Posted tagged ‘crying’

What really works to treat infant colic?

April 17, 2014

The Pediatric Insider

© 2014 Roy Benaroch, MD

Colic is not fun.

You’ve got your little wee baby home, and you’re exhausted. Just when you need some rest the most, Junior cries. And cries, and cries. And nothing seems to help for more than a few moments.

Colic has a medical definition, sometimes called “Wessel’s criteria”: inconsolable crying in an infant less than three months of age, for at least three hours a day, for at least three days a week, for three weeks or more. I doubt many practicing pediatricians or parents rely on all of those “threes.” We use a simpler definition: lots of crying in a baby who we’d hope would cry less.

Babies cry. And that’s the catch, here. They all cry. They don’t have much else they can say. And they’re overwhelmed by all of the changes they’re experiencing, and they haven’t yet learned how to transition from wakefulness to sleep. And some of them don’t like the feeling of rumbly gas in their tummies. And some are scared of their little baby farts. And some of them have parents who are exhausted and strung out and depressed. Honestly, I’m surprised more of them don’t cry all of the time.

But the crying, it can really wear parents down. So all sorts of things have been tried to help soothe crying babies. The latest hip idea (for colic, and almost everything else) is probiotic supplements. These are oral powders that are made of billions of healthy bacteria meant to populate a baby’s gut to help digestion. There’s a lot of research into the “gut biome” and the effect of gut bacteria on the health, specifically relating to digestion and abdominal pain and allergy. Why not toss these at colicky babies, see what helps?

Some studies have shown good promise. Just last month, a study of 589 infants in Italy compared babies given probiotics versus placebo, and found that the babies on a probiotic L reuteri supplement cried for fewer minutes each day (38 versus 71 minutes, on average.) This study looked essentially at the prevention of colic, by giving probiotic supplements to babies whether they had excessive crying or not.

However, the most recent study, a controlled trial of the same probiotic supplement given to colicky babies, showed no effect on any important outcome. The babies, whether given probiotics or not, cried about the same.

Still, there is some good news in common between the studies. The babies, when followed over time, all experienced decreased crying. In other words, colic improved in all groups, whether or not probiotics were given. Also, there we no side effects observed in the probiotic groups. They’re safe, even if they don’t work.

So what does and doesn’t work to help decrease infant crying?

Medicines, universally, don’t seem to work. This includes simethicone (widely available as “Mylicon”, an OTC “gas reliever.”) Studies of medications that reduce acid have also failed to show any effectiveness in improving infant fussiness or crying.

For nursing moms, dietary changes seem to help sometimes—specifically, eliminating dairy consumption. However, this is effective <50% of the time, and you have to weigh a trial of no-dairy-intake versus the effect this has on mom. She needs to be able to eat. Eliminating dairy is difficult (but not impossible)—but eliminating all of the foods possibly implicated in infant crying would be ridiculous. What’s mom supposed to eat, rocks and water? Besides, I don’t like pinning the blame for an upset baby on Mom.

For bottle-feeding families, using a hydrolyzed (hypoallergenic) infant formula has some mixed support from studies. It may be worth a try. What’s unlikely to really help, though, is the endless parade of changing formulas based on manufacturer claims that some are “soothing” or some help in other vague ways.

An insider pro tip I’m not supposed to tell you: As a pediatrician, I can suggest countless alternative formulas for you to try. There are enough alternatives that I can keep changing formulas once a week for at least a few months. By then, baby colic improves. So you’ll think I was smart to finally find the right formula, when in reality I was just changing formula once a week until your baby was going to get better anyway!

So what works best? First, colicky babies need a good, thorough evaluation to make sure that there isn’t a medical problem going on that needs to be addressed. Sometimes that takes more than one visit, and sometimes, if things aren’t going as expected, we have to revisit and re-assess.

But as long as there isn’t a medical issue contributing to the crying, the most important interventions are reassurance, education, and social support. Reassurance that colic does get better, education about safe soothing techniques and signs to look out for, and social support so exhausted parents can get a break once in a while. If parents want to try some safe interventions, that’s fine. But colic isn’t necessarily a medical problem that needs probiotics, diet changes, or medicine. Sometimes, babies just need to cry.

