Distinguishing infant prolonged crying from sleep-waking problems

Effects of psychosocial sleep interventions on improving infant sleep and maternal sleep and mood: A systematic review and meta-analysis

Infant sleep problems are prevalent and have a negative impact on infant growth and development, maternal sleep, and maternal mood. The effects of psychosocial sleep interventions on infant sleep and maternal sleep and mood are unclear. This study aimed to systematically evaluate the effects of psychosocial sleep interventions on improving infant sleep, including nocturnal total sleep time, daytime total sleep, total sleep time, night wakings, and maternal sleep and mood problems (ie, depression and fatigue). We searched PubMed, Web of Science, Cochrane Library, Embase, EBSCO, OpenGrey, DeepBlue, China National Knowledge Infrastructure, and Wanfang databases. We focused on randomized controlled trials examining the effectiveness of psychosocial sleep interventions on infant sleep. The study was preregistered at the International Prospective Register of Systematic Reviews (CRD42022301654). Thirteen studies from 5889 articles were included in the review, which found that psychosocial sleep interventions improved infant nocturnal total sleep time (0.28 [0.04-0.52], p < 0.05, I2 = 83.9%) and maternal depression (-0.10 [-0.28 to -0.08], p < 0.05, I2 = 8.7%). To test and explore heterogeneity, we used the I2 statistic, influence analysis, subgroup analyses, and subgroup meta-analyses. Funnel plots and Egger's tests revealed no evidence of publication bias. Psychosocial sleep interventions improved infant nocturnal total sleep time and maternal depression. Future research should include more randomized controlled trials examining the effect of psychosocial sleep interventions on the improvement of maternal sleep and fatigue.

Impact of baby behaviour on caregiver's infant feeding decisions during the first 6 months of life: A systematic review

Caregivers are often concerned about baby behaviours. Without adequate counselling, parental response can lead to altering infant feeding and jeopardizing breastfeeding. We conducted a systematic review to assess the evidence about the influence of baby behaviours perceived as problematic (crying, sleep waking and posseting) on infant feeding decisions during the first 6 months of life (self‐reported milk insufficiency, breastfeeding duration and introduction of formula). The review focused on quantitative studies published in English, Portuguese or Spanish without date restriction. The search was designed with the support of a medical librarian and conducted in seven databases. Data were managed in Covidence and risk of bias was assessed through the Johanna Briggs Institute critical appraisal checklists. Synthesis of the literature was guided by a conceptual model of the impact of baby behaviours on caregivers feeding practices. We retrieved and reviewed 4312 titles/abstracts and selected 22 for review; 10 were purely descriptive and 12 were cross‐sectional, prospective and quasi‐experimental studies. Although studies from diverse regions were included in the review, more than half were from high‐income countries. All studies reported that baby behaviours affect feeding decisions, the most common baby behaviours studied were crying and fussiness, and the studies suggested relationships with lactation problems and reports of milk insufficiency, maternal breastfeeding confidence, breastfeeding duration and discontinuation, and introduction of formula. There are many factors that lead to perceiving baby behaviours as problematic and there is a need to provide anticipatory guidance to parents and caregivers, starting in pregnancy and counselling through well‐trained health providers.

Although normal infant behaviour is highly variable, caregivers often perceive infant fussing/crying, posseting and sleep to be problematic.

How caregivers interpret such ‘problems’ is critical in shaping how they deal with them and the impacts they have on infant feeding practices.

Developing baby behaviour is not routinely included in training of health care staff, who often misinterpret baby behaviours and advise changes in feeding strategies.

There is a need for large‐scale studies addressing such issues, as well as clearer guidelines for health professionals and caregivers about common baby behaviours and how to cope with them.

Infant colic, young children's temperament and sleep in a population based longitudinal cohort study

Background

Colic and sleep problems are common among infants, constitute challenges and distress for parents, and are often reasons for seeking help from health professionals. The literature debates whether infant colic and sleep problems are linked together or not. Further, limited evidence exists on how colic impacts on child temperament and sleep during early childhood. Thus, the purpose of this study was to increase our knowledge of the characteristics of infants with a history of colic compared to infants without, and to study how infant colic is associated with the development of child temperament and sleep over time.

