We all know babies cry but dreams of new parenthood don’t usually envisage a seemingly inconsolable, bawling, ball of infant fury.
It’s hard not to take it personally if your baby seems impervious to all your attempts at pacification. To be told he or she will “grow out of it” is of little consolation when those cries are shredding the last of your reserves during what is, even with the sunniest baby, a physically and emotionally demanding time.
Excessive crying affects roughly up to one in four babies, primarily in the first three months and peaking at the age of about six weeks. Known as “colic”, in reality that term covers a multitude and is simply defined by the level of crying in an otherwise healthy infant – at least three hours a day, for more than three days a week, for three weeks.
Anecdotally, it appears that “reflux” has now replaced “colic” as the most common explanation in some circles for this enigmatic infant behaviour.
It is a subject of particular interest to osteopath Dr Julie Ellwood in Strandhill, Co Sligo, whose ongoing research into its causes and consequences has led her to question the notion of trying to "fix" the unsettled baby.
No health practitioner, be it an osteopath, a chiropractor, a GP, a paediatrician, or whoever, has “the fix”, she says, “because if we did, there wouldn’t be all these unsettled babies”. The reasons for persistent crying are complex and “if we can get our heads together and look at both the mother and the baby, we have a better chance of getting to the bottom of it”, she suggests in a call for a more co-ordinated approach to the problem among all professionals working in paediatric care.
Both she and the Royal College of Surgeons in Ireland (RCSI) Professor of Paediatrics, Alf Nicholson, who is based at Temple Street Children's University Hospital in Dublin and who has supervised her research, stress how serious colic can be, primarily because of how onerous it is for parents.
Parental stress
“The stress of caring for an inconsolable infant may trigger physical abuse, such as that seen in shaken baby syndrome, where crying is often mentioned as a precipitant,” says Ellwood. Also, parental perceptions that an infant is more difficult than average have been shown to be a strong predictor of later behavioural and emotional problems for that child.
Nicholson, who says he is fascinated by colic “because it is so difficult to explain, it is unique to that early part of life”, describes it as “a huge burden” for parents.
“It’s simplistic to say it is due to reflux, it is simplistic to say it’s due to a windy gut, it’s simplistic to say it’s related to lactose intolerance.” Although he has seen how, for very distressed, colicky babies, the exclusion of cow’s milk protein from the mother if she is breastfeeding, and from the baby’s milk if bottle feeding, can have a dramatic, positive impact. But he estimates only 5-10 per cent of all colicky babies are in that category.
Likewise, while 50 per cent of babies have reflux, the majority just spit up milk and few are so severe as to have acid coming up that makes them uncomfortable. So he dismisses the idea that babies who are colicky have “silent reflux”, although he knows some doctors give this diagnosis when “they are desperately trying to explain the symptom and offer some support and help in terms of medication”.
In fairness, he says, giving a baby medication to reduce acid production sometimes settles them a little bit, “but you are not dealing with the primary problem”.
“My simplistic idea of colic,” he says, “is that it is all to do with a baby’s temperament, which is basically personality, the mother’s personality and her ability.” These factors are interlinked with the environment she and the infant are in – in terms of family support and friends – at what is a very emotional and difficult time for a mother, he stresses.
His advice to GPs is to never ignore or downplay parental concern about colic, to examine the baby very carefully and make sure they don’t have a temperature, and then be very careful about prescribing.
“There is a temptation to go on a rollercoaster ride of changing milk formula, or loads of medication in an attempt to calm the baby down, and I think that is a bit foolhardy.”
Due to the enigmatic nature of the condition, he sees it as an area where mainstream medicine and complementary therapies merge.
Earlier this year, Ellwood became the first doctoral graduate from the British School of Osteopathy in London. Her PhD thesis involved researching potential links between musculo-skeletal discomfort in babies and unsettled infant behaviour.
Although the study did not establish a link in babies aged 12-16 weeks, it is possible that the measurement scales used to assess musculo-skeletal dysfunction and unsettled infant behaviour, although previously validated, were not appropriate to detect an association. It doesn’t mean that none exists, she says.
After an extensive review of literature on unsettled infants, Ellwood has been struck how, despite half a century of research, there are no definitive answers. She believes the importance of patient preference for treatment type (eg natural approach versus medication), placebo effects and the practitioner-patient relationship should not be underestimated.
Fourth trimester
The study also highlighted for Ellwood the significance of the so-called “fourth trimester”, during which the phenomenon of colic occurs.
“I found it was really important to appreciate that infant-mother dyad during that time and that transition to motherhood.”
