1 The Phenomena of Early The Phenomena of Early Infant Crying and Colic Infant Crying and Colic Ronald G. Barr, MDCM, FRCPC Ross Trust Seminar Infant crying: causes, challenges and long-term outcomes Centre for Community Child Health Royal Children’s Hospital Melbourne, Australia March 2, 2009 The Phenomena of Early The Phenomena of Early Infant Crying and Colic Infant Crying and Colic Or, why I hope my next child has colic! Or, why I hope my next child has colic! Ronald G. Barr, MDCM, FRCPC Ross Trust Seminar Infant crying: causes, challenges and long-term outcomes Centre for Community Child Health Royal Children’s Hospital Melbourne, Australia March 2, 2009 Infants crying Infants crying: : “photographs made by the photographs made by the instantaneous process instantaneous process” Darwin, The Expression of Emotion in Animals and Man, 1872 The The “Argument Argument” Clinical crying problems are: a. Costly b. Not explained by “pathology” in the infant or the caregiver c. Should be reconceptualized as a manifestation of normal behavioral development The Argument The Argument (cont (cont’ d) d) The phenomena of early infant crying may be adaptive (from the point of view of evolutionary behavioral ecology). This understanding of early increased infant crying (and colic) as “normal” has some implications for clinical approaches to early infant crying problems. The The “Cost Cost” of Early Infant Crying of Early Infant Crying
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The Phenomena of Early The Phenomena of Early Infant Crying and ColicInfant Crying and Colic
Ronald G. Barr, MDCM, FRCPCRoss Trust Seminar
Infant crying: causes, challenges and long-term outcomes
Centre for Community Child HealthRoyal Children’s Hospital
Melbourne, AustraliaMarch 2, 2009
The Phenomena of Early The Phenomena of Early Infant Crying and ColicInfant Crying and Colic
Or, why I hope my next child has colic!Or, why I hope my next child has colic!
Ronald G. Barr, MDCM, FRCPCRoss Trust Seminar
Infant crying: causes, challenges and long-term outcomes
Centre for Community Child HealthRoyal Children’s Hospital
Melbourne, AustraliaMarch 2, 2009
Infants cryingInfants crying: : ““photographs made by the photographs made by the instantaneous processinstantaneous process””
Darwin, The Expression of Emotion in Animals and Man, 1872 The The ““ArgumentArgument””
Clinical crying problems are:a. Costlyb. Not explained by “pathology” in the infant or
the caregiverc. Should be reconceptualized as a
manifestation of normal behavioral development
The Argument The Argument (cont(cont’’d)d)
The phenomena of early infant crying may be adaptive (from the point of view of evolutionary behavioral ecology).
This understanding of early increased infant crying (and colic) as “normal” has some implications for clinical approaches to early infant crying problems.
The The ““CostCost”” of Early Infant Cryingof Early Infant Crying
2
Crying concerns in the health Crying concerns in the health care systemcare system
Early increased cryingis used as anadvertisement for theQuebec telephone call-inservice.It accounts for about30% of all calls.
Maternal Emotional Distress and Maternal Emotional Distress and ““ColicColic””Miller, Barr et al (1993) Pediatrics 92: 551Miller, Barr et al (1993) Pediatrics 92: 551--558558
Mothers who had infantswith colic (modifiedWessel’s criteria) hadelevated levels ofemotional distress,despite equivalentdistress levels in 3rdtrimester
The The ““costcost”” of cryingof cryingSleep and St. James-Roberts, 1998
• Cost of health professional time for cry and sleep complaints in the first 3 months (salary only): $CDN 46.08/baby
• Annual cost for NHS: $CDN 35,304,652• Equivalents:
a. 775 full time nursesb. 4238 hip fracturesc. 270 patients with HIV treated for life
Evidence that the Evidence that the ““Crying CurveCrying Curve””is a Behavioral Universal of Infancyis a Behavioral Universal of Infancy
There is a similar pattern and timing in:1. All samples of Western infants2. Cultures with radically different caregiving styles3. Prematures4. A wide variety of human infant biological & behavioral functions5. Non-human species
UnsoothableUnsoothable Crying BoutsCrying Boutsin London, Copenhagen, and with a in London, Copenhagen, and with a ““proximalproximal””
form of careform of careInfants with Bouts of Unsoothable Crying
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
10 days 5 weeks 12 weeks
Age of Infants
Perc
enta
ge o
f Inf
ants
London CommunityCopenhagen CommunityProximal Care
St James-Roberts, I., Alvarez, M., Csipke, E., Abramsky, T., Goodwin, J., Sorgenfrei, E. Infant crying and sleeping in London, Copenhagen, and when parents adopt a 'proximal' form of care. Pediatrics,2006.
NonNon--linear Phase Transitions in linear Phase Transitions in Behavioral SystemsBehavioral Systems
NonNon--linear Phase Transitions in linear Phase Transitions in Behavioral SystemsBehavioral Systems
Concept of Infant Behavioral Concept of Infant Behavioral StatesStates (Wolff, 1987)(Wolff, 1987)
Infant behavioral states as a linear continuum of “arousal”
Infant behavioral states as distinct, nonlinear, and discontinuous, organizations of behavior.
The The ““ShapeShape”” of Nonof Non--linear linear TransitionsTransitions
““ExplainingExplaining”” Prolonged Crying Bouts, Prolonged Crying Bouts, Resistance to Soothing and Resistance to Soothing and Paroxysmal Crying BoutsParoxysmal Crying Bouts
No pathologic or abnormal mechanism need be postulated to explain unpredictable, paroxysmal, “unexplained” nature of crying bouts.
They are most likely to be classical state transitions in infants functioning as “well-behaved” non-linearly organized behavioral systems.
