Fussy Baby Network Oakland Strengthening

Connections AIA-September 11, 2011

Mary Claire Heffron, PhD, Clinical Director Childrens Hospital & Research Center Oakland Early Intervention Services

Admissions to ER for Infant Crying

3 0

33% had diagnosis of colic/crying

2 5

2 0

15

10

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Age in Months
Gray et al, 2004

Fussy Babies in the ED

Who are fussy babies?

All Babies Cry

Crying as a Regulatory Function

Increases lung capacity at birth Increases motor activity Helps regulate temperature Triggers attachment system/social interaction
Lester, 2006

What is it like to hear a baby cry inconsolably?

Normal Crying Curve

6 weeks Peaks at 4-6 weeks First documented in Brazeltons practice Replicated 15 times Across cultures

12 weeks

Barr, Konner, Bakeman, & Adamson, 1991; Brazelton, 1962; St. James-Roberts, Bowyer, Varghese, & Sawdon, 1994

The Witching Hour

Brazelton, 1962

Large difference between infants

Brazelton, 1962

Crying Curve for Premature Babies

Timing of crying peak is same as full-terms 4-6 weeks corrected age Quality of crying may be different than full-terms He never cried in the nursery

Definitions
Excessive crying: more than average amount of crying Colic: excessive crying plus sudden onset, more aversive acoustical qualities, physical signs, more inconsolability (Lester et al, 1990) Persistent crying: crying past cry curve months (past 4 months) FBN Fussy Baby: any baby from birth to one year whose parent feels is difficult for him/her to console, feed, or help sleep

Wessels Rule of 3s for Colic

Rule of 3s More than 3 hours/day More than 3 days/week More than 3 weeks
No single known cause
Wessel, 1954

Colic is Not Linked to:

Birth order Gender Feeding style SES Colic can occur in healthy babies, in spite of excellent parenting

Excessive Crying Plus:

Sudden onset
Unpredictable

Cry quality
Higher pitch, reaches peak quickly Like a pain cry

Physical signs
Late afternoon fist-shaking rage
Clenched fists Grimace/flushing Gas/distention

Inconsolable
Lester, Boukydis, Garcia-Coll, & Hole, 1990

How Long does Colic Last?

Begins early:
100% by 3 weeks

End varies:
50% by 2 months 80% by 3 months 90% by 4 months
Weissbluth, 1998

Different pathways to excessive crying

Immaturity of GI tract Cows milk/lactose intolerance Sensory thresholds Transient regulatory problem Abnormal sensitivity of CNS Prenatal influences Parent/child relationship distress

Reflux medication Smaller, frequent meals Upright positioning Thickening feeds

Evaluation and treatment by maternal-infant mental health specialist Maternal psychotherapy

Swaddling, Side positioning, Shushing, Swinging, Sucking Environmental dampening Infant massage / touch Chiropractic manipulation

Maternal dairy elimination if breastfed. Formula change to soy-based or elemental formula

Milk protein allergy

MaternalInfant Distress

Reflux

Regulatory problems, neurological hypersensitivity

Immaturity of the digestive system Excessive gas

Simethicone (Mylicon) Chamomile Gripe water Dill oil, Fennel oil Dicyclomine (Bentyl)

Evaluation and treatment by medical professionals

Excessive Crying in Infancy Underlying medical condition or infection

Crying of normal development

Probiotic foods or supplements Targeted antibiotics

Bacterial over Growth imbalance

Temperament

Colic

Underlying Medical Reasons

Reflux
Milk Protein Allergy Serious Infection (rare)

Gastroesophageal Reflux & GERD

Spitting up is a normal part of growing up as a baby Most babies have reflux, with peak symptoms around 4 months of age, and resolution by 12 months. In about 8% of babies, reflux results in concerning symptoms, and we then assume that the infant suffers from gastroesophageal reflux disease, or GERD. GERD is defined as chronic symptoms or mucosal damage produced by the abnormal reflux in the esophagus. If the reflux reaches the throat, it may be called laryngopharyngeal reflux disease.

Gastroesophageal Reflux
Lower esophageal sphincter (LES) is a muscle between the esophagus and the stomach LES matures at 6-7 weeks While immature, it does not close tightly, so feedings can go in a reverse direction, from stomach to esophagus

Mechanisms of Reflux
Maturation, length and angle of LES affect reflux Breathing (Inspiration and expiration) trigger contraction of different portions of LES Gastric distension (over feeding) and altered angle of LES (flexed position) can increase reflux

When to Suspect GERD in an Excessive Crier

Crying that is worse around feeding Frequent spitting up that seems uncomfortable Refusing feeding Trouble with weight gain Back arching (right) Coughing, choking, gagging Breathing difficulty

Regulatory Imbalance
Imbalance between excitatory (arousing) processes and inhibitory (calming) processes Imbalance impedes infants regulation of stable sleeping and waking states and smooth transitions between states. The underlying cause is not known.
Sucrose hypothesis: central self-soothing mechanism is not developed GO systems (sympathetic nervous system) develops before SLOW systems (parasympathetic) Transient immaturity or temperament Prenatally acquired constitutional factors
Lester, Boukydis,Garcia-Coll, Hole, & Peucker, 1992; Papouek & Papouek, 1984

Infant Sensitivities
Prematurity Drug exposure Sensitive sensory system

Psychosocial Distress
Perinatal Mood Disorder Birth trauma Limited family resources Parental conflict

What Stresses Parents the Most

Prolonged length of cry bouts High intensity of cry (high cry to fuss ratio) Cry not reduced by extra carrying Resistance to soothing which makes parents feel out of control
St. James Roberts, 2007

Photo courtesy of Ruth Fremson/The New York Times, 2008 from: http://well.blogs.nytimes.com/2008/09/05/deliverymethod-affects-brain-response-to-babys-cry/#more-511

Crying, Colic, and Parental Perceptions

The actual duration of crying at a given moment seems to be less relevant than the parents perception of the crying of their infant in the long term.
Reijneveld et al, 2004, p. 1342

Cultural Context of Crying

How does culture perceive crying?
Positive Negative

What strategies are used in various cultures?

