal part of every infant's development.

Table 4.8 - The Letters in PURPLE stand for...

	PERIOD	OF	PURPLE	CRYING
P	U	R	P	L	E
Peak of crying	Unexpected	Resists soothing	Pain expression	Long lasting	Evening
Crying increases with each week, with crying the most problematical in the second month, then gradually tapering off by 3-5 months.	Crying can come and go with no clear reason.	Crying will continue no matter how many ways the caregiver tries to soothe the baby.	A crying baby may look like they are in pain, but they are not.	Crying can last as long as 5 hours per day.	Crying may occur in late afternoon and early evening.

The word PERIOD means crying has a beginning and an end.

"It was so discouraging," said one dad. "Our baby giggles and seems fine during the day and almost like clockwork, he starts crying around 6 pm. He is growing and healthy, so why does he cry like this?"

When these babies are going through this period, they seem to resist soothing. Nothing helps. Some infants seem to be soothed by being held, rocked, or wrapped snugly in a blanket. Some like a pacifier. Even though certain soothing methods may help when they are simply fussy or crying, these bouts of inconsolable crying are different. Nothing seems to soothe them. During this phase of a baby's life they can cry for hours and still be healthy and normal. Parents often think there must be something wrong or they would not be crying like this. Often parents say their baby looks like he or she is in pain. They think they must be, or why would they cry so much. Babies who are going through this period can act like they are in pain even when they are not.

Shaken Baby Syndrome (SBS)

It's very normal to experience frustration when a baby cries nonstop for hours. The key is to focus on calming yourself and understand that you may not be able to calm your baby. It’s not your fault or the fault of the baby’s. It’s normal for healthy babies to cry and some babies cry much more than others. When a baby cannot be consoled, and caregivers may feel pushed to the limit and lose control and shake the baby in an attempt to make them stop crying. This can have devastating life-threatening effects.

Shaken Baby Syndrome (SBS) is a name given to the group of injuries that result from the forceful shaking of a child, with or without direct impact to the head. It is a severe form of physical child abuse that can occur from as little as 5 seconds of shaking. It may be caused from vigorously shaking an infant by the shoulders, arms, or legs. Children's brains are softer, their neck muscles and ligaments are weak, and their heads are large and heavy in proportion to their bodies. The result is a type of whiplash, similar to what occurs in some auto accidents. The whiplash effect created by shaking an infant can cause intracranial (within the brain) or intraocular (within the eyes) bleeding. When an infant or toddler is shaken, the brain bounces back and forth against the skull. This can cause bruising of the brain (cerebral contusion), swelling, pressure, and bleeding in the brain. The large veins along the outside of the brain may tear, leading to further bleeding, swelling, and increased pressure.

Shaken Baby Syndrome (SBS) does not result from gentle bouncing, playful swinging or tossing the child in the air, or jogging with the child. It also is very unlikely to occur from accidents such as falling off chairs or down stairs, or accidentally being dropped from a caregiver's arms. Short falls may cause other types of head injuries, although these are often minor.

Often there is no obvious external head trauma or physical signs of injury, such as bruising, bleeding, or swelling. Outwardly, the infant looks perfectly fine, However, rib fractures are common and can be seen on x-rays. In some cases, the condition can be difficult to diagnose and may not be found during an office visit.

Outward signs such as symptoms can vary, ranging from mild to severe. They may include:

• convulsions or seizures
• decreased alertness
• extreme irritability or other changes in behavior
• confused, restless, or agitated state
• lethargy, sleepiness, not smiling
• loss of energy or motivation
• loss of consciousness
• not breathing
• loss of focus or vision
• pale or bluish skin
• poor feeding, lack of appetite
• vomiting

Shaken Baby Syndrome (SBS) can result in death, mental retardation or developmental delays, paralysis, severe motor dysfunction, spasticity, blindness, and seizures.

Who’s at Risk?

Infants and very small children are especially vulnerable to this type of abuse. Keep in mind how large their heads are heads are large in comparison to their bodies, and their neck muscles are weak. Children under one year of age are at highest risk, but Shaken Baby Syndrome (SBS) has been reported in children up to 5 years of age.

