دکتر زهره بدیعی فوق تخصص نوزادان دانشگاه علوم پزشکی اصفهان 1392

 Could parents teach their breastfed infants to lengthen nighttime sleep periods?

Sleeping  Sleeping through the night has been assumed to be an important developmental milestone dependent on maturation.  First-time parents (n = 26) of exclusively breastfed infants were randomly assigned to a treatment or control group.  The treatment group was instructed to offer a “focal feed” between 10 PM and midnight and then offer reswaddling, diapering, walking, and rocking to postpone the next feeding to 5 AM, minimizing light and sound. By 3 weeks the treated group was sleeping significantly longer

 By 8 weeks, 100% of the treated group, compared with 23% of control infants, was sleeping at least from midnight to 5 AM.  They fed more frequently during the day, especially early morning.  Milk intakes for 24 hours between the two groups were not different.  They concluded that parents can teach their breastfed infants to lengthen nighttime sleep periods

Colic and Crying  When the term colic is used in reference to infants, it usually means a syndrome in which a young infant has unexplained paroxysms of irritability, fussing, and crying for a prolonged period, often at the same time of day, in the early months of life. The infant usually draws the legs up as if in pain

Possible causes  Allergy  hypertonicity  hormone withdrawal  However, it may be a matter of parenting style and expectations that brings a parent to complain about colic

 Colic does occur in premature infants but usually not until they reach 42 weeks’ adjusted gestation

colic  Characteristically, an infant will cry and scream as if in pain from 3 to 4 hours at a stretch, often between 6 PM and 10 PM.  The infant will nurse frequently, then scream and pull away from the breast as if in pain, only to cry a few minutes later.  Sometimes the infant can be comforted by another adult such as the father or grandmother

 The infant will respond to gentle rocking when held against a warm shoulder.  If the infant is put down, the screaming starts again.

 If the nursing mother holds the infant, he or she is frantic unless nursed and yet does not need to be fed.  This may disturb a new mother, who wonders why she cannot console her infant. (Is her milk weak? Does it disagree with her infant? Is she an inadequate mother?) None of these is true, but smelling the mother’s milk makes the infant behave as if it needs to nurse.

 Anyone who is not nursing can quickly quiet the infant.  Picking up the infant does not spoil the child, and rocking and cuddling are appropriate. Warm pressure is usually palliative;

 a warm hot water bottle or warm shoulder with some pressure or massage is comforting. The use of rhythmic incessant sounds or lights (e.g., vacuum cleaner, TV out of focus so it is a changing pattern) has variable success

 A carefully taken history and physical examination are always in order to rule out other pathologic conditions, such as:  otitis media, anal fissure, hair tourniquet, or hernia before a diagnosis of colic is made.  Hunger should be ruled out.  Sometimes an infant who was just fed needs to be fed again.  True colic, however, is characterized by an inconsolable infant who continues to fret, fuss, and cry.  true colic is diagnosed because of the consistency of the screaming for several hours each day at the same time.

Influence of Cow Milk in Maternal Diet  The literature is not straightforward on the issue of the effect of cow milk in the maternal diet and infantile colic

 With a clinical picture of colic, a history of allergy in the family, especially to cow milk, is suggestive.  A diet free of cow milk should be tried for at least a week (2 days rarely produces significant improvement) for any case of severe colic.  Usually a mother eliminates drinking milk, and for some babies that is enough.

 If not, all milk products are then eliminated.  If mild improvement results with elimination of dairy products, elimination of all bovine protein (i.e., beef) may make a difference.  However, not all colic is caused by cow milk.  It may be associated with other dietary items, such as eggs or chocolate, or it may be totally unrelated to maternal food intake

transient colic  Acute 24-hour colic in a breastfed infant may result from particular items in the maternal diet.  If a strong vegetable (e.g., beans لوبیا - باقلا, onions, garlic, and rhubarb ریواس ) is taken for the first time and the infant starts to cry within a few hours and continues for 20 to 24 hours, this may be transient colic.