Methods

The study is based on The Norwegian Mother, Father and Child Cohort Study (MoBa), a population-based cohort study conducted by the Norwegian Institute of Public Health. This sample contains 88,186 mothers and children. Data was retrieved from questionnaires distributed to mothers at recruitment (in pregnancy) and when the child was 6 months, 18 months, 3 years, and 5 years. Data was analysed using linear mixed models and GLM models for repeated measures.

Results

At 6 months, infants with reported colic are described as fussier, present more sleeping problems, are breastfed less, and the families visit the child health centre more often when compared to the non-colic group. Mothers of children with reported colic perceive their children’s temperament significantly more challenging from the age of 6 months to 5 years. Further, children with reported colic were more likely to sleep less than recommended (22%) and to have more frequent night awakenings (14%) than usual for their age (6 months to 5 years).

Conclusion

Infant colic often occurs together with other signs of regulatory problems which may amplify the load on the parents. Moderate differences in temperament and sleep-problems across time, between those with colic and those without, indicate that the diagnosis of colic is moderately associated with later behavioural difficulties. However, it is demanding for the parents, and important to be aware of and act upon symptoms of colic in the child health centres to reduce the parents’ load and prevent adverse long-term outcomes.

Early regulatory problems and parenting: life-long risk, vulnerability or susceptibility for attention, internalizing and externalizing outcomes?

Multiple or persistent crying, sleeping, or feeding problems in early childhood (regulatory problems, RPs) predict increased risk for self-regulation difficulties. Sensitive parenting may protect children from trajectories of dysregulation. Considering self-regulation from a life-course perspective, are children with early multiple and/or persistent RPs affected similarly by parenting as those without (main effects model, ME), or are they more vulnerable (diathesis-stress, DIA-S), or more susceptible (differential susceptibility theory, DST) to variations in sensitive parenting at age 6 years? Participants (N = 302) were studied prospectively from birth to 28 years. RPs were assessed from 5 to 56 months. Sensitive parenting was observed at 6 years. Attention regulation was observed at 8 and 28 years. Internalizing and externalizing problems were rated by parents at 8 years, and by adults at 28 years. Confirmatory-comparative modelling tested whether associations of sensitive parenting with outcomes at 8 and 28 years among individuals with early multiple and/or persistent RPs (n = 74) versus those without (n = 228) were best explained by ME, DIA-S, or DST models. Best fitting models differed according to age at assessment. For childhood attention regulation, the statistically parsimonious DIA-S provided the best fit to the data. At age 28, two additive main effects (ME, RP group and sensitive parenting) fit best. DIA-S and ME explained internalizing and externalizing problems. Using a comprehensive life-span approach, DIA-S and ME models but not DST explained how early RPs and sensitive parenting predicted attention, internalizing, and externalizing outcomes. Individuals with early RPs are vulnerable to insensitive parenting.

Kambakutaisoto Treatment for Children With Night Crying and Arousal Parasomnias Developed During Prolonged Hospitalization for Hematological and Oncological Diseases

OBJECTIVE

The lack of an established treatment standard prompted an examination of whether kambakutaisoto, an herbal formula, is effective for non-rapid eye movement (NREM)-related parasomnias and night crying (provisionally defined as an infantile form of arousal parasomnia).

METHODS

This study included 137 children aged median 4.1 years (range, 0.02-18.5) who were admitted for hematological and oncological diseases.

RESULTS

Of 137, 3 children developed recurrent episodes of NREM-related parasomnias, and 3 developed night crying. The proportion of children with night-crying/parasomnia receiving invasive procedures was significantly higher than those without (100% vs. 47%, P = .013). All 6 children with night crying/parasomnia received kambakutaisoto at a dose of 0.13-0.22 g/kg per os and responded from the start of administration with a significant reduction in the number of episodes. No adverse effects were observed.

