2. 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

3. Gray et al, 2004 Admissions to ER for Infant Crying 33% had diagnosis of colic/crying

4. Fussy Babies in the ED

5. Who are fussy babies?

6. All Babies Cry

7. Crying as a Regulatory Function Increases lung capacity at birth Increases motor activity Helps regulate temperature Triggers attachment system/social interaction Lester, 2006

8. What is it like to hear a baby cry inconsolably?

10. 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

11. Brazelton, 1962 “The Witching Hour”

12. Large difference between infants Brazelton, 1962

13. 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”

14. 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

15. 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

16. Colic is Not Linked to: Birth order Gender Feeding style SES Colic can occur in healthy babies, in spite of excellent parenting

17. 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

18. 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

19. 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

20. Evaluation and treatment by maternal-infant mental health specialist Maternal psychotherapy Reflux medication Smaller, frequent meals Upright positioning Thickening feeds Maternal dairy elimination if breastfed. Formula change to soy-based or elemental formula Evaluation and treatment by medical professionals Probiotic foods or supplements Targeted antibiotics Simethicone (Mylicon) Chamomile Gripe water Dill oil, Fennel oil Dicyclomine (Bentyl) Swaddling, Side positioning, Shushing, Swinging, Sucking Environmental dampening Infant massage / touch Chiropractic manipulation Maternal- Infant Distress Regulatory 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

21. Underlying Medical Reasons –Reflux –Milk Protein Allergy –Serious Infection (rare)

22. 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.

23. 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

24. 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

25. 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

26. 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

27. Infant Sensitivities Prematurity Drug exposure Sensitive sensory system

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

29. 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/delivery- method-affects-brain-response-to-babys-cry/#more-511

30. 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

31. Cultural Context of Crying How does culture perceive crying? –Positive –Negative What strategies are used in various cultures? –Distal caregiving –Proximal caregiving

32. How would your grandma calm a fussy baby?

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

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

35. 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

36. 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

37. 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

38. Risk for Child Abuse Age in Weeks 2.75 hours Barr, Trent, & Cross, 2006

39. Infant Crying & SBS Lee, Barr, Catherine & Wicks, 2007

40. 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

41. 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

42. Parents ask: “Where is the finish line?” “You think it is never going to end…”

43. 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?”

44. 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

45. “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”

46. 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”

47. 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)

49. 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

50. Parents’ Two Worries: Is my baby alright? Am I a good enough parent? T. Berry Brazelton, MD America’s Pediatrician

52. 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

53. 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

54. 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

55. Maternal Depression