Editorials for Clinical Practice
CHADIS Co-Director and President, Dr. Barbara Howard is a regular contributor to the Behavioral Consult column of Pediatric News and an Assistant Professor of Pediatrics at The Johns Hopkins University School of Medicine.
Dr. Howard is a developmental-behavioral pediatrician trained by Dr. T. Berry Brazelton at Harvard University. She is a national speaker on child behavior problems and is a past president of the Society for Developmental and Behavioral Pediatrics. She was a contributing author for Bright Futures™, Diagnostic and Statistical Manual for Primary Care (DSM-PC) and Bright Futures in Practice: Mental Health and has served on national committees of the American Academy of Pediatrics.
Soothing Parents of Infants Who Cry
All babies cry, of course, but some babies cry a lot.
In the old days, these babies were labeled “colicky.” These days, they're often labeled GER (gastroesophageal reflux, basically “spitting up”) babies, or they may be diagnosed with the more meaningful condition, GERD (gastroesophageal reflux disease).
As in times past, the vast majority of these crying infants are not ill, perhaps suffering from overstimulation or an immature digestive system. A few will have real pathology: true GERD, allergies, or even a volvulus of the bowel.
For the rest, you serve a vital preventive role, keeping crying babies safe and protecting them from undeserved labels that could follow them through life.
Ideally, you will have met families new to your practice in a prenatal visit, but we all know that such visits are the exception. Pediatricians often rotate their hospital visits, so in reality, you may encounter new parents frantic over a crying baby in your very first visit with them.
Keep in mind that although your level of concern may be low as you rule out things like a minor respiratory infection or allergies, their level of concern is off the charts. Faced with a screaming baby under 2 months of age, new parents are thinking, “Will our child survive?” In what has been referred to as the fourth trimester, the baby is part of the mother psychologically; her inability to comfort her infant is emotionally devastating.
The baby is inconsolable, there is no quick fix, and your relationship with a new family is on the line. A crying infant, then, represents both a golden opportunity and a time-consuming pain in the neck.
What's more, the stakes couldn't be higher because a third of child abuse occurs in the first 6 months of life. Why on earth would parents vigorously shake a defenseless newborn or hurl a baby against a wall? Because the parents are exhausted, and the baby won't stop crying despite traditional interventions: breastfeeding or bottle feeding, a new diaper, rocking, and cradling.
Often, pediatricians grasp at a solution that's quick to implement, advising a switch of formulas or worse, suggesting that a breastfeeding mother switch to formula. Unless the baby has real diarrhea, real vomiting (not “spitting up), a rash, or hives, I'd recommend against this option, which in fact is not a benign intervention.
Studies have found that when infant formulas are switched, years later parents are more likely to falsely believe their child has gastrointestinal disease. By the time these children are in preschool, they are statistically more likely to be overprotected by their parents.
What's more, right from the start, you will have established a precedent leading to the slippery slope of non-evidence-based medicine. These parents will come to expect that when there is a problem, you're going to write a prescription. And because of a placebo effect for any intervention of about 40%, they're quite likely to believe the medical solution worked, and come to depend on your signature on the next script as well.
A better alternative is to undertake a systematic overview of the problem, just as you would with a medically urgent symptom. No matter how smart you are, or how many years you've been treating healthy crying babies, do a very careful physical examination.
You may find real pathology and surprise yourself, but more importantly, you're being watched. Desperate parents are studying you to decide whether you are taking seriously their baby's obvious distress and their profound concern.
Next, of course, take an equally thorough history.
Look for patterns. How old is this baby? (Colic is technically defined as crying for at least 3 hours a day, at least 3 days a week, starting before 3 months of age post-term.) The onset of developmentally normal crying is usually at 2 weeks and the peak of 2 3/4 hours per day of crying at 6–8 weeks post term. Importantly, does this inconsolable crying occur during one part of the day, in contrast to hours spent as a happy, engaged, easily soothed baby?
This last point is critical to elicit because it establishes evidence that formula or breast milk is not the problem. Presumably, the baby consumes the same food throughout the day and digests it fine most of the time.
Occasionally, underfeeding (especially in a baby younger than 2 weeks of age) or overfeeding (marked by lots of GER, that spitting-up synonym) can be the source of the excessive crying.
Obtain a specific history of the worst crying day ever. If that day included a trip to the store, a baby shower with 15 people, and a long play session with new toys, the ensuing discussion of overstimulation is an easy one. Families need to be taught about swaddling (which you or a nurse should demonstrate, using the family's own blankets to ensure they are adequate to snugly confine the infants' arms). If you're lucky enough to try it on a crying baby, you can amaze parents by the “miracle moment” of shushed crying that generally follows.
Reducing visual stimulation can help as well. Pediatrician Raymond Sturner (my husband) asks parents to see how long they can stare at a light, then explains that babies at this age cannot avert their gaze from such an uncomfortable stimulus.
You also can reassure parents that swaddling and reducing stimulation are “natural” solutions because the infant was tightly confined in darkness in the womb.
There are many other possible interventions you can suggest, but be careful to instruct parents to give each strategy at least 15 minutes to succeed, averting frantic efforts that could make things worse.
These include, after Swaddling, four other S's proposed in Dr. Harvey Karp's book, “The Happiest Baby on the Block”: Swinging (gently!), Stomach (cradling the baby face down along one arm), Sucking (with pacifiers or the baby's or parent's finger or hand), and “Shhhh” sounds (by voice, with white noise: static on the radio, the hum of a fan or air conditioner, or engine noise, which is probably the reason car rides often help).
Chamomile tea has been proven helpful, but should not replace feedings.
On a more general level, I think setting a schedule for the family to firmly establish day-night patterns can be quite effective in babies whose long crying jags occur not in the evening, but at other times of the day.
Once you have offered several specific interventions for crying, turn to the vitally important task of assessing family support, the portion of the crying baby visit that is most likely to make a true difference in the life of a child.
At Brown University, where much colic research has been conducted, Dr. Pamela High and colleagues have found value in a family prescription for REST: Reassurance, Empathy, Support, and Time Away.
A lack of social support and parents vulnerable to depression greatly increase the chance of such a baby being harmed, not only in the immediate short-term (from physical abuse) but across childhood if he or she receives a label as a troubled, sickly, demanding child.
Work with parents to conceptualize ways to find relief for their own frustration, employing help from family and friends, creating safe zones within the home (baby safe in the crib, parent out of earshot for a brief period of time), and even offering as a last-ditch alternative a trip to your office or an emergency department when parents worry they cannot control their understandable aggravation in an exhausted moment.
By teaching parents a systematic problem-solving strategy that will help them learn to know their baby's personality and signals, you will be helping to create a family blueprint for future dilemmas, one free of medicalized solutions for a behavioral problem that may look, to them, like a disease.
Dr. Howard’s contribution to this publication is as a paid expert to Frontline Medical Communications. E-mail her at firstname.lastname@example.org.