Distal caregiving Proximal caregiving

How would your grandma calm a fussy baby?

Proximal Caregiving
Babies communicate through movement and cries Mothers sense babies arousal through body signals and soothe before crying begins
Lester, 2006

Distal Caregiving
Cry now used to call for basic care Have longer crying bouts May have earlier consolidation of sleep

Why worry about fussy babies?

Risk for child behavior/development problems Risk for parent-child relationship problems Risk for child abuse Risk for family stress and maternal depression

Risks to Behavior & Development

Severe colic/persistent excessive crying in infancy past 5 months has been linked to the following child outcomes:
Motor, language, and cognitive delays Behavioral problems (temper tantrums) Negative reactivity (fussiness) Sleep disorders Feeding problems Hyperactivity
DeGangi et al., 2000; DeSantis et al, 2005; Kries, Kalies, & Papousek, 2006; Papousek & von Hofacker, 1998; Rautava et al., 1995; Savino et al., 1995; Wake et al., 2006; Wolke, Rizzo, & Woods, 2002

Risks to Behavior & Development

Infant cry, sleep, & feeding problems associated with externalizing behavior and ADHD across 22 longitudinal studies, particularly in families with multiple risks 75% of babies babies seen in Brown University colic clinic demonstrated some degree of atypical sensory processing between 3-8 years of age Hours of fussingnot cryingwere associated with less efficient skills in sensory processing, coping, and externalizing behaviors
Desantis, Coster, Bogsby, & Lester, 2005; Hemmi, Wolke, Schneider, 2011

Risk for Child Abuse

2.75 hours

Crying Duration Shaking Baby Cases

Age in Weeks

Barr, Trent, & Cross, 2006

Infant Crying & SBS

Lee, Barr, Catherine & Wicks, 2007

Risk for Maternal Depression

Double Whammy of Infant Colic and Maternal Depression 46 % of mothers seen at Brown University Colic Clinic had moderate to high depression
Maxted et al., 2005

Maternal Depression
In mother
frequent crying appetite change sleep problems moderate to high anxiety panic attacks feeling unable to cope, worthless, despair, guilt sluggishness that interferes with childcare expression of little positive emotion with infant fear of harming child or self

In infant
poor eye contact unpredictable sleeping and/or eating patterns after 4 months constricted affect difficult to comfort or soothe developmental delays

Clark, 1994; 2003

Parents ask: Where is the finish line?

You think it is never going to end

Negative emotions

Wishing infancy away Its supposed to be bliss I just want it to be over. Progression of emotions Overwhelmed Angry Guilty
Do you ever get mad at her? feel like youre going to hurt her?

Family Impact
Disrupted lives Criticism and social isolation Search for diagnosis Maternal depression Parental conflict Parent-infant relationship distress Long & Johnson, 2001; Maxted et al., 2005; Wake et al., 2006

No one said it would be this hard..

Disrupted daily routines

-Just doing the simplest thingsits just not possible

Disrupted personal lives

-You read about stress in the marriage. This is the stress in the marriage

Disrupted social lives

-Now that we have a baby, we cant

even leave the house

Criticism and Social Isolation

Family criticism: If only you would.. Parental guilt: Im not hurting her, I swear

Social isolation: I feel so alone and I cant take her any where

Categories of Need for Fussy Baby Oakland

Emerging developmental differences Medical concerns Emerging parent child relationship concerns Family-Baby Stress Parental mental health concerns High risk family (more than 3 risk factors)

Age range of infants

3% 13%

3%

0-3 months 4-6 months 7-9 months 57% 24% 10-12 months Did not report /missing

Screening for Depression & Anxiety

Use of focused questions:
During the past month, have you often been bothered by feeling down, depressed or hopeless? During the past month, have you often been bothered by little interest or pleasure in doing things? On a scale of 1 to 5, how stressed do you feel about your babys crying/sleeping/feeding?

Worry Scale

Parents Two Worries:

Is my baby alright?
Am I a good enough parent?
T. Berry Brazelton, MD Americas Pediatrician

Supportive interventions which embrace a biopsychosocial perspective and which focus on the baby, parents, and parent/baby/family relationships can build competence, decrease stress/risk, and support healthy development
Gilkerson, Gray, Mork, 2005; Papousek, 2007; Maldonado, & Garcia, 1996; Keefe, et al., 2006 ; Maxted, et al., 2005

Help From a Dual Perspective

1. Help parents in the now moment with their urgent concern 2. With your eye on their future Parents confidence Parents view of child Relationship

Fussy Baby Network Approach

Engages families around feeding, sleeping, crying and regulatory concerns Three goals:
Increase parental confidence Strengthen parent-child relationship Promote healthy development of parents and infants

Photo courtesy of: http://images.sciencedaily.com

Maternal Depression
PRIME-MD PHQ Responses
40 35

30

20 25

20

Negatives Positives

15

10 16 5

13

4 0 1 Administration 2

Fussy Baby Network Family Feedback Survey

5.00

4.50

4.00

3.50 How distressed did you feel about your Fussy Baby issue?

Scale of 1 to 5

3.00

2.50

What was your distress level when your involvement with the FBN ended?

2.00 To what extent do you feel that the FBN helped you cope with your distress?

1.50

1.00

0.50

0.00 Response Means