Cry-it-out sleep solutions: Harms versus benefits

September 17, 2012

The Pediatric Insider

© 2012 Roy Benaroch, MD

There seem to be two views percolating about the best way to get a baby to sleep through the night. As is typical of opinions these days, both sides paint the other as extreme by exaggeration:

In this corner! The Cry-It-Out Mama! She puts her child down, and she never goes back! Junior cries his little heart out while she sips martinis and laughs!

 And in the opposite corner! Ms. Crunchy Berries wouldn’t dream of letting a single tear touch her precious’ pillow!

In truth, rare is it that a parent is going to completely ignore—indefinitely—crying. And even the moms who favor an attachment-oriented parenting style are going to put up with tears once a while. Most parents aren’t looking for an all-or-nothing approach. What they do want, though, is a way to help their babies learn to sleep through the night in a way that’s safe and effective.

Which brings us to a recent study from Australia, with the wordy title: “Five-year Follow-up of Harms and Benefits of Behavioral Infant Sleep Interventions: Randomized Trial.” It’s been widely and incorrectly reported that this study supports letting babies cry themselves to sleep, which is a typical media oversimplification of a complex issue. Still, what it does show is reassuring.

The study looked at outcomes 5 years after two original studies looking at the same groups of kids. Initially, 328 families of children who were reported as having sleep problems at 7 months of age were randomized into two groups to look at two different ways of helping children sleep independently. About half of the families received special sessions with trained nurses specifically to discuss sleeping skills. They were taught specifically about two behavioral techniques, and were encouraged to choose one of these methods (or combine the two):

Camping out (also called “adult fading”): This entails staying with a baby as he falls asleep, then later sneaking out. Over time, parents gradually get further away from the baby at bedtime.

Controlled comforting (also called “Ferberizing” or “Gradual Extinction”): Parents leave their baby alone at bedtime, and visit for comforting at fixed intervals if crying continues. The time until the next visit is gradually increased.

So, within the study group, presumably some of the parents camped out, and some Ferberized. Neither group was encouraged to use the “cold turkey” method, which is what I think of as “crying it out.”

The control group wasn’t specifically assigned to any sleep teaching. These families were assumed to continue doing whatever they had been doing—which wasn’t explored or recorded. Parents in the control group could ask for sleep advice (and presumably some of them did), but they weren’t given sleep advice if they didn’t ask.

Previous publications by the same researchers looked at the outcomes of these same children at 12 and 24 months, finding encouraging trends: parents given either kind of sleep advice were more likely to have children with successful sleep habits, and less likely to have depression. The purpose of this new publication was to re-examine the two groups of children five years later, specifically to see if there was any evidence of harm to the children or their parents.

At age six, 225 of the original 326 children participated. They underwent a series of validated screens for a series of emotional and behavior problems, sleep issues, psychosocial quality of life, stress, child-parent relationships, parenting styles, and maternal depression, anxiety, and stress—really, quite a slew of tests. They also had most of the families collect saliva to test for cortisol, a marker of stress. In every measure, children from the control and study groups were the same—there was no objective evidence of any difference, positive or negative, in the physical or emotional health of any of the children or parents.

So: specific counseling about behavioral techniques to help 7 month old babies learn to sleep on their own has benefits. Whether geared towards “camping out” or “Ferberizing”, babies whose parents had counseling have a better chance of helping their children learn to sleep than parents who muddle through on their own. At the same time, parents can be reassured that both of these sleep training styles don’t seem to cause any harm to the child or family 1, 2, and 5 years later.

A good night’s sleep is a blessing for babies and parents alike. Many babies learn to do this quite well, on their own, without much parental coaching or encouragement. Many parents find their own sleep solutions, and if whatever-you’re-doing is working for you, that’s great. What this study adds is reassurance that at least two commonly taught behavioral sleep-teaching styles are safe and effective. If your baby isn’t sleeping well, one of them might just work for you.