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““Colic:Colic:”” a a reconceptualizationreconceptualizationRather than thinking of colic as distinctdistinct,
qualitatively differentdifferent, and due to underlying pathophysiologypathophysiology or pathopsychologypathopsychology…
Perhaps we should think of it as continuouscontinuouswith normal behavior, qualitatively similarsimilar, and due to infants acting as as they shouldthey should, or were designed to, act.
Clifford et al: Clifford et al: SequelaeSequelae of of Infant ColicInfant Colic
Arch Arch PediatrPediatr AdolescAdolesc Med (2002) 156:1183Med (2002) 156:1183--11881188• Diaries at 6 weeks and 3 months of age• Modified Wessel’s criteria• Of those with colic at 6 weeks:
a. 86.3% did not have colic at 3 months: 13.7% still did (“persistent” colic)
• At 3 months, 6.4% had colic:a. Of these, 50% did not have colic at 6
weeks (in other words, 50% with colic at 3 months “developed” it)
Although early increased Although early increased crying (crying (‘‘coliccolic’’) has no long ) has no long term negative outcomes, term negative outcomes,
persistent or repeated elevated persistent or repeated elevated crying crying afterafter 33--4 months 4 months doesdoeshave longhave long--term predictability term predictability
LongtermLongterm Effects of Effects of ““PostPost””Curve Crying Curve Crying
• Papousek, Wurmser, von Hofacker: Clinical perspectives on unexplained early crying: challenges and risks for infant mental infant mental healthhealth and parentparent--infant relationshipsinfant relationships. In Barr, St. James-Roberts, Keefe MR (eds) New evidence on unexplained early infant crying: its origins, nature and management, 2001 (289-316)
• Wolke, Rizzo, Woods: Persistent infant crying and hyperactivityhyperactivityproblems in middle childhood. Pediatrics 2002: 109(6):1054-1060.
• Rao MR, Brenner RA, Schisterman EF, Vik T, Mills JL: Long term cognitive developmentcognitive development in children with prolonged crying. Arch DisChild 2004:89:989-992.
• Wake M, Morton-Allen E, Poulakis Z, Hiscock H, Gallagher S, Oberklaid F: Prevalence, stability and outcomes of crycry--fussfuss and sleep problemssleep problems in the first 2 years of life: prospective community-based study. Pediatrics 2006: 117:836-842.
The limbicThe limbic--hypothalamichypothalamic--midbrain circuits called midbrain circuits called ‘‘Maternal CircuitsMaternal Circuits’’ overlap with the overlap with the mesocorticolimbicmesocorticolimbic dopaminargicdopaminargic reward pathwaysreward pathways..
Breastfeeding mothers had greater activations in the Breastfeeding mothers had greater activations in the mesocorticolimbicmesocorticolimbic reward circuitreward circuit in response to in response to own own baby crybaby cry at at 22‐‐4 weeks4 weeks postpartum. postpartum.
Breastfeeding mothers had greater activations in the Breastfeeding mothers had greater activations in the mesocorticolimbicmesocorticolimbic reward circuitreward circuit in response to in response to own own baby picturesbaby pictures at at 22‐‐4 weeks4 weeks postpartum.postpartum.
DifferencesDifferences in brain responses to in brain responses to own baby picture own baby picture among two groups decrease at 3among two groups decrease at 3‐‐4 months4 months postpartum postpartum became became smallersmaller. .
Runyan.Runyan.TheThe challenges of assessing the challenges of assessing the incidence of inflicted traumatic brain injury: A incidence of inflicted traumatic brain injury: A
world perspective.world perspective.Amer J Prev Med 2008;34 (4S)
“The impact of these private acts must be further studied as there may be other long-lasting and serious intracranial impacts that have not been characterized.”
Infants with ColicInfants with Colicin London, Copenhagen, and with a in London, Copenhagen, and with a
““proximalproximal”” form of careform of careInfants with "Colic"
0%
2%
4%
6%
8%
10%
12%
14%
16%
18%
10 days 5 weeks 12 weeks
Age of Infants
Perc
enta
ge o
f Inf
ants
London CommunityCopenhagen CommunityProximal Care
*
* denotes χ2 test where p < 0.001
St James-Roberts, I., Alvarez, M., Csipke, E., Abramsky, T., Goodwin, J., Sorgenfrei, E. Infant crying and sleeping in London,Copenhagen, and when parents adopt a 'proximal' form of care. Pediatrics, 2006.
ReconceptualizationReconceptualization of of ““Colic:Colic:””Colic is a manifestation of normal Colic is a manifestation of normal
behavioralbehavioral developmentdevelopmentAll of the features of the crying definitive of
excessive crying (or “colic”) can be understood as manifestations of the upper end of a spectrum of crying behavior that is typical of normally normally developing infantsdeveloping infants rather than a distinct crying pattern indicative of underlying disease in the infant or psychopathology in the caregiver(s).
Moderate Retinal Hemorrhage in Moderate Retinal Hemorrhage in Shaken Baby SyndromeShaken Baby Syndrome
Courtesy Alex Levin, MDCourtesy Alex Levin, MD
Guinea Pig Distress as a Function of Guinea Pig Distress as a Function of ““PlacePlace”” & Mother Presence & Mother Presence ((PettijohnPettijohn 1979)1979)
Levels of Levels of Description Description of Cryingof Crying
Barr (1990) Human Nature 1: 355-389
A proposed taxonomy for describing crying phenomena, in which “cycles,” “events” and “bouts” are related hierarchically in terms of the cry cycles and how they are related to each other
Events
Cycles
Bouts
Coded State Changes between Coded State Changes between CryingCrying and and AlertAlert
!Kung San Hunters!Kung San Hunters(Courtesy Marjorie (Courtesy Marjorie ShostakShostak))