CONCLUSION

Kambakutaisoto may be a safe and promising therapy for night crying and NREM-related parasomnias in children.

Manual therapy for unsettled, distressed and excessively crying infants: a systematic review and meta-analyses

OBJECTIVE

To conduct a systematic review and meta-analyses to assess the effect of manual therapy interventions for healthy but unsettled, distressed and excessively crying infants and to provide information to help clinicians and parents inform decisions about care.

METHODS

We reviewed published peer-reviewed primary research articles in the last 26 years from nine databases (Medline Ovid, Embase, Web of Science, Physiotherapy Evidence Database, Osteopathic Medicine Digital Repository , Cochrane (all databases), Index of Chiropractic Literature, Open Access Theses and Dissertations and Cumulative Index to Nursing and Allied Health Literature). Our inclusion criteria were: manual therapy (by regulated or registered professionals) of unsettled, distressed and excessively crying infants who were otherwise healthy and treated in a primary care setting. Outcomes of interest were: crying, feeding, sleep, parent-child relations, parent experience/satisfaction and parent-reported global change.

RESULTS

Nineteen studies were selected for full review: seven randomised controlled trials, seven case series, three cohort studies, one service evaluation study and one qualitative study.We found moderate strength evidence for the effectiveness of manual therapy on: reduction in crying time (favourable: -1.27 hours per day (95% CI -2.19 to -0.36)), sleep (inconclusive), parent-child relations (inconclusive) and global improvement (no effect). The risk of reported adverse events was low: seven non-serious events per 1000 infants exposed to manual therapy (n=1308) and 110 per 1000 in those not exposed.

CONCLUSIONS

Some small benefits were found, but whether these are meaningful to parents remains unclear as does the mechanisms of action. Manual therapy appears relatively safe.

PROSPERO REGISTRATION NUMBER

CRD42016037353.

Systematic Review and Meta-Analysis: Fussing and Crying Durations and Prevalence of Colic in Infants

OBJECTIVE

To determine the mean duration of fussing and crying and prevalence of colic using modified Wessel criteria in infants in the first 3 months of life.

STUDY DESIGN

A systematic literature search was performed using the databases Medline, PsycINFO, and Embase. The major outcome measure was mean total fuss/cry duration during 24 hours at ages 1-2 weeks (11 samples), 3-4 weeks (6 samples), 5-6 weeks (28 samples), 8-9 weeks (9 samples), and 10-12 weeks (12 samples).

RESULTS

Of 5687 articles reviewed, 28 diary studies (33 samples) were suitable for inclusion in meta-analysis; these studies included 8690 infants. No statistical evidence for a universal crying peak at 6 weeks of age across studies was found. Rather, the mean fuss/cry duration across studies was stable at 117-133 minutes (SDs: 66-70) in the first 6 weeks and dropped to a mean of 68 minutes (SD: 46.2) by 10-12 weeks of age. Colic was much more frequent in the first 6 weeks (17%-25%) compared with 11% by 8-9 weeks of age and 0.6% by 10-12 weeks of age, according to modified Wessel criteria and lowest in Denmark and Japan.

CONCLUSIONS

The duration of fussing/crying drops significantly after 8-9 weeks of age, with colic as defined by modified Wessel criteria being rare in infants older than 9 weeks. Colic or excessive fuss/cry may be more accurately identified by defining fuss/cry above the 90th percentile in the chart provided based on the review.

Updated algorithms for managing frequent gastro-intestinal symptoms in infants

Regurgitation, constipation, excessive crying/fussiness, infantile colic and gassiness are frequent GI manifestations in young infants and result in numerous visits to paediatricians and in many cases in unnecessary change of formulas. The aim of this study was to offer paediatricians consensus based and simple algorithms for the management of the most frequent GI symptoms in infants. Paediatric gastroenterologists processed practical algorithms to assist general practitioners and general paediatricians. Four such practice recommendations were developed, based on the in 2013 published algorithms after an updated literature review. These algorithms cannot be considered as an 'evidence based guideline'. To date, these algorithms are the result of a consensus based on the available literature and the algorithms published in 2013.

