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How To Calm Your Crying Baby




Calm Your Crying Baby


Information obtained from articles written by Elizabeth Pantley, Author of Gentle Baby Care and
by Rowena Bennett, RN, RM, RPN, CHN, Grad Dip Health Promotion. Article Source: Baby Care Advice: Articles: Crying

This information listed here is for the education of new parents. No copyright infringements are intentional. I try to cite information as if it is available. Many of these articles have been saved years ago and the original sources were lost. I consider the use of this material to be for educational purposes of the public masses and not for any profit on the part of MoonDragon.org. This information was posted several years ago (2003) and I thought permission was granted for use. Any other information included here was obtained at that time but the resource information was lost, non available or inaccurate. Since there seems to have been some confusion as to authorship, I am adding cites and links to resources as they become known and available. Cites edited May 11, 2008

Learn About It

When we're pregnant or awaiting adoption, we dream about our baby-to-be, we always envision those beautiful Hallmark card scenes: charming baby smiling up at peaceful mother's face. We read books in advance of the big day about how care for a newborn - how to bathe, feed and dress her - and then we feel somewhat prepared. However, a crying baby was never part of that idyllic vision, so this takes us by surprise. But the fact is, all babies cry at one time or another. Some babies cry more than others, but they all do cry. Understanding why babies cry can help you get through this phase and respond effectively to your crying baby - so can the list of ideas that follows.





Why Does My Baby Cry?

Simply put, babies cry because they cannot talk. Babies are human beings, and they have needs and desires, just as we do, but they can't express them. Even if they could talk, very often they wouldn't understand why they feel the way they do, they wouldn't understand themselves well enough to articulate their needs, so babies need someone to help them figure it all out. Their cries are the only way they can say, "Help me! Something isn't right here!"

As distressing as it is for you to hear your baby cry, it's normal for all babies to cry. Crying doesn't necessarily mean there's anything wrong and it certainly doesn't mean you're a bad parent. Some babies simply cry more than other babies. Babies don't know how others feel at the sound of their crying. They don't cry because they're spoiled and they don't cry to annoy you. They're simply trying to communicate that they need something. Crying is one of the ways your baby communicates with you. As part of her survival instinct, crying ensures her basic needs for food and comfort are met. Crying may also be your baby's way of letting of steam. For babies that are overtired and overstimulated crying is a way they unwind and release tension.

During the first few weeks of life your baby will sleep a lot, but when awake she'll cry loud and often, usually without tears. On average newborn babies cry for about 1 1/2 hours a day. By 6 weeks, the amount of time your healthy baby spends crying can have increased to 3 hours a day. This is normal! At this age, there will also be some wakeful periods without crying. As your baby gets older, she'll learn other ways of communicating and the amount of crying will generally slowly reduce. By 6 months, your baby may spend around 3 hours a day playing and gurgling without crying. However, it's still common for a baby of this age to cry for 1 or 2 hours each day. All babies are different, even perfectly healthy babies can cry more or less than these figures. The amount of time your baby spends crying each day can often feel much longer than it actually is - even 1/2 an hour can feel like an eternity when you're tired.





Different Kinds of Cries

As you get to know your baby, you will become the expert in understanding his or her cries in a way that no one else can. In their research, child development professionals have determined that certain types of cries mean certain things. In other words, babies do not cry the same exact way every time. (Other child development experts, also known as mothers, have known that for millennia.)

Over time, you will recognize particular cries as if they were spoken words. In addition to these cry signals, you often can determine why your baby is crying by the situation surrounding the cry. Following are common reasons for Baby's cry, and the clues that may tell you what's up:

Hunger: If three or four hours have passed since his or her last feeding, if he or she has just woken up, or if he or she has just had a very full diaper and he or she begins to cry, he or she is probably hungry. A feeding will most likely stop the crying. Working out whether your baby is hungry or not is not always as simple as it appears! If you find you have a very hungry baby, who is feeding more often than you feel she should, you may be misinterpreting her cues.

Breast fed babies do not need additional water until they start eating solid foods. Breast feed your baby whether you think he or she is hungry or thirsty. Feed on demand and not by schedule. Breast fed babies will need to be fed more frequently than babies fed formula since breast mild is more easily digested and digests faster than formula.

Formula fed babies do not necessarily need additional water until they start on solid foods. However, in warmer climates, during summertime hot weather (or possibly heated homes) small amounts of additional water may be helpful. Offer 1 ounce of cooled boiled water if he or she is less than 3 months old, or 1-2 ounces if he or she is over 3 months, once or twice a day, in addition to regular formula feeds if you think he or she is thirsty.

Feeding problems can cause your baby to develop a tummy pains, spitting up or a pattern of "snack" feeding.

Tiredness: If your baby was tired he or she would fall asleep right? Not necessarily! Some babies will sleep anywhere, anytime. Others need to be provided with the opportunity to sleep in a low stimulating environment. If your baby needs you to provide him or her with opportunities to sleep and you miss his or her cues (signs that indicate that he or she is tired), there is a risk he or she will become over-tired. Once overtired he or she can experience great difficulty "switching off" and eventually he or she can get to the stage of screaming from sheer exhaustion. Babies show signs of tiredness quite differently than we expect. Look for these signs: decreased activity, losing interest in people and toys, rubbing eyes, looking glazed, and the most obvious - yawning. Tired signs for a young baby include clenched fists, waving arm and leg movements, facial grimaces, fussing, whining and grumbling followed by crying. Often these signs are misinterpreted as boredom or hunger. If you notice any of these in your crying baby, she may just need to sleep. Time for bed!

Discomfort: If a baby is uncomfortable - too wet, hot, cold, squished - he or she will typically squirm or arch his or her back when he or she cries, as if trying to get away from the source of his or her discomfort. Try to figure out the source of his or her distress and solve his or her problem.

As parents, we tend to over-dress our babies. This can make a baby feel overheated. Your baby needs to wear similar layers of clothing as you are wearing. While he or she is sleeping, he or she may need to be covered with a sheet and/or blanket(s). Think about how you would feel if you were dressed or covered the same as him or her. Do not cover his or her head with a hat while he or she is sleeping. Your baby could be sensitive to the feel of his or her clothing. Some clothing fibers can feel scratchy or uncomfortable. The seams of clothing could bother him or her by rubbing against his or her skin or his or her clothes could be too tight. Where possible, dress him or her in loose fitting clothing made from pure cotton.

Wet or dirty diapers can be uncomfortable for your baby, particularly if he or she has a diaper rash. Change the baby frequently and treat any diaper rash flair-ups that may occur before they become red and inflamed.

Babies have a very good sense of smell. Some odors that may be familiar to you, could be distressing for your baby, for example the smell of cigarettes (or nicotine on your hands) or strong perfumes or colognes.

Pain: A cry of pain is sudden and shrill, just like when an adult or older child cries out when they get hurt. It may include long cries followed by a pause during which your baby appears to stop breathing. He then catches his breath and lets out another long cry. Time to check your baby's temperature and undress him for a full-body examination.

Teething Pain: The first tooth generally appears around the age of 6 months. But babies can be born with teeth or for some the first tooth may not appear until 15 months. While teething, your baby's gum may become swollen and sore at the spot where the tooth is breaking through the gum. Teething discomfort usually last for no longer than a few days.

Overstimulation: If the room is noisy, people are trying to get your baby's attention, rattles are rattling, music boxes are playing, and your baby suddenly closes his or her eyes and cries (or turns his or her head away), he or she may be trying to shut out all that is going on around him or her and find some peace. It is time for a quiet, dark room and some peaceful cuddles.

Illness: When your baby is sick, she may cry in a weak, moaning way. This is his way of saying, "I feel awful." If your baby seems ill, look for any signs of sickness, take her temperature and call your health care provider.

Frustration: Your baby is just learning how to control his or her hands, arms, and feet. He or she may be trying to get his or her fingers into their mouth or to reach a particularly interesting toy, but his or her body isn't cooperating. The baby cries out of frustration, because he or she cannot accomplish what he or she wants to do. All the baby needs is a little help.

