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  1. Colic and Infant sleep problems July 27, 2009 Imtiaz Ghori

  2. Normal infant crying • 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

  3. Why do they cry? • 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

  4. Colic • 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

  5. Colic – what is it? • 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

  6. How does it differ from “normal” crying? • Sudden, unpredictable onset • Prolonged episodic bouts • Diurnal – evening peaks • Difficult to console • Sometimes physical signs –clenched fists, red face, legs drawn up, distended abdomen

  7. Some Signs and Symptoms that suggest other causes: • 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

  8. Dietary contribution? • 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.

  9. Parenting • 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.

  10. Why do we care about colic? • 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

  11. What can we do? • 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

  12. Herbal remedies • 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

  13. More remedies • 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

  14. Infants and Sleep • 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

  15. Cont.. • “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

  16. Cont.. • 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

  17. Cont.. • 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.

  18. Cont.. • 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

  19. Cont… • 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

  20. Parental support and education are key.