Fussy Baby Network®
Oakland Strengthening
Connections AIA-September 11,
2011
Mary Claire Heffron, PhD, Clinical Director
Children’s 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
5
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
0
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
Brazelton’s 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
Wessel’s 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
• Cow’s milk/lactose
intolerance
• Sensory thresholds
• Transient regulatory problem
• Abnormal sensitivity of CNS
• Prenatal influences
• Parent/child relationship
distress
Evaluation and treatment by maternal-infant
mental health specialist
Maternal psychotherapy
Reflux medication
Smaller, frequent meals
Upright positioning
Thickening feeds
MaternalInfant
Distress
Maternal dairy elimination if
breastfed.
Formula change to soy-based
or elemental formula
Reflux
Regulatory
problems,
neurological
hypersensitivity
Immaturity of
the digestive
system
Excessive gas
Milk
protein
allergy
Evaluation and treatment
by medical professionals
Probiotic foods or
supplements
Targeted antibiotics
Excessive
Crying in
Infancy
Underlying
medical
condition or
infection
Crying of
normal
development
Bacterial
over
Growth imbalance
Temperament
Colic
Swaddling, Side positioning,
Shushing, Swinging, Sucking
Environmental dampening
Infant massage / touch
Chiropractic manipulation
Simethicone (Mylicon)
Chamomile
Gripe water
Dill oil, Fennel oil
Dicyclomine (Bentyl)
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 infant’s 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; Papoušek & Papoušek, 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
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
• 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
Crying, Colic, and
Parental Perceptions
“The actual duration of crying at a given
moment seems to be less relevant than the
parent’s 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 fussing—not crying—were 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
In infant
•
•
•
•
•
•
• poor eye contact
• unpredictable sleeping and/or
eating patterns after 4 months
• constricted affect
• difficult to comfort or soothe
• developmental delays
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
Clark, 1994; 2003
Parents ask:
“Where is the finish line?”
“You think it is never going to end…”
Negative emotions
•
•
•
•
•
•
•
Wishing infancy away
“ It’s 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 you’re 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
things…it’s 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 can’t
even leave the house”
Criticism and Social Isolation
•
Family criticism: “If only you would..”
•
Parental guilt: “I’m not hurting her, I swear…”
•
Social isolation: “I feel so alone and I can’t 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%
3%
13%
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 baby’s crying/sleeping/feeding?
Worry Scale
Parents’ Two Worries:
• Is my baby alright?
• Am I a good enough
parent?
T. Berry Brazelton, MD
America’s 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
• Parent’s confidence
• Parent’s 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
Negatives
20
Positives
15
13
10
16
5
4
0
1
2
Administration
Fussy Baby Network Family Feedback Survey
5.00
4.50
4.00
3.50
Scale of 1 to 5
How distressed did you feel about your Fussy
Baby issue?
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