Loneliness: If your baby falls asleep feeding and you place him or her in their crib, but the baby wakes soon afterward with a cry, he or she may be saying that he or she misses the warmth and security of your embrace and doesn't like to be alone. The baby simply wants to be held and cuddled. A simple situation to resolve. Wearing a baby sling while you are working around the house is helpful for freeing your hands to take care of chores, but also keeps your baby next to your body for familiar warmth, smells, sounds and touch. These are the things that she was used to having while still in your womb and she finds them comforting. If your baby stops crying as soon as they are picked up, the reason may be that the baby simply wants to be held. Where your baby regularly falls asleep while being cuddled, he or she could also want to be held because he or she has learned that "this is the way I go to sleep". In which case, the baby may also want to be picked up when he or she is tired and wants to sleep.

Worry or fear: "Separation anxiety" begins around the age of 6 months, peaks at around 9 months and continues until approx 2-3 years. When your child experiences separation anxiety he or she will cry as soon as his or her main caregiver leaves her sight. As frustrating as this can feel for parents, this is normal behavior and is a healthy sign of a attachment to her main caregiver.

Your baby suddenly finds herself in the arms of Great Aunt Matilda and cannot see you; her previously happy gurgles turn suddenly to crying. The baby is trying to tell you that he or she is scared: The baby does not know this new person, and he or she wants Mommy or Daddy. Explain to Auntie that the baby needs a little time to warm up to someone new, and try letting the two of them get to know each other while Baby stays in your arms.

Stress - Babies can feel stress, especially when parents or caregivers are stressed. If there is a lot of tension, arguments or raised voices around her, your baby can be affected by this.

Boredom: A baby certainly needs loving interaction (talking, signing and playful stimulation) from parents or caregivers. But it is far more common for babies to cry from over-stimulation than it is from boredom. Boredom is rarely a problem for young babies, except in incidences of neglect. Although your baby is learning all the time, your baby does not need to be amused every waking moment. Just as he or she needs your loving interaction, your baby also needs some quiet time to listen and learn from the sights and sounds around him or her. To discover how he or she can control the muscles in his or her limbs and body is a task in itself. If your baby has been sitting in the infant seat for 20 minutes while you talk and eat lunch with a friend. Your baby is not tired, hungry or uncomfortable, but he or she starts a whiny, fussy cry. Your baby may be saying that he or she is bored and needs something new to look at or touch. A new position for the seat or a toy to hold may help.

Colic: Infant colic is not a specific condition but a term used to describe "excessively long periods of inconsolable crying in an otherwise healthy, thriving baby." There are a number of different theories on why colic occurs. As yet none have been proven. The main difference between normal crying and infant colic is whether your baby can be comforted or not. A baby with colic is not able to be comforted during crying, no matter how hard you try. If your baby is able to be comforted it's NOT colic. Inconsolable crying is often interpreted as pain.

If your baby cries inconsolably for long periods every day, particularly at the same time each day, he or she may have colic. Researchers are still unsure of colic's exact cause. Some experts believe that colic is related to the immaturity of a baby's digestive system. Whatever the cause, and it may be a combination of all the theories; colic is among the most exasperating conditions that parents of new babies face. Colic occurs only to newborn babies, up to about four to five months of age. Look for patterns to your baby's crying; these can provide clues as to which suggestions are most likely to help. Then experiment with some of the ideas in this list and in the rest of this article.

  • If breastfeeding, feed on demand (cue feeding), for nutrition as well as comfort, as often as your baby needs a calming influence.


  • If breastfeeding, try avoiding foods that may cause gas in your baby, such as dairy products, caffeine, cabbage, broccoli and other gassy vegetables.


  • If bottlefeeding, offer more frequent but smaller meals; experiment with different formulas with your doctor or health care provider's approval.


  • If bottlefeeding, try different types of bottles and nipples that prevent air from entering your baby as he drinks, such as those with curved bottles or collapsible liners.


  • Hold your baby in a more upright position for feeding and directly afterwards.


  • Experiment with how often and when you burp your baby.


  • Offer meals in a quiet setting.


  • If baby likes a pacifier, offer him one.


  • Invest in a baby sling or carrier and use it during colicky periods.


  • If the weather is too unpleasant for an outside stroll, bring your stroller in the house and walk your baby around.


  • Give your baby a warm bath.


  • Hold your baby with her legs curled up toward her belly.


  • Massage your baby's tummy, or give him a full massage.


  • Swaddle your baby in a warm blanket.


  • Lay your baby tummy down across your lap and massage or pat her back.


  • Hold your baby in a rocking chair, or put him in a swing.


  • Walk with Baby in a quiet, dark room while you hum or sing.


  • Try keeping your baby away from highly stimulating situations during the day when possible to prevent sensory overload.


  • Lie on your back and lay your baby on top of your tummy down while massaging his back. (Transfer your baby to his bed if he falls asleep.)


  • Take Baby for a ride in the car.


  • Play soothing music or turn on white noise such as a vacuum cleaner, hair dryer, or running water.


  • As a last resort, ask your health care provider or midwife about medications or other remedies available for colic and gas.
    •



    swaddling the baby


    What About Fussy Crying?

    There are plenty of times when you cannot tell if your baby's crying is directly related to a fixable situation: hunger, a soiled diaper, or a longing to be held. That is when parents get frustrated and nervous. That is when you should take a deep breath and try some of the following cry-stoppers:

    Hold your baby. No matter the reason for your baby's cry, being held by a warm and comforting person offers a feeling of security and may calm his crying. Babies love to be held in arms, slings, front-pack carriers, and (when they get a little older) backpacks; physical contact is what they seek and what usually soothes them best.

    Breastfeed your baby. Nursing your baby is as much for comfort as food. All four of my babies calmed easily when brought to the breast - so much so that my husband has always called it "The Secret Weapon." And my babies are very typical. Breastfeeding is an important and powerful tool for baby soothing.

    Provide motion. Babies enjoy repetitive, rhythmic motion such as rocking, swinging, swaying, jiggling, dancing or a drive in the car. Many parents instinctually begin to sway with a fussy baby, and for a good reason: It works.

    Turn on some white noise. The womb was a very noisy place. Remember the sounds you heard on the Doppler stethoscope? Not so long ago, your baby heard those 24 hours a day. Therefore, your baby sometimes can be calmed by "white noise" - that is, noise that is continuous and uniform, such as that of a heartbeat, the rain, static between radio stations, and your vacuum cleaner. Some alarm clocks even have a white noise function.

    Let music soothe your baby. Soft, peaceful music is a wonderful baby calmer. That's why lullabies have been passed down through the ages. You don't have to be a professional singer to provide your baby with a song; your baby loves to hear your voice. In addition to your own songs, babies usually love to hear any kind of music. Experiment with different types of tunes, since babies have their own favorites that can range from jazz to country to classical, and even rock and rap.

    Swaddle your baby. During the first three or four months of life, many babies feel comforted if you can re-create the tightly contained sensation they enjoyed in the womb.

    Massage your baby. Babies love to be touched and stroked, so a massage is a wonderful way to calm a fussy baby. A variation of massage is the baby pat; many babies love a gentle, rhythmic pat on their backs or bottoms.

    Let your baby have something to suck on. The most natural pacifier is mother's breast, but when that isn't an option, a bottle, pacifier, Baby's own fingers, a teething toy, or Daddy's pinkie can work wonders as a means of comfort.

    Distract your baby. Sometimes a new activity or change of scenery - maybe a walk outside, or a dance with a song, or a splashy bath - can be very helpful in turning a fussy baby into a happy one.



    Reading Your Baby's Body Language

    Many times, you can avoid the crying altogether by responding right away to your baby's earliest signals of need, such as fussing, stiffening her body, or rooting for the breast. As you get to know your baby and learn her signals, determining what she needs will become easier for you - even before she cries.



    This article is a copyrighted excerpt from Gentle Baby Care by Elizabeth Pantley. (McGraw-Hill, 2003)
    http://www.pantley.com/elizabeth

    This article is a copyrighted excerpt from Rowena Bennet, RN, RM, RPN, CHN, Grad Dip Health Promotion. Article Source: Baby Care Advice: Articles: Crying



    PROBLEM CRYING IN INFANCY - PROFESSIONAL MANAGEMENT & INTERVENTION


    Up to 20 percent of parents report a problem with infant crying or irritability in the first 3 months of life. Crying usually peaks at 6 weeks and abates by 12-16 weeks. For most irritable infants, there is no underlying medical cause. In a minority, the cause is cow's milk and other food allergy. Only if frequent vomiting (about five times a day) occurs is gastro-esophageal reflux a likely cause. It is important to assess the mother-infant relationship and maternal fatigue, anxiety and depression.

    baby crying


    MANAGEMENT OF EXCESSIVE CRYING INCLUDES:
    • Explaining a baby's normal crying and sleeping patterns.
    • Helping parents help their baby deal with discomfort and distress through a baby-centered approach.
    • Helping parents recognize when their baby is tired and apply a consistent approach to settling their baby.
    • Encouraging parents to accept help from friends and family, and to simplify household tasks.