Shaking often occurs in response to a baby crying or having a toilet-training accident. The perpetrator tends to be male and is primarily the biological father or the mother’s boyfriend or partner.

Caregivers are responsible for about 9 - 21% of cases. The explanation typically provided by the caregiver—I was just playing with the baby—does not begin to account for the severity of the trauma. Many times, there is also a history of child abuse.

Can It Be Prevented?

Shaken Baby Syndrome (SBS) is completely preventable. It's dangers are not well appreciated by the general public, with 25-50% of people unaware of the dangers and risks of shaking a baby. Simply worded and well designed information cards on the dangers of shaking and alternatives to dealing with a crying infant have been shown to change parental knowledge and understanding of appropriate child behavior management techniques. Home visitation programs conducted between the prenatal period and the age of two, have shown to decrease rates of maltreatment in certain populations. Physicians are expected to detect and manage cases of child maltreatment, yet they often have inadequate training in this field.

These steps can help decrease the risk for shaken baby syndrome:

• Never shake a baby or child in play or in anger. Even gentle shaking can become violent shaking when you are angry.
• Do not hold your baby during an argument.
• If you find yourself becoming annoyed or angry with your baby, put the baby in their crib and leave the room. Try to calm down. Call someone for support.
• Call a friend or relative to come and stay with the child if you feel out of control.
• Contact a local crisis hotline or child abuse hotline for help and guidance.
• Seek the help of a counselor and attend parenting classes.
• Do not ignore the signs if you suspect child abuse in your home or in the home of someone you know.

Fig. 4.8.1. Shaken Baby Syndrome (SBS) Information Cards

• Image Source: Children's Trust Fund, Missouri.
• Image Source: Lorena Lucas. Shaken Baby Syndrome Prevention Training for Child Care Providers. SlidePlayer. February 2011.

Abusive Head Trauma

Shaken baby syndrome (SBS) is part a bigger picture known as abusive head trauma (AHT), a severe form of physical child abuse that results in a traumatic brain injury for the infant or child. Nearly all victims of abusive head trauma suffer serious, long-term health consequences - vision problems, developmental delays, physical disabilities, or hearing loss. As many as 1 of every 4 babies who experience abusive head trauma (AHT), dies.

Abusive Head Trauma (AHT) facts:

• leading cause of physical child abuse deaths in children under 5 in the United States.
• accounts for approximately one third of all child maltreatment deaths
• the most common trigger for abusive head trauma is inconsolable crying
• babies less than one year old are at greatest risk of injury from abusive head trauma
• can be prevented by awareness and understanding the dangers of shaking a baby
• by providing support to parents and caregivers

The Bottom Line

We learned that shaking a baby can cause death or permanent brain damage. It can result in life-long disability. Always remember, when babies cry, it is normal to feel frustrated, helpless, or angry, but it's most important for you to stay calm than it is to stop the crying. Make a plan ahead of time

Having a plan to cope with crying can help. Healthy strategies for dealing with a crying baby include:

• finding the reason for the crying
• checking for signs of illness or discomfort, such as diaper rash, teething, tight clothing.
• feeding or burping.
• soothing the baby by rubbing its back; gently rocking; offering a pacifier;
• singing or talking.
• taking a walk using a stroller or a drive in a properly secured car seat.
• calling the doctor if the baby seems sick

It’s OK to ask for help. All babies cry. Caregivers often feel overwhelmed by a crying baby. Calling a friend, relative, or neighbor for support or assistance lets the caregiver take a break from the situation. If immediate support is not available, the caregiver could place the baby in a crib (making sure the baby is safe), close the door, and check on the baby every five minutes.

Sources

• About Abusive Head Trauma. Child Abuse and Neglect Prevention. CDC. May 16, 2024.
• Crying Ages 3 and Younger. Health Information and Tools / Health A-Z. MyHealthAlberta.ca . March 22, 2024.
• Leon, Ana R. Children’s Development. Licensed under CC BY 4.0
• Shaken Baby Syndrome. Medical Encyclopedia. Medline Plus. January 24, 2023.
• The Period of Purple Crying,. National Center on Shaken Baby Syndrome.