Excessive crying in infancy

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Crying baby

As excessive crying in infancy , the behavior is an infant called suffering from insatiable, permanent Scream and anxiety attacks. Colloquially the affected infants will cry babies called.

Excessive crying is common in infancy: around 16 to 29 percent of all infants are affected in the first three months of life. In around 8 percent, the behavior persists beyond the third month. The disorder described usually begins around the second week of life and disappears in the vast majority of cases after three to four months. Due to the time of occurrence and the unproven assumption that colic could be the cause of the infant's symptoms, the disorder is referred to as three-month colic .

Several suspicions exist as to the cause of excessive screaming , none of which are generally accepted. In addition to ruling out other illnesses, diagnostics also include recording psychosocial stress factors that are often found in the families of crying babies. The most important therapeutic measures are to educate the parents as well as to instruct them on an understanding parent-child interaction. In German child and adolescent psychiatry , excessive crying forms a syndrome in addition to sleeping and feeding disorders, which is recorded in the so-called regulatory disorders in infancy .

Definition and classification

Crying is part of the normal behavioral repertoire of an infant. By crying, the baby signals, for example, that he is hungry, in pain, is unwell or that he needs attention. According to the most frequently used definition, excessive shouting occurs when the so-called “rule of threes” is met. This states that the screaming occurs more than three hours per day on at least three days per week for a period of at least three weeks. In addition to the rule of three, the insatiability of screaming attacks is emphasized as a characteristic feature. The subjectively experienced stress of the infants and parents plays an important role in assessing the severity of the impairment ("disease value"). Among other things, the extent of the therapeutic efforts is made dependent on this.

The rule of three was formulated by Morris Wessel in 1954 and later named after him ("Wessel criteria") . Although it is the most commonly used definition of excessive screaming, numerous studies have used variations on this definition, so that different studies have come to different conclusions about the frequency and occurrence of excessive screaming. The interpretation of studies that examine the causes of behavior and the effectiveness of treatment measures is also made more difficult by the different definitions on which the respective studies were based.

In 1954, Ronald Illingworth, in one of the earliest studies of excessive crying, examined 50 infants suffering from rhythmic, insatiable crying attacks for no apparent cause. Since the screaming episodes subsided by the age of three months, he spoke of a three-month colic ("three months' colic") . The word "colic" is derived from the Greek word "colon" , which in medical parlance refers to the intestine, and implies a disruption of the gastrointestinal tract as the cause of excessive crying. However, this assumption could not be confirmed in the course of the following decades, so that the term "three-month colic" is understood by some authors as a possible misnomer. Other names used in the medical literature and colloquial excessive crying are Säuglingskolik , Trimenonkolik , cry baby or cry child .

In German child and adolescent psychiatry, excessive crying is understood as a key symptom of regulatory disorders in infancy . Regulatory disorders are defined as a difficulty that is unusual for the infant's age or stage of development in adequately regulating its behavior in one, but often in several, interaction and regulation contexts. Other contexts of interaction and regulation are, for example, sleeping and feeding. The regulatory disorders are not viewed as a disorder of the infant alone: ​​the infant's behavioral problems are part of a symptom constellation that can also include an impaired relationship between child and parents and an overwhelming situation on the part of the parents .

In internationally used disease classification systems such as the ICD-10 , excessive crying is not classified as an independent disorder. The classification system Zero to Three (DC: 0–3R 2005), which specifically records disorders in infants and young toddlers, no longer defines excessive crying as a disease, as the research situation does not justify this.

Classification as an adjustment disorder (F43.2) in the ICD-10 is most likely .

Frequency, course and symptoms

Depending on the particular study, 8–29% of all healthy infants are affected by excessive crying. The scatter in frequency is mainly explained by the fact that different definitions of excessive crying were used in the respective studies.

The seizure-like, insatiable episodes of screaming and restlessness usually begin around the second week of life and increase in intensity and frequency up to around the sixth week of life. As a rule, the symptoms regress to a large extent by the end of the third month of life. In around 4% of all baby cribs, it persists until the sixth month, in rare cases longer. Excessive crying is considered to be a risk factor for the development of further behavioral problems in later childhood if other risk factors are present.