    If they are unable to manage their baby's crying, admission to a parenting center, medical clinic (day stay or overnight stay) or local hospital should be arranged.

    CRYING & IRRITABILITY IN MOST BABIES HAVE NO ORGANIC CAUSE

    The first English language report mentioning problem crying in infants in The boke of chyldren, published in the 16th century, described it as related to "noyse and romblying in the guttes." Although it has long been recognized that some infants cry more than others, the cause (or causes) remains elusive. Infants who present with persistent crying are probably a heterogeneous group, requiring a variety of management approaches. Although considered a trivial problem by many healthcare professionals, persistent crying in babies has been associated with maternal depression, family stress, family breakdown, and child abuse.

    EPIDEMIOLOGY

    From an evolutionary perspective, crying is an attachment behavior, promoting proximity to the infant's primary caregiver and ensuring survival and the development of social bonds. It is not surprising then that all infants cry. However, depending on the definition used, up to 20 percent of infants in the community cry excessively and are irritable. Traditionally, the criteria of Wessel et al have been used to define "problem crying" as unexplained crying and fussing lasting for more than 3 hours per day, on more than 3 days per week, for more than 3 weeks. However, many babies cry less than this but are still perceived by their parents to have a problem.

    Crying begins in the first few weeks of life, and typically the duration peaks at 2.4 hours per day at the age of 6 weeks. Episodes of crying tend to cluster in the evening, but can occur throughout the day. Many parents report that, while crying, their infants go red in the face, pull up their legs, or pass wind. Such behavior is most likely part of normal infant crying and not related to gastro-esophageal reflux. For most babies, crying and irritability decrease substantially by the age of 3-4 months.

    Although the frequency of crying bouts and the timing of the crying "peak" are similar across cultures, the duration of crying bouts has been shown to be shorter when parenting practices include more carrying of babies and breastfeeding on demand. Crying in infants is related to the dynamics of the mother-infant relationship, including maternal anxiety and depression. A prospective study of 1204 infants examining psychosocial factors associated with persistent crying at 3 months found the risk factors to be life stress, poor partner support, unsatisfactory sexual relationships, more maternal physical health problems in pregnancy, a traumatic birth, and perceiving the hospital staff as hostile.

    CAUSES OF CRYING

    For most infants, problem crying is part of a normal spectrum whereby babies who have not yet learned to "self-soothe" and regulate their own crying become persistent criers. This may be a response to tiredness or hunger. Tiredness should be suspected when an infant "total sleep duration per 24 hours" falls more than an hour short of the "average" for their age (see Sleep requirements). Hunger is more likely when a mother reports frequent feeds (ie, 3 hourly), poor weight gain and inadequate milk supply.

    Less than 5 percent of babies with problem crying have an identifiable organic cause, as outlined in the diagnostic and management flowchart for infant irritability.

    GASTRO-ESOPHAGEAL REFLUX

    No causal relationship between gastro-esophageal reflux (GOR) and infant crying and irritability has been demonstrated. In a study of 70 infants with persistent crying, abnormally frequent or prolonged GOR (assessed by pH monitoring) only occurred in babies who vomited more than five times a day. "Silent reflux" - Reflux without vomiting - did not occur. The duration of daily crying did not correlate with the severity of GOR.

    Many health professionals continue to treat babies with antacid medications, but there are no blinded, randomized controlled trials of their effectiveness in irritable infants. Both ranitidine and omeprazole are ineffective in reducing crying. Thus, in the absence of frequent vomiting, antireflux medication to manage persistent infant irritability is not recommended.

    FOOD ALLERGY

    In some irritable infants, food allergy may play a causal role, but its contribution to infant irritability in the general community is unknown. Food allergens commonly implicated include cow's milk protein and soy protein, both of which can be found in human breast milk. These allergens can cause immediate reactions (vomiting, erythema where formula or breast milk touches the skin and/or urticaria developing within 2 hours of ingestion) or delayed reactions (vomiting and diarrhoea 2-48 hours after ingestion).

    Infants with food allergies usually present with one or more of the following symptoms: vomiting, blood or mucus in diarrhea, poor weight gain, and signs of atopic disease (e.g., eczema or wheezing). However, the presence of any one of these symptoms is not diagnostic of food allergy. In practice, a trial of eliminating cow's milk by modifying the mother's diet or changing the formula may be the best diagnostic test. For breastfed infants, a mother must remove all cow's milk and cow's milk products from her diet (including casein and whey products). Breastfeeding mothers can use soy milk and should consider taking a calcium supplement. Formula-fed babies may improve with a soy-based formula. However, some infants are allergic to both cow's milk and soy protein. For these babies, changing to extensively hydrolysed formulas can be effective. An estimated 10-15% of babies with cow's milk allergy are also intolerant of extensively hydrolysed formulas and, for these babies only, treatment with amino acid formulas is indicated. These products should be tried for at least 2 weeks to gauge response.

    LACTOSE INTOLERANCE

    The role of lactose intolerance as a cause of infant irritability remains debatable. It has been hypothesized that some babies have a transient underlying lactase deficiency, leading to a build-up of lactose derived from breast milk or formula. Gut bacteria break down the lactose, converting it to lactic acid and hydrogen. The resulting acidic feces may cause peri-anal excoriation. In a double-blind, placebo-controlled, crossover study of 46 infants with excessive crying and diarrhea, treating breast milk or formula with lactase drops resulted in significantly less crying. These results may not apply to infants without these symptoms. Diagnosis of lactose intolerance includes testing for fecal-reducing substances. A clinical response to a lactose-free diet confirms the diagnosis. Lactose-free formula is readily available. For breastfed babies, expressed breast milk needs to be pre-treated with lactase drops for 12-24 hours and then given to the baby in a bottle. Alternatively, lactase tablets can be crushed and a small amount placed inside the baby's mouth before breastfeeding (as per the manufacturer's instructions).

    BOWEL SPASM OR GAS

    Anti-cholinergic medications have been shown in three randomized controlled trials to effectively reduce infant crying. However, the risk of adverse events, including apnea and seizures, precludes the use of these medications. Simethicone (Infacol Wind Drops, Pfizer; and Degas Infant Drops, Wyeth) has no effect on infant crying when compared with placebo.

    MATERNAL & FAMILY PSYCHOSOCIAL STATE

    Infant behavior needs to be understood in the context of the emotional development of the infant and the developing infant-parent relationship. Social and cultural beliefs, the "psychological style" of the parents (e.g., degree of emotional response, ability to deal with an infant's total dependence), as well as the parents' own childhood experiences, all influence how parents react and respond to persistent infant crying. The demands of fertility treatments may result in a tentative pregnancy and parents do not dare become too attached to the fetus. They may then be overwhelmed and unprepared for the reality of caring for a baby. Grief from previous neonatal loss may resurface with the birth of an infant, and it may be hard for parents to be convinced that this baby will be healthy and survive. Finally, postnatal anxiety or depression may impair a mother's capacity to read her infant's emotional states and behavioral cues. This may lead to soothing strategies not in tune with the infant's state, a paucity of appropriate interaction and play opportunities, and a blunted emotional response to the infant.

    Depressive symptoms are commonly reported by mothers of irritable or unsettled infants attending parenting centers. The extent to which this relationship holds in the general community is unknown. Infant irritability in the presence of other stressors, such as marital and trans-generational conflicts, insufficient social support or single parenthood, may also precipitate maternal depression.

    For some infants, a lack of maturity in their ability to modulate their reactions to internal physical symptoms (eg, bowel spasm) and external stimuli (e.g., loud noise) may result in problem crying. Clinical experience suggests that a traumatic birth may lead to infant distress, or, alternatively, infant sleepiness and difficulty in establishing a feeding routine. The mother may be emotionally and physically unavailable to help her baby with the early stages of learning to self-soothe and anticipate comfort.

