Crying babies part 1: Babies crying out for help
Published in The Medical Republic 4 February 2019 https://medicalrepublic.com.au/babies-crying-help/18926.
The first 100 days of an infant’s life are a critical window of exquisite epigenomic and neural plasticity. Environmental factors, including exposure to stress and method of feeding, can alter a biologically or psychosocially susceptible baby’s developmental potential, with life-long impact on settings of the immune system, the gut, the microbiome, metabolism, and the hypothalamic-pituitary-adrenal axis. It is widely accepted that prevention of the non-communicable diseases of childhood and adulthood, which are so costly to individuals, families and the health system, should begin as early as possible, from conception.1 Yet remarkably, at no other time in the lifespan will an individual receive healthcare so lacking an evidence-base, as he or she receives during “the crying period”.
Excessive crying is one of the most common presentations in early life, affecting 20% of infants.2 Rates of parent-reported problem crying appear to be much higher.3
Jane and Darren bring their firstborn, six-week-old Emily, to see you for vaccinations. You learn that Emily screams for two or three hours a day, and grizzles and fusses for most of the rest of the time when she isn’t sleeping.
Emily also cries and fusses for two or three hours in the middle of the night. Her parents ask you if she might benefit from reflux medication.
Jane is the primary carer. Darren, who returned to his full-time paid work three weeks ago, is worried about her. Last week, when Jane saw the Child Health Nurse, she scored 14 on the Edinburgh Postnatal Depression Scale, and Jane explains to you through tears that she is no longer coping.
Exclude underlying medical conditions
An organic cause for crying behaviours in afebrile babies occurs in less than 5% of cases. Investigations are not required unless indications emerge in a thorough history and examination.4 A urinary tract infection is the most common underlying organic cause.
Jane does not take medications, only postnatal vitamins. She has no allergies, and no relevant past or present medical conditions, including no history of mental health problems. Emily was born at term by spontaneous vaginal delivery at the local hospital, has no allergies, and currently receives BioGaia Probiotic Drops for Infant Colic Relief daily and Infacol a few times a week.
She is predominantly breastfed but also takes one to three bottles of either formula or expressed breast milk each day. She was slow to regain birth weight, which is why formula supplementation was commenced on day 14.
Emily is currently gaining about 140 gm/week, with two to three palmful-sized mustard-coloured stools and five heavy wet nappies each 24 hours. She vomits two or three times during or after most feeds.
She had laser surgery for “tongue and upper-lip tie” at three weeks, and Jane and Darren have just finished the four-times daily course of wound-stretching exercises prescribed by the dentist.
You conduct a thorough physical examination, including an oromotor examination, and find nothing of note, other than a patch of slightly pale mucosa under her tongue and an ablated labial frenulum.
What is ‘normal’ crying and the role of reassurance?
An important 2018 meta-analysis of 28 crying duration studies demonstrated that babies in Western countries cry on average two hours a day from birth in a plateau until six weeks, after which crying durations decrease to on average 68 minutes a day by 12 weeks.5
The authors conclude that crying and fussing is a spectrum condition, and that the “normal crying curve” and “Wessel’s criteria” are outdated clinical concepts, though the latter may be useful in research.5,6 Importantly, this meta-analysis shows that crying and fussing behaviours in the first months of life are modifiable, affected by the variable infant-care practices which occur across Western countries.
This finding corroborates long-standing cross-cultural studies demonstrating that infants in traditional cultures initiate cries as often, but do not have the same durations of crying typical in the West.7 It also corroborates a well-conducted 2006 observational study which found Copenhagan babies, who were more likely to be breastfed, receive cued care (that is, a pattern of responding to the baby’s communications, or cues) from birth, and on average 10 hours of physical contact in a 24-hour period, cried half as much as London babies, who were more likely to receive routinised care, on average six hours of physical contact in a 24-hour period, and were less likely to be breastfed (the UK has the worst breastfeeding rates in the world).8,9
Problem crying is not as benign as previously thought. Babies who cry excessively have an increased risk of premature weaning and non-accidental head trauma.10,11 Their mothers are at increased risk of postnatal depression; 12 their fathers may also be prone to depressive symptoms.13
Infant feeding, sleep and crying problems often interact and co-evolve, and are generically referred to as regulatory problems.14 Multiple studies demonstrate that cry-fuss or regulatory problems in early life are associated with increased risk of behavioural and mental health challenges in later life, explained by developmental cascade models.15-20, 21-24
This is more likely if there is more than one regulatory problems or if the crying and fussing persists beyond five months. It’s not possible, however, to predict which infants will cry and fuss beyond three to four months of age, and effective intervention, as early as possible, is required.