 Mailed questionnaires to 272 mothers when their infants were approximately 4 months old asked about symptoms related to colic.  A high correlation was found between 24-hour colic and the mother’s consumption of cruciferous vegetables, onions, cow milk, and chocolate and less so with beans, legumes, spicy foods, and caffeine

Management of Colicky Behavior  Holding and rocking do not spoil infants. Crying levels normally increase from birth to 6 to 8 weeks.  Most infants spend 2 to 2½ hours per day crying at this age.

 During the period of colic the infant may need frequent small feedings and much cuddling. Sometimes the infants overfeed, then vomit, and settle down and go quietly to sleep, just as an overfed bottle- fed infant does.

 The distress or discomfort may be caused by tension, and “colic” has been noted to be more common in the first infants of high-strung mothers  Colic has been associated with hormone withdrawal and has been treated with progesterone.  In breastfed babies this is a less likely cause because of the presence of hormones in breast milk

 Colicky breastfed infants who are weaned to formula are usually much worse.  Weaning is not an appropriate treatment for the colicky breastfed infant in most cases. Colic usually diminishes in the third month of life, when the infant’s GI tract matures.

 Weizman et al studied an herbal tea preparation and found it improved colic in 57% of infants compared with only 26% of infants who received the placebo of warm glucose-flavored water.  The herbal tea, however, contained chamomile, verbain (Verbena officinalis), licorice, fennel, and balm mint, several of which are not recommended for infants بابونه - رازیانه - نعناع

 A traditional treatment for colic is gripe water, which is an extract of fennel and ginger, both of which are safe herbs for infants. رازیانه - زنجبیل

One or two breast  Another explanation for colic and failure to thrive has been suggested by Woolridge and Fisher, who note that when an infant is taken from the first breast and switched to the second, this may decrease the amount of fat and energy received

 Colicky infants are often given more to eat, first one breast, then the other, which will increase volume but will also increase lactose and discomfort.

five S” system for treatment of colic  Swaddling: Tight swaddling provides the continuous touching and support the fetus experienced while in mother’s womb  Side/stomach position: Place the baby, while holding her, either on her left side to assist in digestion or on her stomach to provide reassuring support  Shushing sounds: These sounds imitate the continual whooshing sound made by the blood flowing through arteries near the womb. This white noise can be in the form of a vacuum cleaner, a hair dryer, or a fan.

 Swinging: Newborns are used to the swinging motions that were present when they were in utero. Rocking, car rides, and other swinging movements can help.  Sucking: “Sucking has its effects deep within the nervous system and triggers the calming reflex and releases natural chemicals within the brain”; this “S” can be accomplished with breast, bottle, pacifier, or even a finger

Weaning  it is the transfer of the infant from dependence on mother’s milk to other sources of nourishment.

 When 4 times of birth weigh  1/3 of adult weight  6*gestation period

Refusal to Breastfeed: ”Nursing Strike”  Sudden onset of refusal to nurse can occur at any time and often is taken by the mother as a personal rejection, who promptly follows through by weaning completely.  Often these mothers consider the refusal to mean that they do not have enough milk or that something is wrong with their milk.  This behavior has been called “nursing strike” and has been noted to be temporary

Causes of Nursing Strike  1.  Onset of menses in the mother  2.  Dietary indiscretion by the mother  3.  Change in maternal soap, perfume, or deodorant  4.  Stress in the mother  5.  Earache or nasal obstruction in the infant  6.  Teething  7.  Episode of biting with startle and pain reaction by the mother

Suggestions that may be made to the mother include the following:  1.  Make feeding special and quiet, with no distractions and no other people in the room.  2.  Increase amount of cuddling, stroking, and soothing the baby. Walk with the infant cradled in the arms or an infant sling.  3.  Offer the breast when the infant is sleepy.  4.  Do not starve the child into submission. کودک را تسلیم گرسنگی نکنید  5.  If simple remedial steps do not result in a return to nursing, the physician should see the child to rule out otitis media, fever, infection, thrush, and so on.  6.  If biting was the associated event, keep finger ready to break suction should it occur again to avoid startling the infant

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