There are various anthropological theories about why human babies are born so helpless compared with other mammals (a foal is on its feet within an hour of being born, for instance) and with so much more brain development still to be done.
One theory is that when our primitive ancestors evolved to being upright, the woman’s pelvis became narrower, so a larger head would not fit through the birth canal. It has also been suggested that the length of gestation has in fact been determined by the ability of a woman’s metabolic system to sustain it.
Whatever the biological reasons, a normal pregnancy lasts between 37 and 42 weeks and is generally viewed through trimesters. But what about the first three months outside the womb? Regarding it as a fourth trimester could be really helpful for both mother and baby – only one of whom knows at that stage that they are now separate beings.
The concept of the fourth trimester was popularised by Harvey Karp, an assistant professor of paediatrics at the University of Southern California, when he wrote the book The Happiest Baby on the Block in 2003. To calm crying babies, he advocated ways to try to simulate the womb experiences, known as the "five Ss" – swaddling, side or stomach position, shush, swing and suck.
"There is no doubt that the baby who is treated for the first three months on the outside as if they were on the inside, just enjoy that experience," says Sue Jameson, a lactation consultant and spokeswoman for Cuidiú, a peer support organisation for all parents. When parents can read their babies' cues and meet their needs, things will go smoother.
“Instead of trying to making the baby fit life, if we fashion life around the baby for the early weeks and months, it does make it easier,” she explains.
Bonding time
This is why the pressure some mothers feel to revert quickly to their pre-pregnancy shape and lifestyle doesn’t help. Instead they need support from their partner, family and friends to give them vital bonding time with the newborn and do little else, to ease that transition from the womb to the world.
When Jameson is working with mothers with troubled infants, she often recommends that they simply take to the bed together.
“It is amazing what can be fixed by a bit of warm and calm,” she says. “If there really is something wrong, we can investigate it, but I think we have to look to the ‘bleedin obvious’ first.”
When Ellwood sees a mother come into her at the BabyBloom Mother and Child Clinic in Strandhill with a four-week-old baby and she has her Shellac nails on, she does wonder how she is changing a nappy.
“There is this tangle they are in, in trying to maintain the person they used to be and also be the perfect mother – and they don’t match.”
About 90 per of the clients Ellwood sees are unsettled babies and during the initial one-hour consultation she tries to give the often over-whelmed and exhausted mother confidence in her parenting. While there are plenty of important osteopathic issues to look out for, Ellwood believes that imparting simple advice during the consultation, such as "it's okay to lie for three hours with your baby on your chest watching Judge Judy", can be key to helping settle a baby.
“People are always treating the baby, giving the baby medicine, changing baby’s feeds and I began to realise that the difference was once they came into the osteopathic clinic, they had the one-hour consultation where the mother got to tell her story,” she says. “I started to question was the problem actually in the baby or was it more of this transition to motherhood that was the difficulty.”
Massage classes
Up to two years ago, mothers coming to Helen Plass’s baby massage classes in north Co Dublin talked about “colic” in relation to unsettled babies. “Now it seems that everybody has ‘reflux’,” she says.
It is one of those things that there is no answer to, she acknowledges, but she has no doubt that baby massage can help in calming the nervous system and increasing secure attachment through non-verbal communication.
Plass always reminds clients of the environment babies come from – they were curled up, in a warm and wet environment, listening to muffled sounds, being continuously rocked and all their needs were being met. She recommends swaddling, babywearing and plenty of skin-to-skin contact.
“All they want is to be held and close to you for those first months,” says Plass of mumandbaby.ie, who also has personal experience of unsettled infant behaviour. The first of her two boys, who are now aged five and six, was discovered to have transient lactose intolerance. “He didn’t have the enzyme lactase for the first 12 weeks,” she says.
“That was an absolute nightmare. After every feed he would pull his legs up and be screaming and it was much worse in the evenings because of the build-up of gas in his body. His poos were pure froth. That was incredibly challenging.”
As she had trained as a baby massage instructor during her pregnancy, “I could help him to an extent but I couldn’t put lactase into his body to break down lactose.” He grew out of it and all was fine after those first three months.
The notion of a “fourth trimester” might sound a bit “alternative” to some, so does Nicholson as a paediatrician buy into the concept?
“I think I do,” he says. “The fourth trimester is the first three months of your baby’s life that are absolutely critical.
“Some babies do need a lot more emotional attachment than others. They want to be close to their mother, they want to be constantly held, they want to be consoled and comforted and almost feel that heartbeat that they felt in the nine months in the first, second and third trimester.”
swayman@irishtimes.com
