Colic and Infant sleep problems

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Colic and Infant sleep problems Powered By Docstoc
					July 27, 2009
 Imtiaz Ghori
   Infants have a normal crying curve during the
    first 3 months
   Peaks at ~6 weeks and decreases by about 12
   Averages 2 hr/day at 2 weeks, 3 hrs at 6
    weeks, and 1 hr/day at 12 weeks
   True across cultures and preemies show the
    same pattern, peaking at 6 weeks after their
    expected due date
   Signaling
   Attachment behavior – assures nutrition,
    protection, maternal interaction
   Up to a point, infants who cry more get more
    maternal attention.
   Reorganization of brain systems occurring
    around 8-12 weeks, reflexive systems
    replaced by cortical control of behaviors.
   Unsoothability related to a temporary deficit
    in responsivity, so have difficulty in stopping
    crying once it starts
   Most widely used definition is: > 3 hours a
    day, > 3 days a week, >3 weeks in a row (i.e..
    rule of 3)
   Affecting an otherwise healthy, well-fed
   Stats range from 2 – 20% of babies
   Diagnosis of exclusion
   Many theories, often thought to be due to
   Based on current evidence infants who have
    colic are at the high end of a normal
    spectrum of crying.
   Benign, self limited. 50% resolve by 2 months,
    80% by 3 months, 90% by 4 months
   Sudden, unpredictable onset
   Prolonged episodic bouts
   Diurnal – evening peaks
   Difficult to console
   Sometimes physical signs –clenched fists, red
    face, legs drawn up, distended abdomen
   Lasts beyond 4 months
   Continuous irritability/lack of diurnal rhythm
   GI symptoms (FTT, vomiting, diarrhea, etc)
   Positive physical exam – including eyes, long
    bones, neuro, CV, GI assessment
   Positive family history of asthma, atopy,
    eczema, migraine
   Maternal drug ingestion
   Although food intolerance and other organic
    causes can cause prolonged crying, these factors
    absent in 90% of cases.
   Most common organic causes suspected are
    GERD and food allergies, but the evidence is
    equivocal and a factor in only a small group
   Large study comparing BFing mothers on low
    allergen diet vs. those not, showed no difference
    in proportions of colicy infants.
   Lactose intolerance – no good supportive
   Studies have shown parental counseling more
    effective than diet changes.
   Cross-cultural studies comparing parenting
    and infant crying.
   High amounts of body contact and responsive
    parenting associated with lower amounts of
   The crying curve and frequency of crying is
    similar but the length of the bouts are
    reduced substantially.
   Affect on parents – feel helpless, inadequate,
   Can contribute to maternal depression
   Prolonged crying may trigger shaken baby
    syndrome/other abuse
   Parents of >3000 infants gave anonymous
    responses in a questionnaire; 2.2% of
    parents of 1 month olds and 3.7% of parents
    of 3 month olds reported having smothered,
    slapped, or shaken their baby at least once
    because of crying
   Parental support and education –acknowledge,
    reassure, offer tips on soothing, absolve guilt,
    recommend time-out.
   Role for diet changes in small percentage so may
    be worth a try
   Simethicone not shown to helpful;
    antispasmodics have adverse effects (apnea,
    seizures, coma) and contraindicated in infants <
    6 months
   Cranial osteopathy – no randomized controlled
    trials. One small study showed decreased crying
    and improved sleeping
   Fennel seed oil – one randomized controlled
    study showed benefit and no adverse effects
    BUT fennel oil can cause allergic reactions of
    skin and repieiratory tract and has been
    reported to cause seizures.
   Herbal blends – teas containing fennel,
    chamomile, vervain, licorice, and lemon balm
    have been studied and shown be effective but
    the volume the infants took concerning ( 5
    oz. TID) b/c may affect milk intake
   Gripe water – mixture of herbs; warn that some
    varieties have been found to contain dangerous
    ingredients, including glass particles and alcohol.
    Also watch for sodium bicarbonate and essential
   Colocynthis – found in Hyland’s colic tablets –
    not proven to effective but unlikely to cause
   Soothing techniques – overall 24 hour amounts
    of crying substantially reduced with more
    physical contact and increased responsiveness
   16 hours at 1month, decreases to 14 hours
    by 1 year, 13 hours by age 2.
   During first 3 months infants go from a
    pattern of short sleep-wake cycles about
    evenly distributed throughout the day and
    night to consolidating sleep into longer
    periods at night.
   Infants spend about 50% of sleep time in REM
    sleep, adults spend about 20% in REM sleep
   Infants active/deep sleep cycles last about 50
    minutes; adults about 90 minutes
   “Sleeping through the night”–most babies by
    12 weeks; actually still awakening several
    times during the night but most infants learn
    to resettle. About 1/3 of babies don’t resettle
    and “signal” their parents.
   80% sleeping all night by 6 months and 90%
    by 12 months
   Breast fed babies continue to need a feeding
    between midnight and 6 am for longer than
    bottle-fed babies
   Should not need to feed during the night
    after 6 months (can go about 6-8 hours)
   Settling babies while awake- sleep onset
    associations. “tired cues” before overtired
   Bedtime routine/environment
   Clearest evidence is that structured care leads
    to infants developing the ability to remain
    settle at night by 12 weeks.
   “structured” parenting – start training at 6
    weeks. 1. maximize diff. b/tw daytime and
    nighttime sleep environments. 2. settle baby
    while awake. 3. once baby at least 3 weeks
    old, healthy, gaining weight well, can begin to
    delay feeding when baby wakes at night –
    cuddle,, change diaper, etc.. Not leaving baby
    to cry.
   Infant-demand care – leads to lower amounts
    overall fussing and crying in the first 2
    months but to waking and signaling at night
    that continues at and beyond 3 months.
   Not a problem if parents don’t think it’s a
    problem. No evidence that babies who wake
    and cry at 3 months will have long term
   Lots of different ideas on getting babies to
    sleep; individualize plan based on family’s
    needs and resources
   Neither parenting approach better overall,
    each is associated with different benefits and
   Copenhagen parents’ care was as effective as
    proximal care in minimizing crying and as
    effective as London care in enabling infants
    to remain settled by 12 weeks.
   SIDS prevention
   Co-sleeping precautions
Parental support and
 education are key.

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