The Phenomena of Early Infant Crying and Colic The Phenomena of

Transcription

The Phenomena of Early
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
Infant Crying and 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:
crying: “photographs made by the
instantaneous process”
process”
Darwin, The Expression of Emotion in Animals and Man, 1872
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 (cont’
(cont’d)
The phenomena of early infant crying may
be adaptive (from the point of view of
evolutionary behavioral ecology).
The “Cost”
Cost” of Early Infant Crying
This understanding of early increased infant
crying (and colic) as “normal” has some
implications for clinical approaches to
early infant crying problems.
1
Crying concerns in the health
care system
Early increased crying
is used as an
advertisement for the
Quebec telephone call-in
service.
It accounts for about
30% of all calls.
Maternal Emotional Distress and “Colic”
Colic”
Miller, Barr et al (1993) Pediatrics 92: 551551-558
Mothers who had infants
with colic (modified
Wessel’s criteria) had
elevated levels of
emotional distress,
despite equivalent
distress levels in 3rd
trimester
© Ronald G. Barr, MDCM, FRCPC 2009
The “cost” of crying
Sleep 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 nurses
b. 4238 hip fractures
c. 270 patients with HIV treated for life
What is colic?
Defining features
(Gormally & Barr, 1997)
1. Age-dependent crying patterns (peak
during 2nd month).
These are due to changes in the amounts of crying
that cluster during the evening.
2. Associated behaviors (prolonged cry
bouts, unsoothability, “pain facies”)
3. “Paroxysmal” (unpredictable)
Wessel’s “Rule of 3’s”
An infant has colic when s/he cries:
> 3 hours/day
> 3 days/week
> 3 weeks
Assumption:
Colic is an abnormality,
or “something wrong”
with the infant
2
The Argument Against
Pathology
• Non-pathological mechanisms
can account for all primary
features of colic
• Good outcome
“Colic”
Colic” is not explained by
pathology in the infant or in
the caregiver
The Lamp Post
What is colic?
Defining features
Anthropology
Clinical
Psychobiology
Nonlinear dynamic
systems (catastrophe)
1. AgeAge-dependent crying patterns
(peak during 2nd month).
The “crying curve”
(Brazelton,
Brazelton, 1962)
“Peak Pattern”
Pattern” of Early
Crying Behavior
Large
differences
from infant to
infant
Hunziker & Barr,
Pediatrics 1986
3
!Kung San Gathering
!Kung San Mother & Infant
(Photos by Marjorie Shostak)
Shostak)
(Photo by Marjorie Shostak)
Shostak)
!Kung San Mother & Infant
(Photo by Marjorie Shostak)
Shostak)
Western Caregiving Styles
Caregiving Contexts
Hourly Cry/Fret Duration in !Kung
San Infants in Early Months
Barr, Konner et al DMCN 1991
!Kung San Western
Contact
Constant
Intermittent
Carry
Constant
Response to cry
Feeding
“Continuous”
“Pulse”
Posture
Upright
Supine
Responsivity Universal
Large infant
to infant
differences
Occ. Non-response
4
Hourly Cry/Fret Frequency in !Kung San,
Dutch, and USA Infants
Hourly Cry/Fret Duration in !Kung
San vs. Dutch Infants
AgeAge-related Crying Patterns in
Preterm Infants
N-shaped curves in other
biological functions
(Barr, Chen, Hopkins et al DMCN)
Age-related changes
in headhead-turning to
rattle sounds.
sounds
Less “turning
towards” and more
“no turns” at 2
months.
Field, Muir et al, Child Dev, 1980
N-shaped curve in caloric intake
“Distress Curves”
Curves” have been found
in all nonnon-human mammalian (i.e.
breast feeding) species
investigated.
•
•
•
•
Guinea pig pups (Pettyjohn, 1979)
Infant rat pups (Hofer et al, 1999)
Chimpanzees (Bard, 2000)
Free-living Rhesus macaques (Barr et al,
2005)
5
Parental Responses to Infant
Chimp Distress
(Bard K, In Barr et al (eds
(eds)) 2000)
Evidence that the “Crying Curve”
Curve”
is a Behavioral Universal of Infancy
There is a similar pattern and timing in:
1. All samples of Western infants
2. Cultures with radically different
caregiving styles
3. Prematures
4. A wide variety of human infant
biological & behavioral functions
5. Non-human species
What is colic?