You both reassure Jane and Darren that the first 16 weeks is a particularly sensitive period neurologically, after which crying and fussing typically settles without causing long-term problems AND explain that while you can never promise, there is usually a lot that can be done right now to make the days and nights with Emily far more enjoyable. You explain that any one strategy on its own is not likely to help.
You suggest the family experiments with a range of new strategies, which will interact together. These strategies, also referred to as Neuroprotective Developmental Care (or the Possums programs), will relate to Emily’s gut, her feeds, sleep, and sensory needs; and, if Jane and Darren are interested, you will also help them with some psychological strategies, because it is normal to have a lot of difficult thoughts and feelings when your baby cries a lot and you are severely sleep deprived.
You might use Possums 5 Domain Visual Tool, to validate the significance and complexity of the problem; to help parents understand the concept of multiple domains which interact together; to prioritise; and then to plan together for enough time to allow everything to be addressed.
You invite Jane and Darren to return as soon as possible, setting up consecutive long appointments for Jane and baby Emily.
The costly merry-go-round of multiple providers, conflicting advice, and hospital outpatient or residential re-admissions
You learn that you are the 13th health professional Jane has consulted in Emily’s short life (not including the midwives in the hospital, each of whom offered conflicting advice, too).
Jane had two home-visits by two different midwives, and another GP in your practice did the Day Seven postnatal check. She has seen three lactation consultants – two at the hospital’s parenting centre, who applied the Thompson method and reassured Jane that Emily’s latch and positioning were good, and a private lactation consultant who applied Baby-led Breastfeeding, again reassuring Jane that Emily’s latch and positioning were fine.
Two of the three lactation consultants diagnosed tongue and upper lip ties, explaining that Emily had a high palate, recessed chin, and restricted upper-lip and tongue mobility.
The dentist who performed the frenotomies at three weeks referred Emily to the chiropractor, who told them Emily had myofascial restrictions in the neck as well as orally, and who has been giving her weekly treatments. The child health nurse advised that Emily was overtired, overstimulated, and needed to learn to self-settle. The pharmacy nurse weighed Emily and advised more formula.
Jane and Darren, in desperation, took her to the Emergency Department last week, where they were reassured that Emily’s crying was normal and Jane was advised to see a psychologist, which she doesn’t wish to do.
A few days ago, Jane took Emily to the paediatrician who’d examined Emily at birth (and who’d asked them to return for a routine six-week check).
The paediatrician diagnosed colic, put Jane on a cow’s milk and soy elimination diet, and advised infant massage.
The paediatrician also gave Jane and Darren a Baby Business booklet.
Studies confirm that parents report large amounts of conflicting and confusing advice concerning infant regulatory and breastfeeding problems.25-27 Much of this advice has been demonstrated not to help, or may even make common post-birth problems worse.28,29 In this context, parents recourse to multiple providers, driving up health system costs.25,30
The UK’s influential Nuffield Foundation, promoting sustainable healthcare, calls for common problems of childhood to be managed in cost-effective primary care settings.31 Yet in a climate of post-birth anxiety induced by the health system itself, new mothers are encouraged to re-present to their birthing hospital’s parenting centre to avail themselves of no-fee outpatient services and day-stay admissions, where conflicting advice is replicated within the one hub, but at multiple times the health system cost of providing primary healthcare services.32
Similarly, unique to Australia, fatigued women coping with baby sleep problems are admitted to our no-fee government-funded residential units for sleep problems, an extraordinarily expensive health system solution.33
I have witnessed high levels of interdisciplinary, interpersonal, and ideological conflict throughout my decades of special interest in early life care. This reflects each health professional’s deep commitment to what they believe is in the women and babies’ best interests at such a vulnerable time of their lives. More accurately though, the conflict is a “horizontal violence” resulting from a failure of health systems in Australia and internationally to invest vertically in rigorous, integrated, theoretical frames and clinically relevant research and training in the common regulatory and breastfeeding problems of early life.34
Market forces take advantage of this policy failure, leveraging social media. Health professionals’ lack of training in research literacy results in powerful group-thinks, where methodologically weak research is mistaken for meaningful contribution, and used to reinforce the discipline-specific lenses that are applied.