    Irritable babies have often been described as having a "difficult" temperament. However, temperament only plays a small part in infant irritability, and labeling an infant as difficult can lead to parents feeling helpless and powerless to change the underlying nature of the problem.

    PRIMARY CARE INTERVENTIONS

    As irritability in most infants has no underlying medical cause, the task of healthcare practitioners, after eliminating medical causes, is to explain babies' normal crying and sleep patterns, to assist parents to help their baby deal with discomfort and distress, and to assess the mother's emotional state and the mother-baby relationship.

    BEHAVIOR DIARIES

    Parents can use a simple diary to record their baby's crying, feeding, and sleeping patterns on a daily basis. A diary can show the baby's usual crying patterns, the total amount of sleep the baby is having per 24 hours, and can help parents and health care providers monitor the response to settling techniques. Most parents enjoy completing a diary. In some cases a diary can help them solve the problem by, for example, recognizing that their baby sleeps better if he or she is awake for longer periods between daytime sleeps.

    SETTLING TECHNIQUES

    A number of different settling techniques are presented in books and videos, and recommended by parenting centers. They all aim to teach babies to fall asleep on their own and to ensure parents have a consistent approach to settling. Consistency is important in a "baby-center" approach whereby the needs of the baby are addressed (e.g., irritable babies require a consistent "message" about how to fall asleep) as well as the needs of the parent. Most techniques recommend that the parent pats or rocks the baby until he or she is quiet but not asleep. The parent then leaves the room. If the baby starts crying, the parent returns after a moment and, if the baby has not stopped crying, begins to resettle the baby. The process continues until the baby falls asleep. Such an approach has been shown to be effective in an uncontrolled trial of sleep-deprived infants staying in a parenting center. It is unknown whether this is due to the approach, the opportunity for mothers to rest, or the other support and counseling offered at the center.

    THE BABY WHO WANTS TO BE CARRIED ALL THE TIME

    Some babies seem to need to be with their mother all the time. If left alone they will cry persistently and will not settle even with the techniques suggested above. Do not battle this. Encourage the mother to minimize separations and remain in the baby's line of sight. Mothers can carry their baby in a sling, or take the baby from room to room in a carriage or stroller. This will not "spoil" the baby. Let the baby go to sleep in the parents' bedroom at night until the baby has settled enough to tolerate being moved into his or her own room. Introduce a transitional object - a doll or teddy for the baby to look at when he or she wakes during sleep - that can gradually come to represent maternal care and help the baby self-soothe.

    THE FATHER'S ROLE

    Fathers are often an invaluable source of practical and emotional support for mothers and their babies during this time, although mothers may need encouragement to allow the father to work out his own way of interacting with the baby, which may be different from the mother's. The role of fathers is often neglected and, if possible, fathers should be actively engaged by inviting them to clinic appointments. Fathers often suffer because they worry about how their partner is coping, particularly if their work means they are away from home for many hours.

    WHEN TO REFER FOR FURTHER ASSESSMENT

    Some babies warrant further assessment. Referral to a pediatrician or professional with expertise in infant mental health should be considered if:
    • The baby continues to have feeding and sleeping problems beyond 3 months of age.
    • Avoids gaze.
    • Withdraws emotionally and does not respond to parents when not crying.
    • Does not enjoy play.
    • Remains distressed beyond 3 months of age.

    The mother should be referred to the same specialists, or to an adult psychiatrist, if she:
    • Lacks empathy, makes hostile comments, or attributes persecutory intent to her baby.
    • Says she does not feel "bonded" to the baby or otherwise indicates a mother-baby relationship problem.
    • Is unable to follow advice.
    • Feels persistently angry, or continues to report anxiety or depression symptoms after the baby's crying improves.

    SUPPORT

    All families with a crying infant are tired. Practical support is greatly needed to help families through this time. Parents should be encouraged to:
    • Mobilize help from family and friends.
    • Rest once a day when the baby is asleep.
    • Plan ahead for the baby's most difficult time of the day (e.g., by preparing dinner in advance).
    • Shop online, arrange home delivery of food, and, if financially feasible, arrange home help or a nanny.

    When the situation becomes overwhelming, parenting centers which offer day or overnight stays can be invaluable.

    OUTCOME

    For most babies, problem crying and irritability settle by 3-4 months of age. Irritable babies are more likely to develop behavior problems and sleep problems in the toddler and preschool years than babies who were not irritable, and families of irritable babies are less likely to have subsequent siblings than families of non-irritable babies.

    EVIDENCE-BASED PRACTICE TIPS:
    • Simethicone (Infacol Wind Drops and Degas Infant Drops) does not reduce infant irritability.
    • In the absence of frequent vomiting, gastro-esophageal reflux is an unlikely cause of infant irritability.
    • For a subgroup of infants, a cow's-milk-free diet may be beneficial.

    History: Take a thorough history of the infant's crying, sleeping and feeding patterns, the strategies tried, and the parents' concerns. Ask about the pregnancy, birth experience, the mother's pre-existing physical and mental health and current social supports, paying particular attention to the risk factors. Ask about frequent vomiting (distinguish between vomiting and "spitting up" small amounts of food, which is normal), diarrhea, diaper rash, and atopic disease such as eczema. Ask about parents' worst fears in regard to their infant, and, if appropriate, explain why you are sure that the baby's distress is not related to these. It is hard for a baby to be reassured and soothed by parents who are frantically worrying that the baby is in pain or unwell.

    Examination: Perform a thorough examination, explaining what you are looking for. Look for eczematous rashes and peri-anal excoriation. Reassure parents that their baby is normal and healthy.

    Medications: Stop any inappropriate medications (see Anti-Colic Medications below).



    ANTI-COLIC MEDICATIONS

    Information Obtained From Baby Care Advice
    Written By Rowena Bennett, RN, RM, RPN, CHN, Grad Dip Health Promotion
    Click on Link to Articles available.
    (Cite Added May 11, 2008)




    Different Categories of Colic Medications

    During your desperate search for solutions for your distressed baby's crying, no doubt  many different types of remedies, mixtures and medications (some of which will be harmless, some potentially dangerous) have been recommended. Most of these will fit in at least one of the following categories:
    1. Anti-Gas Medications
    2. Herbal Remedies
    3. Antacids
    4. Antihistamines
    5. Antispasmodics
    6. Sedatives
    7. Other Medications


    Anti-Gas Medications

    Which anti-gas medications are available to treat infant colic?
    • Simethicone: (e.g. Mylicon Drops®, Infacol Wind Drops®, Phazyme Drops®)
    • Many antacid medications also contain simethicone.

    How do anti-gas medications work? Simethicone reduces the amount of gas in a baby's stomach by dispersing the foam that forms when air is swallowed during feeding. The active ingredient encourages the tiny bubbles of foam to join together to form larger bubbles, thereby making the gas easier to be brought up with a burp.

    Simethicone can assist in removing some air from the stomach but it has NO significant effect on gas in the intestines. (Big or small, the gas will come out the other end, with or without simethicone). Simethicone also has no effect on the production of excessive gas in the intestines, which can occur with certain digestive disorders. (See Infant gas for more information.)

    Is simethicone effective in treating infant colic? The use of medications containing simethicone is based on the assumption that infant colic is due to swallowed air; however numerous studies have shown that swallowed air is not a cause of infant colic. In several studies on the various anti-colic treatments available simethicone worked no better than a placebo in reducing the level of distress experienced by a colicky baby.

    Placebos are sugar pills or sugar water, which are used as a comparison when testing the effectiveness of medications in clinical studies. A placebo effect is when a person reports an improvement in symptoms because they believe the medication was helpful, but in reality they received a sugar pill or mixture that offered no medicinal value.

    Is simethicone safe to be used to treat infant colic? Although no medication can claim to be completely safe, simethicone has been shown to be relatively safe. Simethicone is non-sedating and side effects are rare. However, as studies have shown that simethicone works no better than the same amount of sugar water you may want to save your money.



    Herbal remedies

    For centuries herbal remedies have been used to treat infant colic. Some herbal remedies  offered to infants are based on an assumption that infant colic is due to indigestion. Other herbals remedies are offered because it is believed they have a calming or tranquilizing effect.

    Single herbs or a combination of different herbs may be used; given in the form of a TEA or commercially produced tinctures or extracts.

