Fussy Baby Network® Oakland Strengthening
Connections AIA-September 11, 2011Mary Claire Heffron, PhD, Clinical Director
Children’s Hospital & Research Center OaklandEarly Intervention Services
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Age in Months
Gray et al, 2004
Admissions to ER for Infant Crying
33% had diagnosis of colic/crying
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
• Peaks at 4-6 weeks• First documented in
Brazelton’s practice• Replicated 15 times• Across cultures
12 weeks
6 weeks
Barr, Konner, Bakeman, & Adamson, 1991; Brazelton, 1962; St. James-Roberts, Bowyer, Varghese, & Sawdon, 1994
Brazelton, 1962
“The Witching Hour”
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– Clenched fists– Grimace/flushing– Gas/distention
• Inconsolable
“Late afternoon fist-shaking rage”
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 specialistMaternal psychotherapy
Reflux medicationSmaller, frequent mealsUpright positioningThickening feeds
Maternal dairy elimination if breastfed. Formula change to soy-based or elemental formula
Evaluation and treatment by medical professionals
Probiotic foods or supplementsTargeted antibiotics
Simethicone (Mylicon)ChamomileGripe water Dill oil, Fennel oilDicyclomine (Bentyl)
Swaddling, Side positioning, Shushing, Swinging, SuckingEnvironmental dampeningInfant massage / touchChiropractic manipulation
Maternal- Infant
DistressRegulatory problems,
neurological hyper-
sensitivity
Immaturity of the digestive
system Excessive gas
Crying of normal
development
Temper-ament
Colic
Bacterial over
Growth -imbalance
Underlying medical
condition or infection
Milk protein allergy
Reflux
Excessive Crying in Infancy
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• 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, 2008from: http://well.blogs.nytimes.com/2008/09/05/delivery-method-affects-brain-response-to-babys-cry/#more-511
Crying, Colic, andParental 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 beginsLester, 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 & DevelopmentSevere 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
Crying Duration
Shaking Baby Cases
Age in Weeks
2.75 hours
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 DepressionIn 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• “ 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
57%
24%
13%
3% 3%
0-3 months
4-6 months
7-9 months
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, MDAmerica’s Pediatrician
Supportive interventions which embrace a bio-psychosocial 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
PRIME-MD PHQ Responses
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Maternal Depression
Fussy Baby Network Family Feedback Survey
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How distressed did you feel about your FussyBaby issue?
What was your distress level when yourinvolvement with the FBN ended?
To what extent do you feel that the FBN helpedyou cope with your distress?