July 27, 2009 Imtiaz 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.