The screaming occurs frequently in the evenings; Frequently, during short daytime sleep phases (which usually last less than 30 minutes), the infant becomes increasingly tired and overexcited towards the evening hours. Other symptoms that can also occur are a bloated stomach, reddish discoloration of the skin and increased muscle tension . Typically, the baby's face turns red, the trunk is hyperextended backwards and arms and legs are bent with increased muscle tension. Calming aids such as darkening the room, pacifiers and music boxes have no effect.

From a child and adolescent psychiatric point of view, in addition to the behavioral problems of the infant, the impairment of the parents and the parent-child interaction are considered symptomatic. Mechthild Papoušek , head of the research and advice center “Early Development and Communication” at the Children's Center in Munich, states an age-typical triad of symptoms that can be observed in all regulatory disorders in infancy . Several different areas are affected by the disorder:

  1. Behavioral problem (s) in the child (e.g. excessive crying);
  2. Overtaxing the mother or both parents in dealing with the "difficult" infant and
  3. dysfunctional interaction patterns (due to the conspicuous behavior of the child, the social interaction and communication of the parents with the child is affected, which can increasingly burden the relationship with the child).

diagnosis

It is important to have a detailed discussion with the patient , which should shed light on the physical, psychological and social history and situation of the infant and its parents. Information about the mother-child interaction, the family situation and the availability of specific resources and stress and risk factors can be collected here. Since excessive crying can be both a cause and a consequence of child abuse, therapists are advised to pay attention to information about this in the relevant guidelines on the disorder.

Since the symptom of crying can be caused by abnormal organ changes, various diseases must be ruled out before a diagnosis of excessive crying in infancy can be made. The disorder is therefore an exclusion diagnosis . Diseases that can cause persistent screaming include respiratory infections, otitis media, and urinary tract infections . Various diseases of the gastrointestinal tract such as reflux disease , intestinal inflammation , constipation and invagination of the intestine can also cause the infant to cry incessantly. The gastrointestinal diseases also include cow's milk protein intolerance , which is difficult to diagnose (not to be confused with lactose intolerance ): Non-specific indications that justify this suspicion are, for example, slimy-bloody diarrhea, vomiting and dehydration . The tests available on the market for diagnosing cow's milk protein intolerance are not recommended due to their lack of accuracy. Decisive for the diagnosis of cow's milk protein intolerance is the anamnesis , the course of the symptoms after avoiding all food components containing cow's milk and the recurrence of the symptoms after consuming cow's milk components again.

Unrecognized broken bones and neurological disorders such as early childhood brain damage or various genetic syndromes are also possible causes of the screaming . Overall, the diseases mentioned can be diagnosed in 5–10% of infants who have the symptom of excessive crying.

Behavioral logs are not only used to document phases of crying and restlessness, but are also intended to record phases of sleep, the way in which the parents try to calm the babies, and playful interactions. Examples of behavioral logs include writing and sleeping diaries, and feeding and nutrition logs. These can provide information about the phases of sleep and the regularity of the daily routine. A behavioral observation in different contexts (feeding situation, play, calming situation, separation situation and reunion) completes the diagnosis. Behavioral observation can provide information about inappropriate calming aids or a disturbance in the mother-child relationship.

causes

The cause of excessive screaming is unknown. A number of physical, psychological and social factors are discussed in the medical literature without a generally accepted causal model. Many authors stress the importance of the interplay of several factors. It is also pointed out that individual factors can mutually reinforce one another.

Normal and excessive screaming behavior

All infants cry out in the first few months of life. A total of up to 60 minutes a day is considered normal. During the first three months of life, infants cry an average of 7–29 minutes in a 24 hour period. This number decreases with increasing age, as the attachment researcher Martin Dornes , author of the book The Competent Infant, announced in the context of his extensive research on babies and toddlers .

While the frequency of screaming attacks is the same in infants with normal screaming behavior and those with excessive screaming behavior, the latter's screaming episodes are longer. They are also less easy to calm down through parental calming behavior, such as wearing them on the body. According to some authors, excessive yelling could be an extreme variant of normal screaming behavior. At the same time, it is suggested that excessive crying, regardless of the question of normality, be regarded as a symptom that influences the interaction between the infant and the caregiver in any case.

