This chapter is divided into four main sections. First, a detailed description of what is known about extreme fussiness/ colic and its relation to difficulties in sleeping during the first three to four months; second, what is temperament; third, how the fussiness/crying during months three to four is connected to temperament at four months of age; and fourth, postcolic. I also present data that connects these two ages and tells you how likely it is that your baby will develop on one path or another. You can skip the data if your child already has or had colic and go directly to the management sections or the summary and action plan if you just want to figure out what to do.
The section on postcolic is crucial to help prevent or solve any sleep problems in 20 percent of children.
Introduction
If your child suffered from colic during infancy—and 20 percent of all babies suffer from this mysterious condition—then you'll be most interested in learning how your child's colicky first months could have set the stage for unhealthy sleep habits and turned him into a “crybaby.” This chapter will be of interest to you even if your baby never had colic, though, because all babies experience unexplained fussiness and crying in their first weeks of life, no matter what your ethnic group, no matter what birthing method brought your child into the world, no matter if your lifestyle is that of jet-setter or stay-at-home.
All parents, too, tend to use the same techniques and strategies to successfully weather those first few months of life with baby, whether it's fair sailing for the most part or they feel storm-tossed by colicky waves of crying. Sleep problems arise when some parents don't change their techniques for coping with crying and fussiness at bedtimes and nap times after about three to four months of age, after their babies have become more settled. That's when unhealthy sleep habits and their resulting problems begin.
Sleep and Extreme Fussiness/Colic
For 20 percent of babies, I actually prefer the term “extreme fussiness/colic” instead of colic because fussiness is a bigger problem than crying. All babies have some fussing and crying, and for 80 percent of babies, I call this behavior common fussiness/crying. My idea is that extreme fussiness/colic is a sleep disorder. I also suggest that postcolic sleep problems occur after three to four months of age because some parents experience difficulty in establishing age-appropriate sleep routines. Let us look at the facts.
What Is Extreme Fussiness/Colic?
Dr. Wessel defined a colicky infant as “one who, otherwise healthy and well fed, had paroxysms of irritability, fussing or crying lasting for a total of more than three hours a day and occurring on more than three days in any one week … and that the paroxysms continued to recur for more than three weeks.” He added the criterion “more than three weeks” because nannies left families after about three weeks of crying. He thought nannies knew that if babies cried for more than three weeks, then the crying would continue. Because the mothers were now alone at night caring for their babies, they came to his office after three weeks complaining that their children were always crying. About 26 percent of infants in his study had colic. Dr. Illingworth defined colic as “violent rhythmical, screaming attacks which did not stop when the infants were picked up, and for which no cause, such as underfeeding, could be found.” Together, they studied about 150 infants.
The age of onset of these behaviors is characteristic. Both Dr. Wessel and Dr. Illingworth found that the attacks were absent during the first few days but were present in 80 percent of affected infants by two weeks and in about 100 percent by three weeks. Premature babies also start their attacks shortly after the expected due date, independent of their gestational age at birth. The time of day when these behaviors occur is another characteristic. During the first month, crying appears at any time of the day or night, but later it occurs predominantly in the evening hours. In 80 percent of infants, the attacks start between 5:00 and 8:00 P.M. and end by midnight. For 12 percent of infants, the attacks start between 7:00 and 10:00 P.M. and end by 2:00 A.M. In only 8 percent, the attacks are distributed anytime throughout the day and night. The age of termination of these spells is also characteristic. The attacks disappear by two months of age in 50 percent of infants, by three months of age in 30 percent, and four months of age in 10 percent of infants. The infant's behavioral state is associated with colicky behavior. Among 84 percent of colicky infants, the crying spells begin when they are awake, 8 percent have spells start when asleep, and 8 percent under variable conditions. For 83 percent of infants, when the crying spells end, they fall asleep. It is now known that fussing as opposed to crying is the major feature of colicky behavior, and parental distress over colic may be the major factor in producing postcolic sleep problems.
What Causes Extreme Fussiness/Colic?
A recent study showed that colicky infants had higher levels of serotonin, a chemical found in the brain and in the gut. This supported Linda Weissbluth's theory that some features of colic might be caused by an imbalance between serotonin and melatonin, another chemical found in the brain and in the gut. Concentrations of serotonin are high and present in infants during the first month of life and decline after three months. Immediately after delivery, concentrations of serotonin are higher at night and lower during the day. Melatonin, flowing across the placenta from the mother, causes high concentrations immediately after birth, but they rapidly fall to extremely low levels within several days. Melatonin increases slightly between one and three months, and only after three months is there an abrupt increase in melatonin levels with higher levels at night and lower levels during the day.
Serotonin and melatonin have opposite effects on the muscle around the gut—serotonin causes contraction, melatonin causes relaxation. Linda Weissbluth's theory is that in some infants, high serotonin levels cause painful gastrointestinal cramps in the evening when serotonin concentrations are at the highest. The high nighttime melatonin levels opposes the intestinal smooth muscle contraction caused by serotonin. On the other hand, melatonin and serotonin might be directly affecting the developing brain. For example, high levels of melatonin at night might cause night sleep to become longer.
