Cry-fuss behaviour (=colic etc), mean is just short of 2hrs per day for first 6 weeks, reduces to 72 minutes by 10-12 weeks.
“Colic” suggests that there is a bowel issue, usually suspected due to drawing legs up, passing wind – but these could be considered normal for crying and distress, of any cause. Reflux (GORD) is often blamed, yet international consensus states there is no evidence to support an empiric trial of acid suppression as a diagnostic test in infants and young children, even though symptoms tend to be less specific [Vandenplas, J Pediatr Gastroenterol Nutr. 2009 Oct;49(4):498-547. doi: 10.1097/MPG.0b013e3181b7f563]!
Mums with an anxiety disorder prior to pregnancy are at higher risk of having a child with excessive crying at 2, 4 or 16 months postpartum compared with mothers without an anxiety disorder. Risk increased further for mothers who developed an anxiety disorder during pregnancy.
So does maternal anxiety lead to “intrusive” parenting, in turn increasing infant crying ?[Arch Dis Child 2014;99:800–6]. Else fetal programming? Genetics?
What’s the influence of fathers!?
Surprisingly, maternal depressive disorders, cf anxiety, experienced before or during pregnancy, did not predict maternal report of excessive infant crying. Is the difference withdrawal, rather than intrusiveness?
Consider 2 week trial of anti-secretory eg ranitidine (but NOT PPI – increase risk of infection esp respiratory and GI, associated with parietal cell hyperplasia, and possibly food allergy!). But don’t assume improvement due to response! Or investigate with pH monitoring. Or stick to supporting parents! Even if arching and refusing to feed, no evidence of effectiveness.
5% have UTI retrospectively, but in absence of other signs, investigations not routinely required.
Crying that lasts more than 3 h per day, for more than 3 days per week and for more than 3 weeks in a row—is associated with child abuse and maternal depression! Higher scores on PND scale persists at 6/12 even if crying resolves…
6% of parents retrospectively admit physically abusive behaviours towards baby when crying.
Predicts shorter duration of breast feeding.
Persistent problems with cry-fuss behaviour at 5/12 associated with later behavioural problems (metanalysis, but confounded by psychosocial risk factors).
Reassure the parents/carers that infantile colic is a common problem that should resolve by 6 months of age.
RCTs of behavioural sleep intervention under 3/12 did not decrease crying. So encourage parent-infant reciprocity (ie responding to crying) until old enough to suit Gina Ford type regimented sleep regimes.
Encourage the parents to try relaxed cue based care, sleeping in the same room as the baby (not the same bed – beware SUDI) , offering physical contact esp skin to skin contact, and ensuring the baby gets lots of rich sensory experiences during the day. This, combined with average 10 hours of physical contact per 24hr (even if asleep), associated with 50% less crying and fussing. Only 37% of 3/12 babies sleep 8hrs straight at night.
Night waking is associated with co-sleeping and breast feeding, but breast feeding does not equate with less total sleep for parents over the whole 24hr period (quality, however, may be inferior).
Over sensitive babies may benefit from OT/Physio, but beware removing sensory stimulus as associated with neurodevelopmental problems. Massage, wrapping may help, little evidence for chiropractic, craniosacral, nutritional. Offer diverse sensory stimulation (through parents’ own social life and activities).
If symptoms are severe (subjective, of course) or persist after 4 months, consider an alternative underlying cause for symptoms.
NICE says seek specialist advice from a paediatrician if infant is not thriving, or symptoms are not starting to improve or are worsening after 4 months of age.
Caveat for GPs is “Seek specialist advice if Parents/carers feel unable to cope with the infant’s symptoms despite reassurance and advice in primary care.”
Feed refusal is often linked, often impaired mutual regulation of feeding that result in entrenched patterns of difficult feeding esp breast feeding issues.
The following suggest a feeding problem –
- 4 heavy disposable nappies per day minimum
- 3-4 yellow curdy stools if breast fed minimum
- Nipple/breast pain, attachment problems
- falling asleep within 10 minutes, feeding longer than 30 minutes (active feeding ie not including dozing, interacting) regularly
- clicking sound, gurgly sounds, absence of swallowing sounds
- Increased resp effort
Expect 125g per week growth average in first 3 months. Tongue tie only really relevant to breast feeding babies.
Babies who have infrequent large feeds are not necessarily abnormal, and cue based feeding rather than scheduled 3-4hrly feeds often works better.
So offer feed calmly, unless already full blown crying, in which case calm holding eg skin to skin until more settled. Cochrane review concluded that pacifier use does not interfere with breast feeding in mothers who are motivated.
Some evidence for trial of hydrolysed formula. RCT of 107 breast fed babies with colic excluded dairy, soy, wheat, nuts, fish and shortened duration of crying, but only CMPI really substantiated. Probiotic has helped in RCT but roles of feed management, lactose overload etc need to be elucidated first?
Functional lactose overload? – as feed progresses, fat level usually increases so transit time slows. If insufficient fat, rapid transit leads to lactose fermentation in colon (lower cholecystokinin levels seen).
The self-help support group Cry-sis for families with excessively crying or sleepless children, has a website and runs a national telephone helpline (0845 122 8669).
There’s also parent info including a video at http://www.nhs.uk/Conditions/Colic/Pages/Introduction.aspx
[Clinical review BMJ 2011;343:d7772 doi: http://dx.doi.org/10.1136/bmj.d7772]