editorial: the fourth trimester - mpaeds.my · your baby is still crying. one mother said it helped...
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EDITORIAL
The fourth trimester
As it stands, motherhood is a sort of wilderness through which
each woman hacks her way, part martyr, part pioneer; a turn of
events from which some women derive feelings of heroism, while
others experience a sense of exile from the world they knew.
Rachel Cusk (born 1967), Canadian novelist
Recently, two advanced trainee paediatricians of my acquain-
tance have become first-time mothers in their early 30s and have
felt almost overwhelmed by having a demanding newborn baby.
These highly capable young women are used to nocturnal sleep
deprivation, although when you are on call you can look forward
to some rest when your shift ends. But they both described how
the lack of sleep drained them of energy and confidence. They
felt to blame for their baby’s crying, even though, at an intellec-
tual level they had read and were well aware that many babies
cry a lot during their first few weeks of life. They knew of the
fourth trimester, a term coined by US paediatrician Harvey Karp
referring to the 3 months that babies cry inconsolably every eve-
ning.1 The concept of the fourth trimester is that human babies
are born less mature than other animals and may need nurturing
as if they were in utero (Fig. 1). The mothers tried swaddling and
shushing to soothe their babies as suggested in the world accord-
ing to Karp. And still the babies cried, and the young mothers felt
to blame and struggled to cope.
Both young women had husbands who were sympathetic and
supportive but who had busy, demanding jobs with responsibili-
ties they could not shirk. One had a grandmother who was no
longer in paid employment and was willing and able to drop
everything and look after the baby during the day while the
baby’s mother caught up on much-needed sleep. The other’s par-
ents were overseas, so her feelings of helplessness and
hopelessness were compounded by her sense of isolation. Both
grandmothers reassured their daughters that they were not to
blame, but the mother who could catch up on sleep was better
able to accept the reassurance.
One mother took the intellectual response you might expect
from a highly educated woman and read everything she could
about crying babies. The result was that she discovered PURPLE
crying, which was new to me but apparently is the period when
a baby cries more than any other time.2 This is a colourful way of
formulating what the literature already describes, that babies cry
a lot in the first 9 weeks after birth; then for the vast majority,
the crying gradually settles.3 This can be reassuring to know, but
your baby is still crying. One mother said it helped when she
came to realise that the fourth trimester is a period of rapid
adjustment not only for the mother but also for the baby.
Another response is the medical one: if a baby cries, there
must be a medical explanation. This drives parents to seek medi-
cal help. Doctors never like to admit they do not have a quick
medical fix to a problem, and pharmaceutical companies are
always happy to provide the fix in the form of a marketable med-
ication, even if the evidence shows it is usually ineffective and
possibly harmful.4 So before long the persistently crying baby has
a diagnosis of infantile colic, soon followed by another diagnosis
of infantile reflux, and has been started on a proton-pump inhibi-
tor.4 Reflux is a genuine entity but is over-diagnosed and over-
treated.4
Paediatricians are of course keen to breastfeed and are easy
prey to advise about the importance of exclusive breastfeeding.
Many people will tell them that even a drop of cows milk for-
mula increases their infant’s risk of allergy. As a result, they do
not complement their infant’s breastfeeds with formula top-ups,
even when the infant is hungry and not putting on weight. There
is no evidence to support this strongly held belief that early expo-
sure to cows milk promotes allergy. A randomised controlled trial
comparing early introduction of allergenic foods at 3 months
with delayed introduction at 6 months found no difference for
cows milk, although the overall incidence of food allergy was
lower in the early introduction group.5 Furthermore, there is
strong evidence showing early introduction of peanuts reduces
the incidence of peanut allergy in children from atopic families,6
and similarly early egg introduction reduces the risk of egg
allergy.7 The result of the well-intentioned advice on breastfeed-
ing from experts is that anxious mothers do not top up their hun-
gry babies, and the result can be that the exhausted mother’s
milk supply is compromised, resulting in failure to thrive from
failure to feed.
Young first-time parents often think they will mould their
infant to be a wonderful moral human being who will reflect
their parents’ values. After a while, they come to the realisa-
tion that the infant is born with her or his own personality,
and it is the parents who are being moulded by this extraordi-
nary little human being. Each baby is born with his or her
Fig. 1 Two mothers with crying babies and one in a walking frame,comparing the human infant’s helplessness with the self-sufficiency ofnewborn animals. (Engraving by P. Galle, c1563.)
doi:10.1111/jpc.14257
1174 Journal of Paediatrics and Child Health 54 (2018) 1174–1175© 2018 Paediatrics and Child Health Division (The Royal Australasian College of Physicians)
own characteristics, which are apparent from the moment of
birth. One is alert and inquisitive. That one will always be on
the qui vive, but sleep will be a problem for weeks, months or
years. One is calm and relaxed. Another just wants to feed all
the time and is always going to be needy but rewarding. And
so it goes. Influential British paediatrician Ronald Illingworth
published his book The Normal Child in 1953 and wrote a new
edition after the birth of each of his three children as his con-
cept of normality broadened. Berry Brazelton, who died at the
grand old age of 99, was a keen observer of newborn behav-
iour and, in his 1969 book Infants and Mothers, described three
different kinds of babies: quiet, active and middle of the road.8
Brazelton called these differences ‘constitutional’ and suggested
parents should learn to adjust to these differences. Brazelton
promoted the idea that newborn infant behaviour affects par-
enting and helped shatter the myth of the baby as a clean
slate.8
Parenthood is a privilege and can be as challenging and as
rewarding as anything we do in our lives. Surely, Charles
Dickens must have been remembering becoming a new parent
when he wrote: ‘It was the best of times, it was the worst of
times’.
Acknowledgements
Thank you to Carmel Isaacs, Ameneh Khatami and Catherine
White for helpful suggestions.
Professor David Isaacs,Editor-in-Chief
Children’s Hospital at WestmeadSydney, New South Wales
Australia
References
1 Karp H. The Fourth Trimester and Crying. c2004. Available from:https://www.drdefranca.com/the-fourth-trimester-and-colic.html[accessed 8 April 2018].
2 National Center on Shaken Baby Syndrome. The Period of PURPLE Crying.Farmington, UT: The Center; 2018. Available from: http://purplecrying.info/[accessed 8 April 2018].
3 Wolke D, Bilgin A, Samara M. Systematic review and meta-analysis:Fussing and crying durations and prevalence of colic in infants.J. Pediatr. 2017; 185: 55–61.
4 Isaacs D. Disease marketing. J. Paediatr. Child Health 2017; 53: 1141–2.5 Perkin MR, Logan K, Tseng A et al. Randomized trial of introduction of
allergenic foods in breast-fed infants. N. Engl. J. Med. 2016; 374:1733–43.
6 Du Toit G, Roberts G, Sayre PH et al. Randomised controlled trial ofpeanut consumption in infants at risk of peanut allergy. N. Engl.J. Med. 2015; 372: 803–13.
7 Natsume O, Kabashima S, Nakazato J et al. Two-step egg introductionfor prevention of egg allergy in high-risk infants with eczema (PETIT): Arandomised, double-blind, placebo-controlled trial. Lancet 2016; 389:276–86.
8 Oates K. “Always say something positive about the child” T. Berry Bra-zelton 1918–2018. J. Paediatr. Child Health 2018; 54: 828–9.
Journal of Paediatrics and Child Health 54 (2018) 1174–1175© 2018 Paediatrics and Child Health Division (The Royal Australasian College of Physicians)
1175
D Isaacs The fourth trimester
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