Other hormones might be involved. In one study, extremely fussy/colicky infants had a blunted rhythm in cortisol production while the control infants exhibited a clear and marked daily rhythm in cortisol that was not observed in the colicky infants. In addition, researchers in this study coded behavioral measures from videotapes and arrived at the same conclusion as have many other studies: The crying of these infants was not due to differences in handling by the mother; the colic was not simply a maternal perception.
Other studies have clearly shown that food hypersensitivity, gastroesophageal reflux, maternal anxiety, and so forth are not linked to infantile colic.
Crying
Some degree of irritability, fussing, or crying is universal—that is, crying for “unknown reasons” occurs in all babies. Dr. Brazelton reported that half of all babies cry for one and three quarter hours during the second week with a gradual increase to two and three quarter hours at six weeks, followed by a decrease in crying thereafter to one hour or less by twelve weeks of age. He called the fussiest infants “colicky.” They cried two to four hours per day every day, and their crying also increased between six and eight weeks of age.
The distress caused to parents because of their inability to deal with this crying cannot be overstated. Recent government data has shown infant homicides to increase after the second week and peak at the eighth week, and the researchers concluded that the “peak in risk in week eight might reflect the peak in the daily duration of crying among normal infants between weeks six and eight.”
There are no clear cut-off points in measurements of irritability, fussing, or crying, whether by direct observation in hospital nurseries, voice-activated tape recordings in homes, or parent diaries. Thus, extreme fussiness/colic appears to represent an extreme amount of normally occurring, unexplained fussing or crying that is present in all healthy babies.
/> Because the spells of irritability, fussing, or crying are universal, differing only in degree among infants; because the occurrence of spells peaks at forty-six weeks after conception and independent of parenting practices; and because the behaviors exhibit behavioral state specificity and a day-night rhythm, it is reasonable to believe that these behaviors reflect normal biological processes. One example is the normal biological process involving the development of wake/sleep control mechanisms. In all babies, the consolidation of night sleep develops during the second month (after the peak of crying occurs) and that periodic alternation of wake and sleep states is well developed by three to four months of age (when colic ends).
Fussing
Persistent low-intensity fussing, rather than intense crying, characterizes infants diagnosed as having colic. In fact, to emphasize fussiness instead of crying, the title of Dr. Wessel's paper was “Paroxysmal fussing in infants sometimes called ‘colic’” Fussing is not a well-defined behavior, and although not defined in Wessel's paper, it is usually described as an unsettled, agitated, wakeful state that would lead to crying if ignored by parents. Because sucking is soothing to infants, some parents misattribute the “fussing” state to hunger and vigorously attempt to feed their baby. These parents may misinterpret their infants as having a “growth spurt” at six weeks because they were “hungry” all the time, especially in the evening. They view their child as hungry, not fussy. Even if they spend more than three additional hours a day, more than three days a week, for more than three weeks “feeding” them at night to prevent crying, these parents do not think their baby is colicky because there is so little crying. Over a thirty-four-month period, at newborn visits, I routinely questioned every new parent who joins my general pediatric practice whether their child fulfilled Dr. Wessel's exact diagnostic criteria for colic. All families had been followed since the child's birth and received counseling regarding the normal development of crying or fussing. There were 118 extremely fussy/colicky infants out of 747 (16 percent). However, the vast majority of infants had little or no crying. Instead, they fulfilled Dr. Wessel's criteria because they had long and frequent bouts of fussing, which did not lead to crying because of‘intensive parental intervention.
Studies show that, between two to six weeks, there is an increase predominately in fussing, not crying. Furthermore, fussing and sleeping, but notably not crying, were found to be stable individual characteristics from six weeks to nine months of age. The amount of crying during the first three months did not predict crying behavior at nine months. Crying alone is not a prediction of sleep problems. Two separate and well-designed studies agree with Dr. St. James-Roberts that “high amounts of early crying do not make it highly probable that an infant will… have sleeping problems at nine months of age.”
Colic-Sleep
Dr. Kirjavainen asked parents to keep a daily diary and performed sleep recordings in the lab at night between 9:00 P.M. and 7:00 A.M. At about four and a half weeks, the total sleep time from the diary was significantly shorter in the colic group (12.7 versus 14.5 hours per day). The most dramatic decrease in sleep in the colicky babies occurred at night between 6:00 P.M. and 6:00 A.M. The diary data showed that by six months of age the extremely fussy/colicky infants slept slightly less than the noncolicky infants, but the group differences were small. The first sleep lab recording was performed when the infants were about nine weeks old. There were no differences in sleep characteristics between the groups in the night recordings. The second sleep lab recording was performed at about thirty weeks of age, and again, there were no differences in sleep characteristics between the infants formerly with and without extreme fussiness/colic.