Defining features
Unsoothable Crying Bouts
in London, Copenhagen, and with a “proximal”
proximal”
form of care
Infants with Bouts of Unsoothable Crying
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.
50%
London Community
45%
Copenhagen Community
Proximal Care
40%
35%
Percentage of Infants
during 2nd month).
bouts, unsoothability,
unsoothability, “pain facies”
facies”)
30%
25%
20%
15%
10%
5%
0%
10 days
Uniqueness of Unsoothable
Crying Bouts to Early Crying
Daily Unsoothable Cry
Minutes/day (mean + 1 SD)
40
Colic
30
Non-colic
20
By 5 months, the
mean amount of
unsoothable crying
is 1-3 minutes/day
in all infants.
Gustafson: Can we
hear the causes of
infant crying?
“He sounds just like a
porpoise”
Barr, Paterson et
al, JDBP, 2005
6 Weeks
12 weeks
The early cry is a graded
signal, not a typological
sign or signal
10
0
5 weeks
Age of Infants
In Barr, Hopkins, Green: Crying as
a Sign, a Symptom and a Signal,
London: MacKeith Press, 2000
5 Months
Age
6
“If you were a good mother,
you would…”
•
•
One is crying following a pain
stimulus, one crying before a feed.
Can you tell which is which?
Listen carefully to the cry and learn to
read what the cause of the crying is
so that you address the needs of your
baby…
Learn the right way to soothe your
infant so that s/he can be calmed and
not cry…
What is colic?
Defining features
during 2nd month).
These are due to changes in the amounts of crying
that cluster during the evening.
3. “Paroxysmal”
Paroxysmal” (unpredictable)
“Classic” colic: Paroxysmal
•
•
•
Unpredictable
Begins and ends apparently
unrelated to anything in the
environment
May begin or end “suddenly”
Basic Phenomenon in “Well behaved”
behaved”
Chaotic Systems: the Lorenz Attractor
Non-linear phase transitions
GAS
Temperature
LIQUID
SOLID
7
NonNon-linear Phase Transitions in
Behavioral Systems
NonNon-linear Phase Transitions in
Behavioral Systems
Concept of Infant Behavioral
States (Wolff, 1987)
The “Shape” of Non-linear
Transitions
Infant behavioral states
as a linear continuum of
“arousal”
Infant behavioral states
as distinct, nonlinear,
and discontinuous,
organizations of
behavior.
“Explaining”
Explaining” Prolonged Crying Bouts,
Resistance to Soothing and
Paroxysmal Crying Bouts
X1 =
soothing
attempt
while in
stable
state.
X2 =
soothing
attempt
while in
transitional
state
Summary re: “Paroxysmal”
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 “wellbehaved” non-linearly organized
behavioral systems.
8
“Colic:” a reconceptualization
Rather than thinking of colic as distinct,
distinct
qualitatively different,
different and due to
underlying pathophysiology or
pathopsychology…
pathopsychology
Perhaps we should think of it as continuous
with normal behavior, qualitatively
similar,
similar and due to infants acting as
they should,
should or were designed to, act.
“Colic” has a good outcome
There are 3 curves, not 1
Outcome of “colic” in Infants
(Lehtonen, Gormally and Barr, 2000)
•
•
•
•
•
•
•
Wt. Gain delay
Allergy
Crying
Behavior disturbance
Temperament difficult
Sleep problems
Negative reactivity
Transient
None
Much reduced
None
None
None
None
Wessel’s
criteria
1
2
3
4
5
Persistent motherinfant distress
syndrome
(Papousek et al)
#2
“Difficult”
infant
Wessel’s
criteria
#1
Wessel’s
criteria
#3
1
2
3
4
5
1
2
3
4
5
9
Clifford et al: Sequelae of
Infant Colic
Persistent motherinfant distress
syndrome
Arch Pediatr Adolesc Med (2002) 156:1183156:1183-1188
•
•
•
Diaries at 6 weeks and 3 months of age
Modified Wessel’s criteria
Of those with colic at 6 weeks:
“Difficult”
infant
a. 86.3% did not have colic at 3 months:
13.7% still did (“persistent” colic)
•
6.4%
Wessel’s
criteria
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)
1
Although early increased
crying (‘
(‘colic’
colic’) has no long
term negative outcomes,
persistent or repeated elevated
crying after 3-4 months does
have longlong-term predictability
to later poorer outcomes
Typical Assumption:
Colic is an abnormality,
or “something wrong” with the
infant
2
3
4
5
Longterm Effects of “Post”
Post”
Curve Crying
•
Papousek, Wurmser, von Hofacker: Clinical perspectives on
unexplained early crying: challenges and risks for infant mental
health and parentparent-infant relationships.