Maternal anxiety versus depressive disorders: specific relations to infants' crying, feeding and sleeping problems

BACKGROUND

Maternal depression has been associated with excessive infant crying, feeding and sleeping problems, but the specificity of maternal depression, as compared with maternal anxiety remains unclear and manifest disorders prior to pregnancy have been widely neglected. In this prospective longitudinal study, the specific associations of maternal anxiety and depressive disorders prior to, during and after pregnancy and infants' crying, feeding and sleeping problems were investigated in the context of maternal parity.

METHODS

In the Maternal Anxiety in Relation to Infant Development (MARI) Study, n = 306 primiparous and multiparous women were repeatedly interviewed from early pregnancy until 16 months post partum with the Composite International Diagnostic Interview for Women (CIDI-V) to assess DSM-IV anxiety and depressive disorders. Information on excessive infant crying, feeding and sleeping problems was obtained from n = 286 mothers during postpartum period via questionnaire and interview (Baby-DIPS).

RESULTS

Findings from this study revealed syndrome-specific risk constellations for maternal anxiety and depressive disorders as early as prior to pregnancy: Excessive infant crying (10.1%) was specifically associated with maternal anxiety disorders, especially in infants of younger and lower educated first-time mothers. Feeding problems (36.4%) were predicted by maternal anxiety (and comorbid depressive) disorders in primiparous mothers and infants with lower birth weight. Infant sleeping problems (12.2%) were related to maternal depressive (and comorbid anxiety) disorders irrespective of maternal parity.

CONCLUSIONS

Primiparous mothers with anxiety disorders may be more prone to anxious misinterpretations of crying and feeding situations leading to an escalation of mother-infant interactions. The relation between maternal depressive and infant sleeping problems may be better explained by a transmission of unsettled maternal sleep to the fetus during pregnancy or a lack of daily structure and bedtime routine with the infant. Maternal disorders prior to pregnancy require more attention in research and clinical practice.

Assessment of nocturnal sleep architecture by actigraphy and one-channel electroencephalography in early infancy

OBJECTIVE

To elucidate characteristic sleep architecture of different nocturnal sleep patterns in early infancy.

METHODS

Participants were 27 infants at the same conceptional age of 3-4months. Nocturnal sleep of these infants was monitored at home by simultaneously using actigraphy and a one-channel portable EEG device. According to the infants' activity for 6h from sleep onset, each night's sleep pattern was classified into three categories: sleeping through the night (STN), sleeping with weak signals (crying/fuss episodes <10min or fed), and sleeping with strong signals (crying/fuss episodes≧10min). Associations of sleep patterns with sleep variables (percentage of time in sleep stages, pattern of slow-wave sleep (SWS) recurrence, etc.) were investigated.

RESULTS

Analysis was conducted in 95 nights. STN pattern (n=36) was characterized by suppressed body movements while EEG represented a state of wakefulness. Weak signal pattern (n=27) tended to indicate rich and regular distributions of SWS across the night. Strong signal pattern (n=32) was characterized by reduced sleep time, although the amount of SWS was not reduced to that degree. Exclusively breastfed infants accounted for 78% of weak signal patterns, whereas formula-feeding infants, 67% of STN patterns. In several nights with STN or strong signal pattern, SWS did not occur in >50% of the sleep cycles. Multiple regression analysis showed that exclusive breastfeeding may increase the proportion of SWS in non-REM sleep.

CONCLUSIONS

Each nocturnal sleep pattern was associated with some sleep architecture, part of which would be attributed to infant's feeding methods.