Therefore, among infants with extreme fussiness/colic, parent diary data showed shorter total sleep times compared with the age-matched control group at four and a half weeks, but that by nine weeks there were no group differences in sleep lab data obtained during the night. Also, this report suggests that over time, between ages five and nine weeks, the sleep duration increased among extremely fussy/colicky infants. Based only on the sleep lab data, the authors concluded that infantile colic was not associated with a sleep disorder. However, Dr. Kirjavainen told me that the lab data was questionable because all children slept poorly in the lab setting.
Dr. St. James-Roberts used the term “persistent criers” to describe extremely fussy/colicky infants. At six weeks of age, the extremely fussy/colicky infants slept significantly less than non-colicky infants (12.5 versus 13.8 hours per day). There were no group differences regarding time spent awake or time spent feeding. Extremely fussy/colicky infants slept less throughout the twenty-four-hour diary record. The clearest group differences for sleep were during the day. In fact, there were no group differences regarding sleep at night. In addition, at night, there were no group differences for cry/fuss behavior. The clearest group differences for cry/fuss behavior were in the daytime. The groups were similar in the timing and duration of the infant's longest sleep period. This analysis of sleep cycle maturation led to the conclusion that the “chief difference between them lies in amounts of daytime fuss/crying and sleeping, rather than in the diurnal organization of sleep and waking behavior.” In addition, at six weeks of age, the less a baby slept, the more amounts of fuss/crying were observed. Because the authors observed no deficit in calm wakefulness, only sleeping, they felt that there was a specific trade-off between fuss/crying and sleep. In other words, more fuss/crying behavior reduced sleep time only, not calm wakeful time. The researchers concluded that persistent crying is associated with a sleeping deficit.
Another study of extremely fussy/colicky infants using sensors embedded within a mattress to continuously monitor body movements and respiratory patterns showed that at seven and thirteen weeks of age, they slept less than common fussy infants. The extremely fussy/colicky infants had more difficulty falling asleep, were more easily disturbed, and had less quiet, deep sleep.
At about eight weeks of age, it was noted that colicky infants slept significantly less (11.8 versus 14.0 hours per day). The colicky infants slept less during the day, evening, and night; however, the big difference in sleeping was during the nighttime. Again, crying more was associated with sleeping less. The authors concluded that extreme fussiness/colic might be associated with a disruption or delay in the establishment of the circadian rhythm of sleep/wake activity. At four months of age, my study showed that the average total sleep duration based on parental reports of forty-eight infants who had had extreme fussiness/colic, based on Dr. Wessel's exact definition, was 13.9 plus or minus 2.2 hours, much less than those with common fussiness/crying.
In my general pediatric practice, where all parents receive anticipatory advice regarding sleep hygiene at every visit, parents of extremely fussy/colicky infants describe a late development of early bedtimes, self-soothing to fall asleep at night, longer night sleep periods, fewer night wakings, and regular, longer naps compared to common fussy/crying infants. This suggests that while extreme fussiness/colic may be associated with a delay in maturation of sleep/wake control mechanisms, the data shows that by six, eight, and twelve months there are no differences in duration of night sleep between extreme fussiness/colic and common fussy/crying groups.
However, night waking has been reported to be more common following extreme fussiness/colic at four, eight, and twelve months. This might be interpreted as a persistent impairment of the learned ability to return to sleep unassisted during a naturally occurring nighttime arousal from sleep.
Colic-Wakefulness
Parents of extremely fussy/colicky infants often report that daytime sleep periods are extremely irregular and brief. Also, some parents of extremely fussy/colicky infants describe a dramatic increase in daytime wakefulness and sometimes a temporary but complete cessation of napping when their infants approach their peak fussiness at age six weeks. It has been suggested that, before three to four months of age, the period of inconsolability in the evening hours, when the infa
nt cannot sleep and cries, may reflect periods of high arousal similar to the circadian “forbidden zone.” In adults, the forbidden zone is a time period during which sleep onset and prolonged, consolidated, and restorative sleep states do not easily occur. In this context, it might be more appropriate to describe colic not as a disorder of impaired sleep but as a disorder of excessive wakefulness in the evening. This view is supported by recent sleep lab investigations showing that, in infants, a circadian forbidden zone does exist between 5:00 and 8:00 P.M.
Extreme Fussiness/Colic-Temperament
Temperament characteristics of mood, intensity, adaptability, and approach/withdrawal are related to one another, and infants who were described as negative in mood, intense, slowly adaptable, and withdrawing were diagnosed as having difficult temperaments because they were difficult for parents to manage. These infants were also observed to be irregular in all bodily functions. When parents performed a temperament assessment at two weeks of age and a twenty-four-hour behavior diary at six weeks of age, it was observed that more difficult temperaments at two weeks predicted more crying and fussing at six weeks. At four weeks of age, infants who were more difficult in general, more intense and less distractible (less consolable) in particular, cried more during their second month of life than other infants.
Healthy Sleep Habits, Happy Child Page 16