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 hyperactivity
problems in middle childhood. Pediatrics 2002: 109(6):1054-1060.
Rao MR, Brenner RA, Schisterman EF, Vik T, Mills JL: Long term
cognitive development in children with prolonged crying. Arch Dis
Child 2004:89:989-992.
•
Wake M, Morton-Allen E, Poulakis Z, Hiscock H, Gallagher S,
Oberklaid F: Prevalence, stability and outcomes of crycry-fuss and
sleep problems in the first 2 years of life: prospective communitybased study. Pediatrics 2006: 117:836-842.
The Argument Against
Pathology
Non-pathological mechanisms for primary
features:
a. Crying curve
b. Unsoothable crying bouts
c. Paroxysmal crying
Good outcome
a. For infants with classical colic (first 3-4
months)
b. Less good for infants with “post-curve”
persistent elevated crying
10
In Summary
Current Evidence-based
Assumption:
Colic and early increased
crying are normal,
and there is nothing wrong
with the infant
Increased Crying May Be
Adaptive
How Crying Signals May Have
Functioned in our Evolutionary Past
(after Bowlby)
Bowlby)
“Colic” is a manifestation of normal
behavioral development
“Colic” is the upper end of a continuum
of crying behavior in normal infants
(like height: some infants are taller and
some are shorter)
“Colic” is not an indication of disease in
the infant.
The PeriodFRCPC
of PURPLE2009
Crying is a registered
© Ronald G. Barr, MDCM,
trademark and all content is copyright protected.
All rights reserved, Ronald G. Barr, MDCM and the National Center on Shaken Baby Syndrome (2004-2008)
Increased Crying May Be
Adaptive:
1. They contribute to survival
2. They have the properties of an
“honest signal”
signal”
Cry as a Stimulus for Milk
Letdown (after Lind et al)
11
Cry-Feed Relationship Among
!Kung San (Konner)
Konner)
Crying promotes mothermotherinfant attachment and
“bonding”
bonding”
Probability of
nursing
following
cry/fret in
!Kung San
infants, from
direct
observations
Percentage
Thanks to Pilyoung Kim and
colleagues (James Swain, Gary Evans)
Months of age
The limbiclimbic-hypothalamichypothalamic-midbrain circuits called
‘Maternal Circuits’
Circuits’ overlap with the
mesocorticolimbic dopaminargic reward pathways.
pathways.
Swain et al. (2007)
30 sec
Other
Baby
Noise
Rest
Own
Baby
Noise
Rest
30 sec
Rest
30 sec
Rest
Rest
10 sec
Other
Baby
Cry
Insula
Substantia nigra
Own baby
DLPFC
30 sec
Periaqueductal Gray
Febo, Numan, Ferris, 2005
Breastfeeding mothers had greater activations in the mesocorticolimbic reward circuit in response to own in response to own baby cry at 2
at 2‐4 weeks postpartum. Mothers were exposed to cries and pictures of their Mothers were exposed to cries and
own and others’
own and others’ babies.
Own
Baby
Cry
Rodent mothers have greater activations in the reward circuits while nursing. Other baby
Amygdala
Precuneus
Also, hypothalamus, VTA, OFC, Putamen
p<.05, corrected
12
Breastfeeding mothers had greater activations in the mesocorticolimbic reward circuit in response to own baby cry at 3‐4 months postpartum.
