Fortunately, most colicky babies aren’t really ill, they’re more “homesick”—struggling to cope with life outside Mama’s womb. That’s why the 5 S’s can be so helpful. But, what do you do if the S’s aren’t doing the trick?

If fussing continues despite the 5 S’s, first check that you’re doing them right (speak to your doctor or a Happiest Baby educator, or review The Happiest Baby DVD). If you are, you should have your child examined to make sure he is not sick.

Here’s a primer of the ten signs that doctors look for to decide if your little one’s cries are a sign of frustration or truly signal illness. Then, you’ll find a review of ten red-­alert conditions your doctor may mention to you as medical conditions that might be causing the crying.

Ten Red Flags: Signs of A Problem

When you bring your fussy child to see yoru doctor, she will likely ask you these three questions to help figure out if your baby just has colic, or something more serious:

  1. Is your baby growing well?
  2. Is your child normal in all other ways?
  3. Is your baby content and alert for long periods of the day?

If you answered no to any of those questions, your doctor will then ask how your baby acts when she isn’t crying. She’s looking for one of these ten red flag signs and symptoms:

  1. Persistent moaning (frequent groans and weak cries)
  2. Shrill cry (high pitched and sharp, unlike your baby’s usual cry sound)
  3. Vomiting (more than one ounce per episode; more than five episodes a day; or any green or yellow vomit)
  4. Change in stool (constipation or diarrhea, especially with blood)
  5. Fussing during eating (twisting, arching, crying that begins during or shortly after a feed)
  6. Abnormal temperature (a rectal temperature over 100.4°F or under 97.5°F; over 38°C or under 36.4°C)
  7. Irritability (persistent crying with almost no calm periods)
  8. Lethargy (a baby sleeping twice as long as usual, acting “out of it,” or not sucking well over an eight- to twelve-­hour period)
  9. Bulging soft spot on the head (even when your baby is sitting up)
  10. Poor weight gain (gaining less than a half ounce a day)

Ten Medical Red Alerts: Illnesses Your Doctor May Mention 

When doctor sees a fussy baby with red-­flag symptoms, we try to figure out if the crying might indicate one of the following serious problems.

Note: Food allergy/sensitivity is the only common medical cause of colic. All the other problems listed below occur in less than one percent of very fussy babies.

  1. Infection: From Ear Infections to Appendicitis

You might think the best way to tell if your baby has an infection is to take her temperature, but many sick newborns don’t get fever (some even have a low rectal temperature, below 97.5°F).  If your baby acts lethargic or irritable for more than a few hours, call your doctor immediately. She may check her for:

Ear Infection—Fussy and upset, but rarely swipe at their ears.

Urine Infection—May have smelly urine, but usually don’t.

Brain Infection (meningitis)—Lethargic (and/or irritable), vomiting and a bulging soft spot…worsening over just a day or two.

Appendicitis—A hard stomach, poor appetite, and constant irritability (extremely rare in infants).

Intestinal Infection— “Stomach flu” causes vomiting, diarrhea, and the baby usually has been in contact with a sick relative.

  1. Intestinal Pain: From Intestinal Blockages to Acid Reflux

These problems are the most common medical causes of persistent crying, explaining five to ten percent of infant colic. (I’ve listed the most common conditions first.)

Food Sensitivity—Five to ten percent of fussy babies have a food allergy or sensitivity and get better with a change in formula in their mother’s diet (if they are breastfed). Besides crying, allergy may cause vomiting, diarrhea, rash, or blood streaked mucous in the stools. (For more about food allergy/sensitivity, see page xxxx.)

Acid Reflux—This uncommon problem causes burning pain, during or after eating. It occurs in less than one percent of fussy babies. (For more on acid reflux see pages xxxx.)

Intestinal Blockage—This extremely rare medical emergency may occur right after birth or weeks later. Babies suffer from waves of severe painful spasms plus vomiting and/or they may stop pooping. With intestinal blockages, the baby’s vomit may have a distinct yellow or green tint.

Note: During the first days of life, a breast-­fed baby’s spit–up may also be yellow, because that is the color of colostrum. However, if your baby has yellow vomit, never assume it’s from your milk. Immediately consult your doctor to make sure it isn’t the sign of something more serious.

  1. Breathing Trouble: From Blocked Nostrils to Oversize Tongues

The most common cause of breathing trouble is a condition where a baby’s tiny nostrils are blocked. Babies don’t breathe through their mouths, except when they’re crying. That’s why babies who are born with tight nostrils or openings swollen shut from allergies/colds get so frantic.

