Pamela Douglas is a GP, academic and writer, with a particular interest in a subject close to many parents’ hearts: crying babies. In the article below, she says many parents and their babies are not getting the help they need.
Instead, they may be getting advice “flavoured by old ideologies popular throughout the second half of the 1900s, including simplistic, algorithmic approaches to infant sleep and feeding, which have no basis in evidence”.
At the bottom of the post are details of related articles that may be of interest.
Beyond the misery and the muddle: some useful advice
Pamela Douglas writes:
Crying: adjective 1. that cries; clamorous; wailing 2. demanding attention or remedy
Baby: noun 1. an infant; young child
Parents know that if you put these two words together for long enough, they often turn into a third word, misery: noun: 1. great distress of mind 2. a cause or source of wretchedness.
What can you do when the new little person in your world is fussing and fretting with feeds, awake and crying at nights, wailing clamorously, demanding attention hour after hour during the day and there appears to be no remedy?
Cry-fuss problems occur in one in five otherwise healthy babies in the first months of life, and usually disappear around 12 to 16 weeks without causing long-term problems.
But in the meantime, put together the two words “crying” and “baby,” and parents may soon be overwhelmed by stress and sleep deprivation, quarrels, and a gnawing sense of having somehow failed when they only ever wanted to be wonderful, loving, competent parents. Of course, they are wonderful, loving, competent parents but the baby isn’t giving them much positive feedback!
If there’s one thing that health professionals agree on when it comes to unsettled babies, it’s that it can be very difficult for parents to find the help they need.
In 2009, a comprehensive review of Australian maternity services found that postbirth care is often difficult to access and unco-ordinated, and that parents receive conflicting advice.
Families with unsettled babies try everything in the hope of finding relief. They go the child health nurse and the GP and the paediatrician and the breastfeeding counsellor. They go to the chiropractor and they put their names down for the sleep school, except they have to wait weeks for that though they feel they can hardly take another day. They even turn up at strange hours in emergency departments, demoralised and desperate.
In this muddle, having someone offer a simple solution may seem like a godsend. So the baby is diagnosed with gastro-oesophageal reflux disease and put on medication. Or the baby is put on a sleep schedule for “overtiredness.” Or the mother is put on an elimination diet. Or the chiropractor is visited weekly.
But the latest evidence shows that gastro-oesophageal reflux disease is not a cause of unsettled behaviour in the first few months of life, that no “one-size-fits all” approach to sleep helps crying in this age group, that the only allergy that may be reliably relevant is to cow’s milk, and that complementary therapies, chiropractic and craniosacral therapies do not help.
In fact, high quality trials of programmatic approaches for otherwise well unsettled babies in the first three to four months of life show no difference, or even increased parental stress and infant crying.
There is also growing concern about the unintended consequences of simplistic interventions. We do know that mothers cope better with any kind and caring health professional support, regardless of the exact nature of the program. And we do know that there are gaps in the training of doctors, midwives and child health nurses concerning some of the areas of knowledge vitally relevant to infant cry-fuss problems.
Both in the workplace and at home, the lives of Gen Y mums and dads are imbedded in connectivity. They celebrate the world’s complexity as their fingers and thumbs dance over the keypads of the iPhone or the iPad or the laptop. They understand that multiple inputs may co-evolve unpredictably, and that the unpredictability of the world demands resilience and flexibility.
But when they see a health professional about a baby who screams throughout the first weeks and months of life, they may still receive advice flavoured by old ideologies popular throughout the second half of the 1900s, including simplistic, algorithmic approaches to infant sleep and feeding, which have no basis in evidence.
Or the baby is prescribed proton pump inhibitors though this medication is no better than placebo, places the baby at risk of respiratory infection, and has also been linked with the rise of paediatric food intolerances.
Care of the unsettled baby is undergoing a paradigm shift. It’s a complex problem, and a big-picture perspective is required. Some factors that predispose certain babies to crying just can’t be helped, whether it’s genetics or temperament or the baby’s unique level of neurodevelopment.