Thalamus
Substantia nigra
DL Prefrontal Cortex
Precuneus
Insula
Head of Caudate
Posterior Cingulate
Amygdala
Substantia Nigra
p<.05, corrected
Crying Levels and “Affective”
Affective”
Caregiver Responses (Acebo & Thoman)
Thoman)
Prefrontal Corex
Higher levels of
crying are
associated with
increased levels of
positive interaction
Insula
Also, OFC, VTA, Putamen, fusiform gyrus, precuneus
p<.05, corrected
Caudate
Thalamus
Visual Cortex
Differences in brain responses to own baby picture in brain responses to own baby picture among two groups decrease at 3‐
among two groups decrease at 3‐4 months postpartum became smaller
. became smaller. Anterior Cingulate
Breastfeeding mothers had greater activations in the mesocorticolimbic reward circuit in response to own in response to own baby pictures at 2
at 2‐4 weeks postpartum.
p<.05, corrected
“Modeling” Adaptive Value of Cry
Functions: Cry-Feed 1st Pathway
Even the highest
levels of crying are
associated with
more positive
interaction than the
lowest levels of
crying
“Modeling”
Modeling” Adaptive Value of Cry
Functions: CryCry-Attachment
13
Summary: the “good”
• Early crying may be
advantageous for survival
Some clinical implications
of the normality of early
increased crying
Soltis J (2004) “The signal functions of
early infant crying” Beh & Brain
Sciences, 27(4): 443-458
Barr RG (2004) “Infant crying as a
behavioral state rather than a signal”
BBS 27(4), 460
For the parent: Scott the
High Crier--Marilyn’s Story
Clinical Implications
•
Stopped
breastfeeding;
start
Similac
Vitamins
Goat’s milk—success!
Crying
started to
increase
If you do not take the curve into account,
therapeutic interventions can be
misinterpreted as effective when they are
not effective, or ineffective when they are
effective
Change to soy
1
2
3
4
5
Months of age
“False positive” effective
•
Wessel’s
criteria
“False negative”
ineffective
1
2
3
4
•
If you do not take the curve into account,
therapeutic interventions can be
misinterpreted as effective when the are
not effective, or ineffective when they are
effective
ALL infants experience the curve, and
“organic causes” only move the infant
“up” within the range of crying
5
14
New York
Times
July 8, 1944
“…who admitted
that he had killed
his 31/2 week old
daughter because
she cried too
much…”
Wessel’s
criteria
1
2
3
4
5
Intracranial “Cascade”
Cascade” from Shaking
The Shaking
•
•
•
Weak Neck
Muscles
Normal Large
Head to Body
ratio
Violent,
sustained
shaking
Mechanical Stresses During
Shaking & Eye Lesions
Outcomes of Hospitalized
Cases
•
•
20-35% die
Of the survivors, 65-80% have
significant long term neurological
and developmental abnormalities
15
Questionnaire Study of
Soothing Methods in Holland
van der Wal et al, Arch Dis Child, 1998
Why is crying in normal infants
relevant to Shaken Baby
Syndrome?
Techniques used to soothe infants:
1. Smother
2. Slap
3. Shake
2%
3%
5%
Runyan.The
Runyan.The challenges of assessing the
incidence of inflicted traumatic brain injury: A
world perspective.
The “crying curve”
(Brazelton, 1962)
Amer J Prev Med 2008;34 (4S)
“The impact of
these private acts
must be further
studied as there
may be other longlasting and
serious
intracranial
impacts that have
not been
characterized.”
Hypothesis: IF crying was a
significant stimulus for sbs,
THEN the pattern of agerelated incidence of sbs should
be similar to the age-related
properties of the crying curve
AgeAge-specific incidence of
hospitalized cases of SBS
AgeAge-specific Incidence of
PubliclyPublicly-reported Cases of SBS
(Barr, Trent et al Child Abuse & Neglect 2006)
(Lee, Barr et al JDBP 2007)
50
120
45
40
100
30
80
25
No. of C ases
No. of cases
35
20
15
60
40
10
5
20
0
0
8
16
24
32
40
48
56
64
72
80
0
0-4
5-8
9-12 13-16 17-20 21-24 25-28 29-32 33-36 37-40 41-44 45-48 49-52 53-56 57-60 61-64 65-68 69-72 73-76 77-80
Age (weeks)
Baby's Age (weeks)
Crying Stimuli (n=166)
All Stimuli (n=591)
16
Curves of Early Crying and
SBS Incidence
Sheets L et al.:
Sentinel injuries
precede abusive
head trauma in
infants
Lag
Cry Curve
SBS Curve
Onset
Presented Helfer Society,
Sept 2008, Tucson, AZ
1
2
3
4
Months of Age
5
Used with permission from L. Sheets
The Pathways to Prevention:
Pathways to Shaking
Appropriateness
of Advice
Shaking
Threshold
Threshold
Appropriate
Accurate
Advice
Frustration ……….Anger
Crying
Crying
The Pathways to Shaking:
Wrong Advice?