To check for nasal blockage, place the tip of your little finger snugly over one of your baby’s nostrils, closing it off for a few seconds. She should easily be able to breathe through the open nostril (you will hear the slight woosh of air moving in and out). Then repeat this test on the other side.

If your baby can’t breathe or gets agitated when you do this test, have your baby examined by the doctor. If it seems the nostril is blocked from mucus, ask the best ways to clear it (like, saline or breast milk drops, nasal aspirator, etc.). And do your best to rid your home of dust, molds, sprays, perfumes, smoke (cigarettes, wood fires, candles, incense) and anything else that might make her nose congested.

Very rarely, an infant will have trouble breathing because her tongue is too big for her mouth. It literally falls back into the throat and chokes her when she lies on her back. This problem is usually obvious shortly after birth because her tongue will be so big it will tend to stick out of her mouth. And, it can usually be remedied by a minor surgical procedure.

  1. Increased Brain Pressure

When pressure builds up inside a baby’s head, it also causes:

– Irritability and crying from a headache
– Vomiting
– An unusual high-­pitched cry
– A bulging fontanelle (soft spot) even when the baby is seated
– Swollen veins on the forehead
– A head that grows too rapidly (your doctor should measure your baby’s head size at every well-baby checkup)
– Sunset sign (a big-­eyed stare with a crescent of the white of the eye displayed over the colored iris, making the eye look like a setting sun)

If your baby fits the symptoms described above, contact your doctor immediately.

  1. Skin Pain: A Thread or Hair Twisted Around a Finger, Toe, or Penis

In years past, the sudden onset of sharp screaming in an otherwise calm baby made parents search for an open safety pin inside the diaper. Today, however, modern parents who hear abrupt, shrill cries should look for a fine hair or thread wrapped tightly around the baby’s finger, toe or penis. This requires immediate medical attention. (Doctors often treat it by applying a dab of depilatory cream to dissolve the hair.)

  1. Mouth Pain: From Thrush to Teething

Thrush, a yeast infection in the mouth, is easy to recognize because it causes a milky white residue on the lips and inside of the mouth that cannot be wiped away. Thrush may cause a bumpy, red diaper rash and/or itchy, red nipples in a breast-­feeding mom.

Thrush rarely causes fussiness, but on occasion babies with thrush may have irritated mouths. Fortunately it is easy to treat, and recovery is rapid.

Many parents ask if teething might cause crying. This is extremely unlikely during the fourth trimester. However, if you think your baby is having teething pain, ask if you can give her some acetaminophen drops. This won’t help colic, but it may reduce mild teething pain.

  1. Kidney Pain: Blockage of the Urinary System

A kidney blockage is a very rare cause of persistent crying. Unlike classic colic, which worsens in the evening, kidney pain afflicts children any time, day or night. And, where  colic begins improving after two or three months, kidney pain usually gets worse and worse.

  1. Eye Pain: From Glaucoma to a Corneal Abrasion

Eye pain, also very rare, may come from glaucoma (high pressure inside the eyeball), an accidental scratch of the cornea, or even from a tiny, irritating object stuck underneath a baby’s eyelid (such as a cinder or eyelash). Your doctor should consider these problems if your crying baby has one or two red, tearing eyes.

  1. Overdose: From Excessive Sodium to Vitamin A

Persistent moaning/crying can result from giving babies excessive sodium (salt). This may occur when a parent mixes formula with too little water. It has also been described during the first few weeks of life in breast-fed babies whose mother is making very little milk. (Very low milk production can result in milk with a high salt level.) These problems are easily diagnosed because the babies are losing weight, not drinking any other liquids, and are both irritable and lethargic all day long.

Excess Vitamin A is extremely rare and only causes crying in babies given high doses of supplemental vitamins or fish oil.

Diet supplements and stimulant Chinese herbs may also pass into the breastmilk and cause irritability and crying.

10.Others: From Migraines to Heart Failure

Migraine headaches have been reported to occur more often in children who had colic during infancy. But, it is very hard to believe that babies get headaches. If this were the cause, why would the crying peak at six weeks and magically disappear after three or four months?

Other super–rare conditions that may cause unstoppable crying include: bone fractures, sugar intolerance in babies fed fruit or fruit juice, over–active thyroid and heart failure. These babies usually act poorly all day long.