Looking for new treatments of Infantile Colic

Infantile colic is a common disturbance occurring in the first three months of life. It is a benign condition and one of the main causes of pediatric consultation in the early part of life because of its great impact on family life. Some pediatricians are prone to undervalue this issue mainly because of the lack of evidence based medicine guidelines. Up to now, there is no consensus concerning management and treatment. Literature reports growing evidence about the effectiveness of dietary, pharmacological, complementary and behavioral therapies as options for the management of infantile colic. Dietary approach, usually based on the avoidance of cow's milk proteins in breast-feeding mothers and bottle-fed infants, more recently has seen the rise of new special formulas, such as partially hydrolyzed proteins and low lactose added with prebiotics or probiotics: their efficacy needs to be further documented. Investigated pharmacological agents are Simethicone and Cimetropium Bromide: the first is able to reduce bloating while the second could reduce fussing crying, but it has been tested only for severe infantile colic. No other pain relieving agents have been proposed until now, but some clinical trials are ongoing for new drugs.There is limited evidence supporting the use of complementary and alternative treatments (herbal supplements, manipulative approach and acupuncture) or behavioral interventions.Recent studies have focused the role of microbiota in the pathogenesis of this disturb and so new treatments, such as probiotics, have been proposed, but only few strains have been tested.Further investigations are needed in order to provide evidence-based guidelines.

Trajectories and predictors of nocturnal awakenings and sleep duration in infants

OBJECTIVES

To examine the trajectories of sleep duration and nocturnal awakenings in infants from 6 to 18 months of age and to identify predictors of short sleep duration and nocturnal awakenings.

METHODS

Data for this study come from the Norwegian Mother and Child Cohort Study conducted at the Norwegian Institute of Public Health. A total of 55,831 mother reports of child sleep were used to estimate the stability and predictors of awakenings and short sleep.

RESULTS

Nocturnal awakenings were frequent among 6-month-old children. Although there was an overall reduction in both sleep duration and nocturnal awakenings from 6 to 18 months, the chronicity of sleep problems was high and impacted by prior sleep behavior and sleeping arrangements. Bedsharing was an independent and graded predictor of nocturnal awakenings and short sleep duration, also after controlling for prior sleep. Breastfeeding was related to concurrent nocturnal awakening but was not negatively related to later nocturnal awakenings.

CONCLUSIONS

Considering the chronicity of nocturnal awakening and its association with bedsharing, our findings support current recommendations of reducing bedsharing to improve sleep among infants.

Behavioral sleep interventions in the first six months of life do not improve outcomes for mothers or infants: a systematic review

OBJECTIVE

The United Kingdom's National Institute for Health Research has recently invited proposals for the design of a multicomponent primary care package of behavioral interventions to reduce parental distress caused by excessive infant crying in the first 6 months of life. A systematic review was performed to determine whether behavioral interventions for sleep, when applied by parents to infants younger than 6 months, improve maternal and infant outcomes.

METHODS

Searches of PubMed, CINAHL, and Cochrane Database of Systematic Reviews were conducted to identify systematic reviews, meta-analyses, clinical trials, and cohort studies investigating the effects of behavioral sleep interventions in infants younger than 6 months (January 1993-March 2013). The evidence is critically analyzed, according to PRISMA guidelines.

RESULTS

Cry-fuss, feeding, and sleep problems emerge out of multiple dynamically interacting and co-evolving variables in early life and are for this reason generically referred to as regulatory problems. Studies that link behavioral interventions for sleep in the first 6 months with positive effects on maternal and infant health demonstrate 3 methodological constraints. They fail to identify and control for feeding difficulties, fail to distinguish between the neurodevelopmentally different first and second halves of the first year of life, and apply reductive analyses to evaluations of complex interventions. Despite substantial investment in recent years in implementation and evaluation of behavioral interventions for infant sleep in the first 6 months, these strategies have not been shown to decrease infant crying, prevent sleep and behavioral problems in later childhood, or protect against postnatal depression. In addition, behavioral interventions for infant sleep, applied as a population strategy of prevention from the first weeks and months, risk unintended outcomes, including increased amounts of problem crying, premature cessation of breastfeeding, worsened maternal anxiety, and, if the infant is required to sleep either day or night in a room separate from the caregiver, an increased risk of SIDS.

