July 27, 2009Imtiaz Ghori

Infants have a normal crying curve during the first 3 months

Peaks at ~6 weeks and decreases by about 12 weeks

Averages 2 hr/day at 2 weeks, 3 hrs at 6 weeks, and 1 hr/day at 12 weeks

True across cultures and preemies show the same pattern, peaking at 6 weeks after their expected due date

Signaling Attachment behavior – assures nutrition,

protection, maternal interaction Up to a point, infants who cry more get

more maternal attention. Reorganization of brain systems occurring

around 8-12 weeks, reflexive systems replaced by cortical control of behaviors.

Unsoothability related to a temporary deficit in responsivity, so have difficulty in stopping crying once it starts

Most widely used definition is: > 3 hours a day, > 3 days a week, >3 weeks in a row (i.e.. rule of 3)

Affecting an otherwise healthy, well-fed infant

Stats range from 2 – 20% of babies Diagnosis of exclusion

Many theories, often thought to be due to gas.

Based on current evidence infants who have colic are at the high end of a normal spectrum of crying.

Benign, self limited. 50% resolve by 2 months, 80% by 3 months, 90% by 4 months

Sudden, unpredictable onset Prolonged episodic bouts Diurnal – evening peaks Difficult to console Sometimes physical signs –clenched fists,

red face, legs drawn up, distended abdomen

Lasts beyond 4 months Continuous irritability/lack of diurnal rhythm GI symptoms (FTT, vomiting, diarrhea, etc) Positive physical exam – including eyes,

long bones, neuro, CV, GI assessment Positive family history of asthma, atopy,

eczema, migraine Maternal drug ingestion

Although food intolerance and other organic causes can cause prolonged crying, these factors absent in 90% of cases.

Most common organic causes suspected are GERD and food allergies, but the evidence is equivocal and a factor in only a small group

Large study comparing BFing mothers on low allergen diet vs. those not, showed no difference in proportions of colicy infants.

Lactose intolerance – no good supportive evidence

Studies have shown parental counseling more effective than diet changes.

Cross-cultural studies comparing parenting and infant crying.

High amounts of body contact and responsive parenting associated with lower amounts of crying.

The crying curve and frequency of crying is similar but the length of the bouts are reduced substantially.

Affect on parents – feel helpless, inadequate, rejected

Can contribute to maternal depression Prolonged crying may trigger shaken baby

syndrome/other abuse Parents of >3000 infants gave anonymous

responses in a questionnaire; 2.2% of parents of 1 month olds and 3.7% of parents of 3 month olds reported having smothered, slapped, or shaken their baby at least once because of crying

Parental support and education –acknowledge, reassure, offer tips on soothing, absolve guilt, recommend time-out.

Role for diet changes in small percentage so may be worth a try

Simethicone not shown to helpful; antispasmodics have adverse effects (apnea, seizures, coma) and contraindicated in infants < 6 months

Cranial osteopathy – no randomized controlled trials. One small study showed decreased crying and improved sleeping

Fennel seed oil – one randomized controlled study showed benefit and no adverse effects BUT fennel oil can cause allergic reactions of skin and repieiratory tract and has been reported to cause seizures.

Herbal blends – teas containing fennel, chamomile, vervain, licorice, and lemon balm have been studied and shown be effective but the volume the infants took concerning ( 5 oz. TID) b/c may affect milk intake

Gripe water – mixture of herbs; warn that some varieties have been found to contain dangerous ingredients, including glass particles and alcohol. Also watch for sodium bicarbonate and essential oils.

Colocynthis – found in Hyland’s colic tablets – not proven to effective but unlikely to cause harm

Soothing techniques – overall 24 hour amounts of crying substantially reduced with more physical contact and increased responsiveness

16 hours at 1month, decreases to 14 hours by 1 year, 13 hours by age 2.

During first 3 months infants go from a pattern of short sleep-wake cycles about evenly distributed throughout the day and night to consolidating sleep into longer periods at night.

Infants spend about 50% of sleep time in REM sleep, adults spend about 20% in REM sleep

Infants active/deep sleep cycles last about 50 minutes; adults about 90 minutes

“Sleeping through the night”–most babies by 12 weeks; actually still awakening several times during the night but most infants learn to resettle. About 1/3 of babies don’t resettle and “signal” their parents.

80% sleeping all night by 6 months and 90% by 12 months

Breast fed babies continue to need a feeding between midnight and 6 am for longer than bottle-fed babies

Should not need to feed during the night after 6 months (can go about 6-8 hours)

Settling babies while awake- sleep onset associations. “tired cues” before overtired

Bedtime routine/environment

Clearest evidence is that structured care leads to infants developing the ability to remain settle at night by 12 weeks.

“structured” parenting – start training at 6 weeks. 1. maximize diff. b/tw daytime and nighttime sleep environments. 2. settle baby while awake. 3. once baby at least 3 weeks old, healthy, gaining weight well, can begin to delay feeding when baby wakes at night – cuddle,, change diaper, etc.. Not leaving baby to cry.

Infant-demand care – leads to lower amounts overall fussing and crying in the first 2 months but to waking and signaling at night that continues at and beyond 3 months.

Not a problem if parents don’t think it’s a problem. No evidence that babies who wake and cry at 3 months will have long term problems

Lots of different ideas on getting babies to sleep; individualize plan based on family’s needs and resources

Neither parenting approach better overall, each is associated with different benefits and costs.

Copenhagen parents’ care was as effective as proximal care in minimizing crying and as effective as London care in enabling infants to remain settled by 12 weeks.

SIDS prevention Co-sleeping precautions

Parental support and education are key.