    Herbal Teas
    Herbal Colic Mixtures

    Many different herbs (listed above) can be used together. The various combinations of different herbs are huge. There are also many commercially produced "natural infant colic remedies" available on the market today, which claim to soothe the discomfort of infant colic.

    Different herbs work in different ways. There are many herbs that are used to aid digestion; reduce inflammation of the bowel; lessen gas production; and/or calm and tranquilize. There have not been enough studies done to understand exactly how each herb works, yet alone to understand how they work when combined.

    Are herbal remedies effective in treating colic? Many parents and midwives have faith in the benefits of herbal remedies to relieve the distress of a colicky baby. While some health care providers also believe herbal remedies may help, others believe they offer no more than a placebo effect. There have been so few studies on the effectiveness of herbal remedies in the treatment of infant colic, so the "jury is still out" as far as conventional medical practice is concerned.

    Are herbal remedies safe to be used to treat infant colic? Many people believe herbal remedies are "natural" and therefore they must be safe; however this is not always the case. Some of the most potent medications available today originate from herbs. When taken in too large a quantity a herbal remedy can be harmful. Infants have died from the inappropriate use of herbal remedies. However, if used appropriately in the correct dosage and preparation, they are often much safer than using medical drugs for treatment of ailments. If you have questions about using herbal remedies and preparations, consult with your midwife, herbalist or naturopathic health care practitioner. Many herbal remedies are not recommended to be given to children. Be aware that some so called "natural infant colic remedies" used in the past contained ethanol, i.e. alcohol. In most countries these products have been removed from the market, but it will pay to check labels carefully. Alcohol is still used in making medicinal herbal tinctures / extracts. For infants, use non-alcoholic preparations such as tea.

    The same care should be taken when using herbal remedies as it is when using medications. Always talk to a herbalist in person before giving herbal teas or mixtures to children.



    Antihistamines

    Which antihistamines are used to treat infant colic? Many different medications contain antihistamines. The most commonly suggested to parents to treat infant colic are often those that have greater sedative properties, these include:
    • Promethazine (Phenergan®)
    • Diphenhydramine (Benadryl®, Banophen®)
    • Dimenthdrinate (Dramamine®, Gavol®)
    • Brompheniramine (Dimetap®)

    How do antihistamines work? Antihistamines are most commonly used to relieve the discomfort of nasal congestion and red, inflamed eyes which are caused by hay fever and other allergies. They also help to reduce feelings of nausea and vertigo (dizziness and loss of balance) associated with motion sickness. Antihistamines work by restricting our body's production of histamine, which is responsible for producing allergic symptoms (but not causing them). Histamine is one of our body's natural defenses against foreign bodies i.e. microorganisms or allergens, which can enter our body and cause illness. Many antihistamines have a tranquilizing (sedating) effect, which will make a baby feel drowsy and "out of touch" OR alternatively some babies will experience the opposite effect and become extremely excited and irritated.

    Are antihistamines effective in the treatment of infant colic? Using these medications generally results in a decrease in the amount of time a baby spends crying and an increase in the amount of time a baby spends sleeping. However, apart from providing a sedating effect they offer nothing more in the treatment of infant colic.

    In a small number of cases, where infant colic is thought to be caused by food or milk allergy or intolerance, antihistamines may be used to reduce allergic symptoms, such as wheezing, rash, chronic runny nose, eczema, spitting up, diarrhea and bloody stools. However, dietary changes are far more effective in the long term management of this condition.

    Are antihistamines safe in the treatment of infant colic? Unfortunately because these medications are available over-the-counter this provides a false sense of security regarding their safety. Alarmingly, manufacturers warnings that these medications are not recommended for the use in children under the age of 2 years (due to the danger of impaired breathing) are often ignored, with some parents being advised to give these potentially harmful medications to infants as young as 1 month of age.

    Any medication has the potential for unwanted side effects. When an antihistamine is given for the purpose it was intended i.e. to relieve the discomfort of allergic symptoms, the benefits often outweigh the risk of side effects. However, when antihistamines are given solely for their sedating effect (such as in the treatment of infant colic) then the potential risk of side effects often outweigh any perceived benefits.

    Side effects from the sedating antihistamines in particular are: headaches, difficulty passing urine, dry mouth, blurred vision, nausea, vomiting, constipation or diarrhea. Rarely, some antihistamines can also cause palpitations and abnormal heart rhythms, high blood pressure, allergic reactions (such as swelling, rash and breathing difficulties) dizziness, confusion, depression, disturbed sleep, tremor, convulsions, blood and liver disorders and over-excitement in children.

    Phenergan® which has a similar chemical structure to phenothiazine (a potent anti-psychotic medication) have been linked with an increased incidence of Sudden Infant Death Syndrome. Although very rare, they can also cause a potentially fatal condition called Neuroleptic Malignant Syndrome. Symptoms include high fever, rigid muscles, sweating, and rapid or irregular heartbeat.

    NEVER give antihistamines to a child without first consulting a health care provider.



    Antispasmodics

    The 2 most commonly prescribed antispasmodic medications used in the treatment of infant colic are:
    • Dicyclomine (Bentylol®, Merbentyl®)
    • Hyoscyamine (Levsin Drops®, Donnalix Infant Drops®)

    All antispasmodics relax the muscles in the wall of the intestines (and also the urinary bladder) preventing spasms from occurring. Although the exact process of how antispasmodics work is unclear, it is known that these medications block nerve impulses from the brain and spinal cord to the intestinal wall, reducing intestinal spasms.

    Are antispasmodics effective in the treatment of infant colic? Antispasmodic medications are prescribed with the assumption that infant colic is due to an abdominal cramps OR spasms from an overactive gastro-colic reflex. Studies using antispasmodics have demonstrated a reduction in the amount of time a colicky baby spends crying each day and an increase in sleeping. However, there is much debate among health professionals as the whether this is due to relief of gastric discomfort OR due to the sedative effects of these medications.

    Are antispasmodics safe in the treatment of infant colic? No medicine is completely safe. Although side effects from antispasmodics are not common, they can occur. Side effects include: heartburn, dilated pupils, dry mouth, rapid heartbeat, constipation, blurred vision, confusion, dizziness, decreased sweating, drowsiness or difficulty sleeping, headache, breathing difficulties, weakness, lack of co-ordination, loss of taste, nausea, vomiting, skin reactions, nervousness and allergic reactions. Up to 5% of infants treated with dicyclomine (Bentylol®, Merbentyl®) may develop serious side effects, including breathing difficulties, apnea, seizures, syncope, asphyxia, coma and muscular hypotonia. In addition, several cases of death have been reported in infants taking dicyclomine. As a result dicyclomine is no longer approved for use in the United States in babies younger than 6 months of age. Antispasmodic drugs are only available by a health care provider's prescription. Given the severity of potential side effects it is not surprising that these drugs are rarely prescribed by pediatricians for infant colic.



    Sedatives

    Several sedative or sleep-inducing drugs including alcohol have been reported as effective treatments for infant colic. However, there is a potential for serious side effects associated with using these medications and the risk to a healthy (yet colicky) child far outweigh any benefits.

    What sedatives have been used in the past to treat infant colic?
    • Phenobarbital (also known as phenobarbitone in some countries)
    • Chloral hydrate (Notec®)
    • Alcohol (brandy, whiskey etc.)
    • Paregoric
    • Many medicines contain mixtures of different drugs which combines antispasmodic medications with Phenobarbital or alcohol, or both e.g. Donnatal®.

    Sedatives (including alcohol) are strong drugs which depress a child's whole central nervous system; this means pulse, breathing rate and level of awareness, resulting in abnormally deep sleep. The child's ability to respond is also affected. Feelings of pain are decreased.

    Phenobarbital is frequently used in the treatment of seizures.

    Are sedatives effective in the treatment of infant colic? These medications are very effective in reducing the amount of time a baby spends crying and increasing the amount of time a baby spends sleeping (albeit abnormal sleep); apart from the sedative effects of these medications, they do nothing to treat any possible underlying problems that cause a baby to cry in the first place, so crying is likely to continue once the sedation wears off.