CONCLUSION

The belief that behavioral intervention for sleep in the first 6 months of life improves outcomes for mothers and babies is historically constructed, overlooks feeding problems, and biases interpretation of data.

Practical algorithms for managing common gastrointestinal symptoms in infants

OBJECTIVE

In early infancy, various gastrointestinal symptoms (e.g., constipation, regurgitation, crying/fussiness, infantile colic, and excessive gas) are common problems and may result in numerous visits to pediatricians. Worldwide, this often results in switching infant formulas because parents (and sometimes doctors) believe these symptoms reflect a formula intolerance. However, in many cases, these infants are growing and developing normally. This study was performed to offer family pediatricians consensus-based algorithms on the management of the most common gastrointestinal symptoms in infants.

METHODS

A group of pediatric gastroenterologists and pediatric allergists from Europe, USA, Latin America, and Asia developed guidelines and practical algorithms to assist general pediatricians in addressing this challenge.

RESULTS

Five such practice recommendations were developed after a thorough literature review. These algorithms should not be considered as an "evidence-based guideline"; on the contrary, the authors are convinced that challenging these proposals will result in updated and improved versions.

CONCLUSION

To date, these algorithms, based on the published literature, are the result of a broad consensus of pediatric gastroenterologists from different continents.

Relationship between duration of crying/fussy behavior and actigraphic sleep measures in early infancy

OBJECTIVE

The objective of the study is to understand the relationship between sleep development and crying episodes during early infancy more accurately by longitudinal and objective sleep evaluations.

DESIGN

The study is designed as a prospective longitudinal study of infants in the first 4 months of life.

METHODS

This study included 31 healthy term infants. At approximately 4- to 6-week intervals, when the infants were aged 4-6 weeks, 8-10 weeks, and 14-16 weeks, their mothers recorded the duration of crying/fussy behavior of infants in a timetable and attached an actigraph to the infants for 3 days. The relationship between 24-h crying/fussy behavior duration and actigraphic sleep measures was examined from both a cross-sectional (age group) and longitudinal (within-infants) perspective. Interactions with diverse covariates were studied by multiple regression analysis.

RESULTS

A significant correlation was found between 24-h crying/fussy behavior duration and proportion of active sleep in infants at 14-16 weeks and in within-infant relationships. Among potential covariates, gestational age and co-sleeping had a significant impact on proportion of active sleep. Results of multiple regression analysis showed that gestational age and co-sleeping were positively associated with proportion of active sleep, whereas 24-h crying/behavior duration was not associated with proportion of active sleep.

CONCLUSIONS

Subsiding of early crying and decreasing of proportion of active sleep are parallel phenomena in some infants. However, this association was thought to be attributable to the influence of covariates, including co-sleeping or gestational age. The underlying mechanisms regulating these developmental processes might overlap with one another, as covariates that affect one process could affect the other.

The crying baby: what approach?

PURPOSE OF REVIEW

Cry-fuss problems are among the most common clinical presentations in the first few months of life and are associated with adverse outcomes for some mothers and babies. Cry-fuss behaviour emerges out of a complex interplay of cultural, psychosocial, environmental and biologic factors, with organic disturbance implicated in only 5% of cases. A simplistic approach can have unintended consequences. This article reviews recent evidence in order to update clinical management.

RECENT FINDINGS

New research is considered in the domains of organic disturbance, feed management, maternal health, sleep management, and sensorimotor integration. This transdisciplinary approach takes into account the variable neurodevelopmental needs of healthy infants, the effects of feeding management on the highly plastic neonatal brain, and the bi-directional brain-gut-enteric microbiota axis. An individually tailored, mother-centred and family-centred approach is recommended.

SUMMARY

The family of the crying baby requires early intervention to assess for and manage potentially treatable problems. Cross-disciplinary collaboration is often necessary if outcomes are to be optimized.