Inaccurate
Inappropriate
Wrong
Advice
The Period of PURPLE
Crying
Shaking
Threshold
Crying
•Must not result in
more harm than good
Shaking
P
U
R
P
L
Peak of Crying
E
Evening
Unexpected
Resists Soothing
PainPain-like Face
Long Lasting
17
Five Things We Think We Know
•
•
•
•
•
The “crying curve” (and “colic”) is a behavioral
universal of infancy
Unsoothable bouts are unsoothable!
Post-curve, persistent or repeated elevated
crying after 3-4 months is an important, but
different, phenomenon, and has long-term
predictability to later outcomes;
The early cry is a graded signal, not a
typological sign or signal
The most important negative clinical
consequence of “colic” for the infant is shaken
baby syndrome or infant abuse
How Do “Increasing
Carry, Comfort, Walk
and Talk
Responses” Work?
Increasing
contact
reduces
distress
Fuss
F
CrossCross-species Caregiving and
Breastmilk Composition
But it does
not reduce
inconsolable
crying
Cry
Inconsolable Cry
C
Infants with Colic
in London, Copenhagen, and with a
“proximal”
proximal” form of care
Infants with "Colic"
A counter-example
or an explainable
variant?
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.
*
16%
London Community
Copenhagen Community
Proximal Care
Percentage of Infants
14%
12%
10%
8%
6%
4%
2%
0%
10 days
* denotes χ
2
test where p < 0.001
BlurtonJones
50% less
18%
Both Jack and I
thank you
5 weeks
Age of Infants
12 weeks
Reconceptualization of “Colic:”
Colic:”
Colic is a manifestation of normal
behavioral development
All 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
developing infants rather than a distinct
crying pattern indicative of underlying
disease in the infant or psychopathology
in the caregiver(s).
18
Moderate Retinal Hemorrhage in
Shaken Baby Syndrome
Courtesy Alex Levin, MD
Guinea Pig Distress as a Function of
“Place”
Place” & Mother Presence (Pettijohn 1979)
Levels of
Description
of Crying
Cycles
Coded State Changes between
Crying and Alert
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
!Kung San Hunters
(Courtesy Marjorie Shostak)
Shostak)
Events
Bouts
N-shaped curves in habituation to
visual stimuli
19
Is there an “early crying peak”
peak” in freefreeranging Rhesus macaques?
Time Spent in
“Crying”
Crying” or “Alert”
Alert”
States or “In
transition”
transition”
(Barr, Warfield, Catherine SRCD Apr 9, 2005)
Rate Distress Vocalizations (dv/hr)
35
Mean
Frequency histograms of %
negative vocalizations in
10-second blocks, prior to
(upper graph) and following
(lower graph) taste
administrations.
30
Median
25
20
15
10
Negative Vocalizations:
5
Crying = 100%
0
0-6
7-12
13-18
19-24
25-30
31-36
Alert = 0%
37-42
Age (Weeks)
Barr, Beek &
Calinoiu, 1999
Transition = 10-90%
Is there a "curve"?
Methodological Caveat for
Measuring Curves
You must make enough measurements at
the right times to capture the properties
of the phenomenon you are measuring.
Brazelton
160
Minutes/day Distress
Principle:
180
140
Green
diamonds
includes
St J-R
(1999)
120
100
80
60
“6 weeks of
age” is week
7 of life
40
20
Recording Week
w
11
w
12
w
9
w1
0
w8
w7
w
5
w
6
w
3
w
4
w2
w1
0
Symposium
organized by M.
Alvarez, Stockholm
20

The Phenomena of Early Infant Crying and Colic The Phenomena of

Transcription

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