    Are sedatives safe in the treatment of infant colic? Although these drugs are important in treating certain medical conditions most health care providers would agree these drugs should never be given to a healthy baby simply to stop their crying because of the serious risk of moderate to severe side effects. Side effects include: decreased breathing rate, slow heartbeat, sluggishness, excessive drowsiness, lack of muscle coordination, temporary cessation of breathing, apnea, nightmares, anxiety, delirium, difficulty sleeping,  excitement, irritability and hyperactivity in children, hallucinations, increased physical activity and muscle movement, headache, confusion, dizziness, seizures, nausea, vomiting, poor feeding, constipation, nervousness, agitation, anemia, allergic reactions (localized swelling, especially of the eyelids, cheeks, or lips, skin redness and inflammation), angioedema (swelling of face around lips, tongue, and throat, swollen arms and legs, difficulty breathing), low blood pressure, fainting, fever, muscle, nerve or joint pain,  softening of bones. Many sedative medications are habit forming i.e. addictive.



    Antacids

    Many different antacid medications are used to treat infant colic with the assumption that an infant's distress is due to the burning effects of heartburn, associated with gastro-esophageal reflux. Antacids should not be used for infant colic without consulting with a health care provider. (See For more information about antacid medications.)



    Other Medications

    Antidiarrheals
    • Diphenoxylate (Lamitol®, Lomitol®)

    Past generations of parents were advised to use diphenoxylate to treat infant colic. Diphenoxylate works by reducing excessive contractions of the intestines which result in diarrhea.  However, diphenoxylate is not a medication that health care providers would recommend these days to treat infant colic, because diphenoxylate is a narcotic-derivative, which means it has sedative properties. Many of the side effects described under "Sedatives" above are also relevant to diphenoxylate. Even in the treatment of diarrhea, antidiarrheals are not generally recommended for children. Diphenoxylate should not be used for children under the age of 2 years. Loose watery bowel movements (diarrhea) can be perfectly normal for infants or they can be a sign of an illness or underlying medical condition. Have your child seen by a health care practitioner if you are concerned about her bowel movements.

    Analgesics (Pain killers)
    • Ibuprofen (Mortin®, Advil®, Nurofen®)
    • Acetaminophen (Tylenol®)
    • Paracetemol (Panadol®, Dymadon®)

    These drugs are used to treat fever and pain. Many pain killers also have a mild sedative effect. Although a colicky baby often appears to be in pain, many causes of infant colic are not related to physical discomfort or pain. Pain killers should not be used for healthy crying babies when the cause of crying is unclear.

    Over-the-counter pain killers need to be treated with respect and caution, like any other drug. It's always a good idea to discuss the use of medication with your health care provider or midwife. Over-the-counter pain killers also have potential side effects, particularly if they are taken in large doses over a long period of time. Side effects include:

    Ibuprofen - Headache, nausea, stomach irritations and upsets, skin rashes, fatigue, dizziness, sleep problems.
    Acetaminophen - Anorexia, abdominal pain, nausea, vomiting, liver failure.
    Paracetamol - Skin rash, fever, kidney damage. Lactase Drops (LactAid®) - Lactase drops are often recommended based on the assumption that colic is due abdominal gas caused by lactose intolerance. However, studies have shown no difference between lactase drops and placebos in reducing colicky babies' crying.



    Do Anti-Colic Mixtures/Medications Work?

    Infant colic is a mystery that has plagued worried and wearied parents for centuries; and yet, despite numerous studies into infant colic over the past 40 years, medical research appears to be no closer to understanding what it is, or what to do about it. Keep in mind that infant colic is not a condition but a term used to describe "excessively long periods of crying in an otherwise healthy, thriving baby". In other words "infant colic" describes how a baby behaves rather than what a baby has. Recommendations to treat infant colic with a particular mixture, remedy or medication are often based on personal  assumptions about what is causing your healthy baby to cry. By reading the article on infant colic you should be able to understand that there are multiple different theories on potential reason or reasons. By providing treatment which targets only one possible reason, it may completely "miss the point", especially if there is no physical cause for your baby's crying. The use of medications in the treatment of infant colic is highly debatable among health professionals. While some health care providers recommend the use of medications, many do not. Medications that can appear to successfully treat infant colic often do so because of their sedating effects. Once the sedating effect wears off, crying quickly returns.



    Advantages To Using Anti-Colic Medications

    For a child: Sedating a child may reduce the risk of harm from overwrought and over-stressed parents/caregivers whose tolerance has been stretched beyond their ability to cope.

    For parents: As any parent with a colicky baby will testify, it is exhausting and extremely stressful to continue to cope with the demands of a distressed, overtired, crying baby day after day (sometimes night after night); sedating a child may provide exhausted parents with much needed relief where no other options are available.

    For health care providers: Recommending medications to treat infant colic is time efficient for health care providers. Many have limited time for appointments and are not prepared to spend the necessary time counseling and comforting worried parents. Also many health care providers are not familiar with the use of effective behavioral methods to calm colicky (yet healthy) babies. See Baby Care Advice: Why Health Professionals Often Fail To Help Parents.



    Disadvantages To Using Anti-Colic Medications

    For a child: Separate from the risk of serious side effects (some of which can be life threatening) there are also the possibility other less obvious problems that may result from long term use of sedating medications (i.e. antihistamines, antispasmodics and sedatives).
    1. Feeding may be affected resulting in decreased weight gain.
    2. The sleep obtained by sedation is abnormally deep sleep. Babies normally spend 50% of their time in REM (rapid eye movement) sleep, which is a light sleep stage. The human growth hormone is released during REM sleep. See Baby Care Advice: Infant Sleep Patterns.
    3. The use of sedating medications may interfere with bonding as a baby cannot engage fully with parents when he/she is sedated.
    4. When experiencing the "out of touch" feeling caused by sedation a baby cannot fully appreciate and interact with the world around them.
    5. Babies are learning from birth (before birth in fact). Anything that impairs with their ability to interact may also affect their ability to learn.
    6. Children need to practice physical tasks (such as hold their head up, rolling etc.) in order to develop muscle control and master these skills. Prolonged use of sedating medications restrict a baby's ability to practice.
    7. The side effects of using medications in the treatment of infant colic may create greater problems than the drug was intended to treat.

    For Parents: Once on the path of believing their baby's crying is due to a medical reason parents often search for a 'cure' in the form of medications. As each medication fails (as they often do) this may result in further use of different medications or herbal remedies, in addition to making multiple dietary changes. All of which further complicates the situation making it more and more difficult for parents to work out exactly what is going on. Medications are expensive - especially if they don't work.



    EXPLAIN NORMAL CRYING AND SLEEP PATTERNS

    Crying: Explain that all babies cry, that crying duration peaks at 6 weeks and that most crying disappears by 3-4 months of age. Sleep requirements: Explain normal sleep requirements for babies, emphasizing that all babies are different and will therefore need different amounts of sleep. On average, babies sleep for 16 of every 24 hours at birth, falling to 14 hours by 2-3 months of age. If babies are awake during the day and happy, they are unlikely to need more sleep. Generally, a 6-week-old baby becomes tired after being awake for 1.5 hours, while a 3-month-old baby becomes tired after being awake for 2 hours.

    Recognizing Tiredness: Encourage parents to recognize when their baby is tired and put the baby to sleep then. Signs of tiredness can include frowning, clenched hands, jerking arms and legs, and crying or grizzling.

    Interaction & Play: Discuss the baby's need for interaction and play. For some families, a "campaign" to soothe the baby and avert a crying episode takes over. Some parents spend the whole day trying not to "overstimulate" their baby. Encourage parents to "go with the flow" - for example, by letting the baby continue to play if there are no signs of tiredness, or by taking the baby for a walk if he or she does not settle to sleep after 20-30 minutes. Alternatively, mothers can give their baby a warm, deep bath, and then try to settle the baby when he or she next looks tired.

    ASSIST PARENTS TO HELP THEIR BABY DEAL WITH DISCOMFORT & DISTRESS

    Normal Physical Sensations: Explain to parents that some babies may struggle to cope with normal physical sensations, such as digestion, elimination, normal reflux, tiredness and hunger. When babies find these sensations too overwhelming or frightening, they become irritable and cry.

    Reading An Infant's Behavior: Help parents to "read" their infant's behavior as an indicator of the infant's emotional state and ways of self-regulating distress.

    Baby-Centered Approach: Discuss ways of helping this baby cope with distress. In your consulting room, observe the baby's capacity to self-soothe when distressed. A baby who is easily startled and cannot calm him/herself down may need a quiet and gentle approach to nappy changing and bath-time and other day-to-day tasks. A baby who frantically looks around the room when distressed may need to be held in such a way that he or she can "lock onto" the mother's face. The baby may then be able to be gently engaged in looking at something else in the room.