How Jane and Darren interpret Emily’s distressed behaviour
Jane explains that Emily’s latch improved immediately after the oral laser surgery. Breastfeeds are still a nightmare though, and Jane dreads them. Each breastfeed takes about an hour.
Emily pulls off and fusses a lot, sometimes because there is not enough milk or because she can’t cope with the letdown, but mostly because she swallows a lot of air, which causes reflux and wind pain. Jane and Darren burp Emily frequently during and after breastfeeds and bottle-feeds to try to prevent this, and hold her upright for 20-30 minutes after feeds, day and night.
Sometimes Jane uses breast massage while breastfeeding, as a lactation consultant advised, to help Emily take in more calories. Jane also tries to pump three times a day. She finds it upsetting that Emily seems to take the bottle eagerly, without any problems. By the time the pumping and formula top-ups are over, Jane may have taken an hour and a half or more to feed Emily. She waits three hours or so before the next feed.
Darren observes that Emily is overtired much of the time, desperately needing to sleep but fighting it, and that she also becomes overstimulated very quickly.
Jane has stopped going out in the last fortnight, to set up calming routines. Since they can’t put Emily down due to her pain and reflux, she often has to sleep on either Jane or Darren’s chest.
At night she can be awake for hours with gut pain. Jane knows it is not hunger because Emily has just fed, but still, she offers the breast more often in the night, maybe every two hours. Jane says that she knows she is setting up bad habits and might be making the tummy pain worse. She feels guilty about this. She says that most of the time she feels she is failing as a mother.
Although families often believe they can see a difference, proton pump inhibitors, simethicone (Infacol), and herbal mixtures don’t decrease crying on objective measures.35,36 The neurobiological power of expectation, or placebo effect, increases parental report of intervention efficacy by up to 50%, and has similar powerful effect on health professional perceptions.35, 37-40
Crying baby research is always complicated by the natural attrition of crying behaviours. However, crying baby research internationally is characterised by serious omitted variable bias and discipline-specific interpretative bias.
It is also often confounded by the placebo effect, which may affect measures based on parent report. Concerningly, as one of my research heroes, John Ioannidis, Professor of Medicine at Stanford University, has demonstrated, most clinical research is not relevant, and the findings likely to be reversed in time, due to biased study design and interpretation of data.41-43
In Part 2 we will explore the impact of omitted variable and discipline-specific interpretative biases on existing evidence concerning the gut and infant cry-fuss behaviours, and offer a neurobiological explanatory model. Part 2 will also offer integrated, evidence-based management strategies for the baby who cries and fusses, in the domain of feeds.
Dr Pamela Douglas is a GP and Medical Director of Possums & Co. www.possumsonline.com, a charity which educates health professionals in the evidence-based Neuroprotective Developmental Care (NDC) or Possums programs, including the Possums Baby and Toddler Sleep Program. If you wish, you can refer to an NDC accredited practitioner. There are lots of free videos and other resources for parents with babies here, and online parent peer support is available for a nominal fee. Pam is an Associate Professor Adjunct with the School of Nursing and Midwifery, Griffith University, and Senior Lecturer with the Primary Care Clinical Unit, University of Queensland. She is author of The discontented little baby book: all you need to know about feeds, sleep and crying.
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