But there are various other factors which interact and contribute to unsettled infant behaviour that can be changed. To take just one important example: feeding problems are under-identified in unsettled babies, and contribute very early on to stressed and upset behaviour.
Every family has the right to have every potential contributing factor considered by properly trained professionals as early as possible, to prevent them amplifying. Every family deserves a holistic approach that integrates the evidence across many different fields of research, including neurobiology, in an individually-tailored plan that aims to both minimise the baby’s crying, and to enhance the family’s capacity to find pleasure together – despite everything – in those first amazing weeks and months.
• Pamela Douglas has been in general practice since 1987, and is Clinical Lead of Possums The Clinic for Unsettled Babies, UQ Health Care Annerley, and Adjunct Senior Lecturer, The Discipline of General Practice, The University of Queensland
Pam has been researching unsettled infant behaviour for many years, since the gastro-oesophageal reflux disease epidemic really began to take hold in crying babies, and has written about her experiences as a general practice researcher in an article published this year in the Griffith Review.
Her medical publications call for a paradigm shift in the care of crying babies in the first months of life, and offer guidelines for the clinician.
Her fascination with the relative under-representation of the gestating, birthing and (literally or metaphorically) lactating woman in our cultural imaginary – and the impact that has on a new mother’s well-being – led to a PhD in Creative Writing and Women’s Studies.
“The unsettled baby: how complexity science helps”
(Full paper available on request to Croakey)
“The crying baby: what approach?”
(Full paper available on request to Croakey)
“The unsettled baby: crying out for an integrated, multi-disciplinary approach”
“Excessive crying and gastro-oesophageal reflux disease in infants: a misalignment of culture and biology”
(Full paper available on request to Croakey)
“Managing the baby who cries excessively in the first few months of life” BMJ (in press)
“Interdisciplinary perspectives on the management of the unsettled baby: key strategies for improved outcomes” Australian Journal of Primary Health (in press)
“feeding problems are under-identified in unsettled babies, and contribute very early on to stressed and upset behaviour.” Exactly! and there are far too many silly notions around feeding still bandied about for my liking.
What an interesting article. I too am a GP and have spent most of the last 25 years specifically looking after ‘distressed babies’ in Perth.
My experience is somewhat different and I am concerned about the information that these parents are given. After years of hearing the information that is given to parents to explain the cause of the crying I have found that a proportion of these infants have a combination of reflux and allergy [usually as intolerance of dairy protein]. This causes irritation of their Eustachian tubes and they develop ET dysfunction [i.e. negative pressure in their middle ears]. This causes pain on sucking and when lying down and often progresses to middle ear effusions and infections.
There are many longer term implications for these infants with developmental delays, emotional and social issues. There is also a high risk for the children later having Central Auditory Processing Disorder with major problems with school learning–and this is rarely thought of as being related to the early ‘difficult’ behaviour.
I call this condition Eustachian tube Irritation [ETI].
The condition is diagnosed by the pattern of behaviour, the presence of reflux and atopy and the finding of an abnormal tympanogram.
The infants respond well to treatment, but treatment needs to be started early if sequelae are to be prevented.
Detailed information is available in the book i have written called Crying Babies & Beyond–the ins & outs and ups & downs’. there is a website at http://www.cryingbabies.com.au and I can be contacted at firstname.lastname@example.org
Dr Renee Shilkin
I posted a comment above about the crying babies issue and realise that i have given an incorrect email address! How does one make a mistake giving one’s own contact address? Please note that my email contact should be email@example.com
Great article, thank you.
1 – Please can I have a copy of the 3 publications you listed at the end.
2 – Do you have any real-world, use now techniques that you use in consultations to help mothers feel supported, whilst steering them away from opting to try medication? Are there any online resources or help lines that you have found that will consistently give the information above?
I find that mothers will often come to me (a GP) after speaking to another health professional and forming an opinion that their child might have reflux. It’s very hard to dissuade them from trying medication without coming across uncaring and alienating the mother – sending them to someone who will prescribe more readily.
I’ve been a dad for just two weeks, and the only thing wrong with this article is it ended just as it was getting started.