    Establish A Predictable Routine: Experiencing the world as less chaotic and frightening through a predictable routine of feeding and settling is important. The following may be appropriate:
    • Aim to settle the baby for daytime naps and night-time sleep in a predictable way, such as quiet play, moving to the bedroom, wrapping the baby, giving the baby a brief cuddle, and then settling in the crib while still awake.


    • Aim for a routine of feeding, playtime, and then letting the baby sleep when tired (not just after a set amount of time!).


    • Aim for a regular evening bedtime, which can help all families and give the baby some routine and consistency.


    • During this phase, avoid weaning from breast milk or making frequent formula changes unless there is a good medical reason to do so.

    Partnership with parents: Engage in a partnership with the parents to help the baby and the parents through this phase. Arrange proactive follow-up by phone or weekly review appointments. Reassurance that no medical problem exists may not be enough. Give mothers permission to rest once a day when their baby is asleep and not to carry out household chores.

    ASSESS MATERNAL EMOTIONAL STATE & MOTHER-BABY RELATIONSHIP

  • Invite the mother to talk about how stressful it is to care for a baby who cries persistently. Enquire whether she also has enjoyable times with her baby - if not, the mother may be depressed.


  • Ascertain whether the mother is worried that she is depressed or may become so. Discuss the link between exhaustion and depression. Consider screening for postnatal depression with the Edinburgh Postnatal Depression Scale. Mothers with a score over 12 or thoughts of self-harm need further assessment, and, if appropriate, treatment.




    • Edinburgh Postnatal Depression Scale (EPDS)
    Taken from the British Journal of Psychiatry
    June, 1987, Vol. 150 by J.L. Cox, J.M. Holden, R. Sagovsky


    The Edinburgh Postnatal Depression Scale has been developed to assist primary care health professionals to detect mothers suffering from postnatal depression; a distressing disorder more prolonged than the "blues" (which occur in the first week after delivery) but less severe than puerperal psychosis. Previous studies have shown that postnatal depression affects at least 10% of women and that many depressed mothers remain untreated. These mothers may cope with their baby and with household tasks, but their enjoyment of life is seriously affected and it is possible that there are long-term effects on the family. The EPDS was developed at health centers in Livingston and Edinburgh. It consists of ten short statements. The mother underlines which of the four possible responses is closest to how she has been feeling during the past week. Most mothers complete the scale without difficulty in less than 5 minutes. The validation study showed that mothers who scored above threshold 92.3% were likely to be suffering from a depressive illness of varying severity. Nevertheless the EPDS score should not override clinical judgment. A careful clinical assessment should be carried out to confirm the diagnosis. The scale indicates how the mother has felt during the previous week and in doubtful cases it may be usefully repeated after 2 weeks. The scale will not detect mothers with anxiety neuroses, phobias or personality disorder.

    INSTRUCTIONS FOR USERS:

    The mother is asked to underline the response which comes closest to how she has been feeling in the previous 7 days. All ten items must be completed. Care should be taken to avoid the possibility of the mother discussing her answers with others. The mother should complete the scale herself, unless she has limited English or has difficulty with reading. The EPDS may be used at 6-8 weeks to screen postnatal women. The child health clinic, postnatal check-up or a home visit may provide suitable opportunities for its completion.

    Name: _________________________________________________
    Address: _______________________________________________
    Baby's Age: ____________________________________________

    As you have recently had a baby, we would like to know how you are feeling. Please UNDERLINE the answer which comes closest to how you have felt IN THE PAST 7 DAYS, not just how you feel today.

    1. I have been able to laugh and see the funny side of things.
    • As much as I always could.
    • Not quite so much now.
    • Definitely not so much now.
    • Not at all.
    2. I have looked forward with enjoyment to things.
    • As much as I ever did.
    • Rather less than I used to.
    • Definitely less than I used to.
    • Hardly at all.
    3. * I have blamed myself unnecessarily when things went wrong.
    • Yes, most of the time.
    • Yes, some of the time.
    • Not very often.
    • No, never.
    4. I have been anxious or worried for no good reason.
    • No, not at all.
    • Hardly ever.
    • Yes, sometimes.
    • Yes, very often.
    5. * I have felt scared or panicky for not very good reason.
    • Yes, quite a lot.
    • Yes, sometimes.
    • No, not much.
    • No, not at all.
    6. * Things have been getting on top of me.
    • Yes, most of the time I haven't been able to cope at all.
    • Yes, sometimes I haven't been coping as well as usual.
    • No, most of the time I have coped quite well.
    • No, I have been coping as well as ever.
    7. * I have been so unhappy that I have had difficulty sleeping.
    • Yes, most of the time.
    • Yes, sometimes.
    • Not very often.
    • No, not at all.
    8. * I have felt sad or miserable.
    • Yes, most of the time.
    • Yes, quite often.
    • Not very often.
    • No, not at all.
    9. * I have been so unhappy that I have been crying.
    • Yes, most of the time.
    • Yes, quite often.
    • Only occasionally.
    • No, never.
    10. * The thought of harming myself has occurred to me.
    • Yes, quite often.
    • Sometimes.
    • Hardly ever.
    • Never.
    Response categories are scored 0, 1, 2, and 3 according to increased severity of the symptoms. Items marked with an asterisk are reverse scored (i.e. 3, 2, 1, and 0). The total score is calculated by adding together the scores for each of the ten items. The EPDS contains 10 items and each item is rated on a four-point scale, giving maximum scores of 30. A score of 13 or more is considered to be a significant 'case' of postnatal depression, while scores of 10 to 12 represent 'borderline' and 0 to 9 'not depressed'.

    Users may reproduce the scale without further permission providing they respect copyright by quoting the names of the authors, the title and the source of the paper in all reproduced copies.



    A behavior diary records a baby's daily pattern of sleeping, waking, feeding and crying.

    MEDICAL CASE STUDY - A 2-month-old boy with crying and irritability

    A 2-month-old boy is brought to you by his mother because of difficulty settling to sleep, and excessive crying and irritability from Week 3. He currently tends to cry from 4 pm to 9 pm, but can cry any time of the day. When he cries, he arches his back, goes red in the face and his mother is unable to console him. She thinks he has "wind". During the day he has two sleeps in the carriage lasting 20 minutes each. At night, he is put to bed around 10 pm, sometimes wrapped, and falls asleep by himself. He wakes twice a night to breast-feed. He starts the day at 7 am. He is gaining weight and developing normally. He vomits once or twice a day. His mother has tried ranitidine (Zantac®) 0.6 mL orally twice a day with little change. Ranitidine works by reducing the amount of acid production in the stomach.

    In your office, the baby suddenly starts to cry loudly. The mother rocks the carriage but the baby cries more. So she picks him up, puts him over her shoulder and starts patting his back harder and harder while telling you about all the advice she has been given. Although the baby is crying, he is scanning the room with his eyes open.

    MEDICAL MANAGEMENT
    • Take a thorough history and perform an examination to exclude medical cause(s). Reassure the mother that the baby is normal and healthy and that, in the absence of frequent vomiting, reflux is unlikely to be a cause of this baby's irritability. Stop ranitidine.


    • Encourage the mother to talk about her feelings for her baby, and her frustration or ambivalence when he continues to cry. Ask about the impact on family life. Validate her concerns.


    • Point out that her baby is alert and interested in what is going on around him and that this can be used to distract him from any unpleasant bodily sensations.


    • Suggest that the mother interact with the baby by talking or singing to him when he begins to cry without obvious cause. If the baby is still crying in your office, model this approach.


    • Explain normal crying and sleep patterns, and discuss settling techniques and the need for a consistent approach to settling.


    • Suggest that the mother aim for three daytime sleeps, lasting at least an hour each, and an earlier bedtime to allow the baby to get enough sleep. Recommend wrapping the baby for sleeps until around 6-months of age.


    • Suggest that the baby should be encouraged to settle himself to sleep when he looks tired, which is best achieved in a darkened, reasonably quiet place.


    • Discuss strategies for dealing with persistent crying or the baby not settling to sleep. Ask the mother to fill out a behavior diary until the review appointment.


