New Evidence on Unexplained Early Infant Crying: Its Origins, Nature and Management.

New Evidence on Unexplained Early Infant Crying: Its Origins, Nature and Management. Edited by Barr RG, St. James-Roberts I, Keefe MR. Johnson and Johnson Pediatric Institute, New York, 2001. This book is a summary of one of Johnson and Johnson's Pediatric Round Tables, which took place in Palm Beach Florida in January 2000. Organized by Drs. Ronald Barr, Ian St. James-Roberts, and Maureen Keefe, the meeting included about 25 speakers and participants from the United States, England, Ireland, Canada, Germany, Australia, and the Netherlands, brought together to look at what is new in unexplained infant crying. The panelists included authorities from the fields of child development and behavior, child psychology, general pediatrics, nursing, gastroenterology, and neonatology. The symposium was divided into five sections entitled, “What is Unexplained Early Crying?” “Crying as a Developmental Phenomenon,” “The Challenge of Assessing Crying Complaints,” “Empirically Based Approaches to Management: Behavioral Strategies,” and “Is There Life After Unexplained Crying? Outcomes and Consequences.” There was an introductory segment by Dr. Ronald Barr, which set out the goals of the Round Table, and a superb summary at the end by Dr. Ian St James-Roberts, which in a nutshell defined the problem of “colic” anew and put the situation in perspective in plain English. Do not read this book if you think it will clarify all the pesky issues that we as gastroenterologists face in practice when encountering the fussy infant. However, there were several excellent presentations that were both scientifically informative and clinically relevant. Dr. St. James-Roberts' presentation in the first section was a clear discussion of the techniques of measuring crying, stressing the differences between continuous tape recordings and the diaries of parents. Parent diaries routinely indicate fivefold more time spent in crying than do tape recordings. Dr. St James-Roberts points out that this does not mean that parents of crying infants are inaccurate, just that they are reporting on a combination of activity, fussy verbalizations, and crying, which is not identified as crying by a recorder. He points out that infants with unexplained crying do not have more episodes of crying per day, but that their episodes are of longer duration, greater intensity, and accompanied by more crying and less fussing than noncrying infants. He also stresses, as did many clinical presentations, that the inability to soothe the infant's crying is a characteristic of prolonged crying in infancy and, more than the crying itself, is the factor that puts parents under stress. He debunks several old notions, including the idea that it is the firstborn infant (with inexperienced, anxious parents) that is most likely to be affected by unexplained crying. A short section later in the book by Green and Gustafson documents the finding that the cries of the colicky infant are not different in acoustic qualities from pain cries, hunger cries, and the like, and that the identification of the cry as “colicky” depends on visual cues at the time of the crying spells, such as facial grimace and body position. A highlight of this symposium was the paper by Dr. Ronald Barr in the second section. Here he makes a clear case for the fact that normal infant crying and “excessive unexplained crying,” which peaks at 6 to 8 weeks in all human cultures and tapers off by 16 weeks, is part of a greater scheme of other neurologic developments taking place at the same time. He reports on some very interesting experiments in which orally administered sucrose solutions were used to interrupt crying in newborn babies. He found that the soothing effect of sucrose could be divided into two recognizable parts: an oral–tactile phase (i.e., pacified by sucking) and later an orogustatory phase, which is longer lasting and which interestingly is not present in premature and postmature babies and those born to drug-addicted mothers. These data suggest again that the calming effect of feeding is not a gastrointestinal phenomenon, but is a neurologic function that may be abnormal in some identifiable infant groups. In part 3 there were three papers investigating the organic sources of prolonged unexplained crying. A thorough literature review by Gormally reinforced the concept that most babies with excessive crying are physically normal and that babies found to have organic disease in retrospect often do not have the features associated with “typical” unexplained crying. He concludes that 5% to 10% of babies with unexplained crying will have an organic explanation and points to cow milk protein allergy, fructose intolerance, undiagnosed maternal drug abuse, infant migraine, and aberrant left coronary as being the most commonly reported organic causes, with gastroesophageal reflux disease, child abuse, corneal abrasion, lactose intolerance, urinary tract infection, and other central nervous system disorders being less common. Dr. William Treem presented a thorough review of data relating unexplained infant crying to food allergy and gastroesophageal reflux and reached the same conclusions as Dr. Gormolly, that these were responsible for a minority of cases. A third presentation by Murray and Cooper looked at the impact of maternal depression on the incidence of unexplained crying. This and other articles dealing with maternal depression were less easy to understand. As I read this and other articles on the same subject in the fifth section on outcome, I concluded that having an infant with excessive unexplained crying is a significant stress on a depressed mother or one with an identified risk of depression and that the maternal attitude toward the baby as being “difficult” may long outlast the crying. Additionally, it is clear that when there an infant with excessive crying is part of a very dysfunctional family with other mental and emotional problems, the situation is high risk to the baby for future behavior problems lasting well into childhood. The section on treatment includes three approaches to the care of parents and infants with unexplained crying. I was particularly impressed by the description of the REST program by Dr. Maureen Keefe, probably because Dr. Keefe started her research on the “fussy baby” in our institution and her clinic is still a going concern. REST is an acronym for the major concepts (regulation, entrainment, structure, and touch) guiding preventative interventions and for the major concepts (reassurace, empathy, support, and time-out) guiding parent therapy. I continue to find the nurses who run this clinic to be extremely effective in helping these parents in need by using a combination of education and support. Unfortunately some of the articles were a bit jargon filled, and I did not find the recapitulation of the group discussions following the presentations to be sufficiently detailed to be helpful. However, I would recommend this book as one that clearly describes the “state of the art.” There is a short attractive parent booklet developed by Johnson and Johnson, which I thought was a bit elementary, but which did stress the important facts about unexplained crying: that babies with unexplained crying are generally healthy and that early infant crying follows a predictable developmental pattern and disappearance. This may be of comfort to families with infants with these symptoms. The book and parent booklet cost $15 (U.S.) and can be obtained from Johnson and Johnson through their Pediatric Institute at 1-877-565-5465. I couldn not find it in the medical bookstore of the University of Colorado.

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