      • Assess the mother's emotional state. Recommend that she accept offers of help from friends and neighbors; consider home delivery of groceries; and rest once a day.

    • Arrange a follow-up appointment with the whole family, or at least the father present, within a week. At the review, invite the father to talk about how the baby's crying affects him and the couple's relationship.


    • If these management strategies do not produce improvement, consider referral to a pediatrician, infant mental health professional or early parenting center.

    Wrapping a baby for sleeps until around 6 months of age is recommended.

    REFERENCES
    • Phaer Thomas. The boke of chyldren (1544) (edited with an introduction, notes and glossary by Rick Bowers. Tempe, Ariz: Center for Medieval and Renaissance Studies, 1999. (Medieval and Renaissance Texts and Studies, vol 201.)
    • Pinyerd B. Strategies for consoling the infant with colic: fact or fiction. J Pediatr Nurs 1992; 7: 403-411.
    • McMahon C, Barnett B, Kowalenko N, et al. Postnatal depression, anxiety and unsettled infant behaviour. Aust N Z J Psychiatry 2001; 35: 581-588.
    • Barr RG, Kramer M, Pless IB, et al. Feeding and temperament as determinants of early infant crying/fussing behavior. Pediatrics 1989; 84: 514-521.
    • Bowlby J. The nature of the child's tie to his mother. Int J Psychoanal 1958; 39: 350-373.
    • Wade S, Kilgour T. Infantile colic. BMJ 2001; 323: 440.
    • Wessel MA, Cobb JC, Jackson EB, et al. Paroxysmal fussing in infancy, sometimes called "colic" Pediatrics 1954; 14: 421-424.
    • Brazelton TB. Crying in infancy. Pediatrics 1962; 29: 579-588.
    • St James-Roberts I, Halil T. Infant crying patterns in the first year: normal community and clinical findings. J Child Psychol Psychiatry 1991; 32: 951-968.
    • Jordan B, Heine RG, Meehan M, et al. The irritable infant intervention study: effect of antireflux medication and infant mental health intervention on persistent irritability. Abstracts of the Division of Pediatrics Annual Scientific Meeting, May 1999 Perth. J Pediatr Child Health 1999; 35: A7.
    • Barr RG. Crying in the first year of life: good news in the midst of distress. Child Care Health Dev 1998; 24: 425-439.
    • St James-Roberts I, Bowyer J, Varghese S, Sawdon J. Infant crying patterns in Manali and London. Child Care Health Dev 1994; 20: 323-337.
    • Alvarez M. Caregiving and early infant crying in a Danish community. J Dev Behav Pediatr 2004; 25: 91-98.
    • Barr RG. Colic and crying syndromes in infants. Pediatrics 1998; 102: 1282-1286.
    • Armstrong K, Previtera N, McCallum RN. Medicalizing normality? Management of irritability in infants. J Pediatr Child Health 2000; 36: 301-305.
    • Rautava P, Helenius H, Lehtonen L. Psychosocial predisposing factors for infantile colic. BMJ 1993; 307: 600-604.
    • Heine R, Jaquiery A, Lubitz L, et al. Role of gastro-oesophageal reflux in infant irritability. Arch Dis Child 1995; 73: 121-125.
    • Garrison M, Christakis A. A systematic review of treatments for infantile colic. Pediatrics 2000; 106: 184-190.
    • Moore DJ, Tao BS, Lines DR, et al. Double-blind placebo-controlled trial of omeprazole in irritable infants with gastroesophageal reflux. J Pediatr 2003; 143: 219-223.
    • Lucassen PL, Assendelft WJ, Gubbels JW, et al. Effectiveness of treatment for infantile colic: a systematic review. BMJ 1998; 316: 1563-1569.
    • Kilshaw PJ, Cant AJ. The passage of maternal dietary proteins into human breast milk. Int Arch Allergy Appl Immunol 1984; 75: 8-15.
    • Hill DJ, Firer MA, Shelton MJ, Hosking CS. Manifestations of milk allergy in infancy: clinical and immunological findings. J Pediatr 1986; 109: 270-276.
    • American Academy of Pediatrics. Committee on Nutrition. Hypoallergenic infant formulas. Pediatrics 2000; 106: 346-349.
    • Kanabar D, Randhawa M, Clayton P. Improvement of symptoms of lactose intolerance following reduction in lactose load with lactase. J Hum Nutr Diet 2001; 14: 359-363.
    • Willimas J, Watkins-Jones R. Dicyclomine: worrying symptoms associated with its use in some small babies. BMJ 1984; 288: 901.
    • Murray L, Stanley C, Hooper R, et al. The role of infant factors in postnatal depression and mother infant interaction. Dev Med Child Neurol 1996; 38: 109-119.
    • von Hofacker N, Papousek M. Disorders of excessive crying, feeding, and sleeping: the Munich interdisciplinary research and intervention program. Infant Mental Health J 1998; 19: 180-201.
    • Barr RG. Changing our understanding of infant colic. Arch Pediatr Adolesc Med 2002; 156: 1172-1175.
    • Cox JL, Holden JM, Sagovsky R. Detection of postnatal depression: development of a 10-item Edinburgh Postnatal Depression Scale. Br J Psychiatry 1987; 150: 782-786.
    • National Health and Medical Research Council. How to use the evidence: assessment and application of scientific evidence. Handbook series on preparing clinical practice guidelines. Table 1.3: Designation of levels of evidence. Canberra: NHMRC, February 2000: 8.
    • Don N, McMahon C, Rossiter C. Effectiveness of an individualized multidisciplinary programme for managing unsettled infants. J Paediatr Child Health 2002; 38: 563-567.
    • Rautava P, Lehtonen L, Helenius H, Sillanpaa M. Infantile colic: child and family three years later. Pediatrics 1995; 96: 43-47.
    • Article Reference



    BOOKS & EDUCATIONAL INFORMATION

    Baby Care Advice.com: An Australian Based Service By Rowena Bennett
    Parenting Advice Articles & Services are available to parents seeking help from health care providers.

    The No-Cry Sleep Solution: Gentle Ways to Help Your Baby Sleep Through the Night
    By Elizabeth Pantley & William Sears M.D.

    Kid Cooperation: How to Stop Yelling, Nagging & Pleading & Get Kids to Cooperate
    By Elizabeth Pantley & William Sears M.D.

    Perfect Parenting: The Dictionary of 1,000 Parenting Tips
    By Elizabeth Pantley

    Hidden Messages: What Our Words & Actions Are Really Telling Our Children
    By Elizabeth Pantley

    Gentle Baby Care: No-cry, No-fuss, No-worry -- Essential Tips for Raising Your Baby
    By Elizabeth Pantley

    HERBAL REMEDIES FOR COLIC

    HerbalRemedies: Tummy Troubles For Babies, Wellness Oil, Colic Remedy, 2 fl. oz.
    Shake Tummy Troubles for Babies Wellness Oil, Colic Remedy before each use and apply in a circular motion (clockwise) on baby's tummy to ease upset stomach and soothe the spirits. For external use only. Keep out of reach of children. Ingredients: Grapeseed oil and an essential oil blend of lavender and dill.

    HerbalRemedies: Get Better Bear Colic, Improvita Homeopathic, 2 fl oz.
    Get Better Bear Colic is a homeopathic medicine for infants and toddlers that has a combination of several single remedies. It relieves the symptoms of colic and gas pains. It relieves minor abdominal pain associated with colic and gas in young children. It has all natural ingredients, pleasant natural peach flavoring, no sugar added, honey free, minute amounts of alcohol, safe & effective with no known side effects. DOSAGE: For children 2 years and under. Take 1 ml every 2 hours, up to 9 times per day or as directed by a health professional. WARNINGS: Keep out of reach of children. If pregnant or breast-feeding, ask a health care professional before use. If abdominal discomfort persists for more than 24 hours or worsens, discontinue use and consult a health care professional.

    HerbalRemedies: Colic & Gas Pains Formula Tincture, 100% Organic, 2 fl. oz.
    Colic & Gas Pains Formula is a natural colic remedy and offers baby gas relief. Dilute 1-5 drops in bottle, or dilute 1 drop in water and place in mouth. Start with 1 drop and increase up to 5 drops as needed. Ingredients: Catnip, Fennel, Peppermint, Lobelia R/O Water, 12% grain Alcohol.

    HerbalRemedies: Colic Supplements, Information & Products



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