Psychological and social factors

The parent-child relationship is characterized by complex non-verbal communication based on facial expressions , sounds and touch. The infant communicates with its environment very early and shares its basic needs. The caregivers usually react instinctively to these statements. In doing so, they adapt their answers to the child's condition. In doing so, they support the infant in developing its self-regulatory abilities and compensating for the limitations of this ability related to the level of development. In this context, Mechthild Papoušek describes the behavior of the parents as intuitive parenting . If this preverbal communication succeeds, the parents feel strengthened and secure in their actions. If it fails, however, parents often feel unfounded guilty if they cannot calm the child down.

The parent-child interaction can be disturbed by comparatively small deviations. These deviations are very individual and occur in a variety of forms. For example, by turning its head away, the infant signals that the stimuli presented are currently overwhelming. Parents can misinterpret this gesture as rejection, disinterest, or the like. In this constellation, they can try to reverse the suspected rejection by reestablishing eye contact or by intensifying play with the child. In doing so, they increasingly overwhelm the child. The result is a situation in which the tension and excessive demands of parents and child can mutually reinforce and thus escalate through their actions. An inborn temperament of the infant, which can be classified as difficult, can make it more difficult . If the infant's ability to absorb stimuli or to calm down quickly is limited, this can induce or encourage crying.

Family stress

Often there are psychosocial, organic and prenatal stress factors in the families of cry babies. These factors can affect both the parent and the infant alone and the family as a whole. Diseases, conflicts between parents, conflicts with families of origin, poverty or a single parent, fears, depression , social isolation and limited resources in the context of a mental disorder of the mother as the child's main caregiver are possible. There is also a connection between the child's crying behavior and the type of attachment of the mother, which can be measured by the adult attachment interview , and biographical factors such as emotionally stressful or traumatic attachment and relationship experiences can be expressed in the relationship with one's own child . These factors can put a strain on the parent-child interaction and directly and indirectly increase the overburdening of the parents. ( See also: Trauma and Attachment and Multi-Generational Psychotraumatology according to Franz Ruppert .)

Prenatal stress is seen as a risk factor for excessive crying in the 3rd to 6th month of life. The effect of prenatal stress is less in mothers who have a high expectation of self-efficacy before birth .

Conversely, there are indications that the infant's crying can also lead to problems in the partnership. In a study of couples who became parents for the first time, for example, satisfaction with the partnership after birth decreased more in those whose child cried a lot. On rare occasions, a dangerous overreaction occurs in which a parent tries to shake the child to silence the child, causing the baby to experience shaking trauma.

Psychoanalytic attempts at interpretation

Psychoanalytic theories see a cause in a divergent interaction between the caregiver and the infant, both in an unfavorable, life-history constellation in the parents and in unfavorable temperament factors in the children. The caregivers have a greater influence on the interaction. The cause is seen mainly in conscious and unconscious assignments of meaning through parental projections .

Behavioral therapeutic attempts at interpretation

Behavioral therapeutic models assume that the cause of regulatory disorders in infants is the emergence of negative reciprocity (interaction) in the social exchange processes between parents and children. The symptom of excessive crying can have different causes. Above all, temperament factors are discussed. These encounter blocked intuitive competencies in the parents. In such a rather unfavorable constellation, escalating communication and relationship disorders can occur. But psychodynamic factors can also burden communication.

It has also been suggested that many children are born with a predisposition to emotional overreaction. In a study, however, it was shown that this child's temperament can be strongly influenced by upbringing. The exercise of authority and consequent consistency was positively correlated with the children's ability to learn to cope with disturbing stimuli.

Organic factors

Physical factors affect the infant and parent-child interaction at different levels. For one, other underlying diseases that may cause the symptom of excessive crying must be ruled out. At the same time, other diseases of both the child and the mother can be stress factors that encourage and intensify excessive crying. Organic causes are also discussed as independent factors that are intended to directly disrupt the function of the gastrointestinal tract.

In the first six months of life, infants double their body weight. This phase of intense growth is characterized by a strong activity of the child's intestine and requires its optimal functioning. A disturbed adaptation of the function of the child's gastrointestinal tract could lead to cramp-like pain in two different ways: on the one hand, increased movements of the child's intestine ( peristalsis ) could directly cause cramps ; On the other hand, too slow bowel movements could cause painful inflation of the bowel by gases ( flatulence ). In addition, the infant's eating and drinking behavior is discussed as a further cause: for example, drinking too quickly, too much food and swallowing air while eating ( aerophagia ) could promote the accumulation of gases in the intestine. The cause of a disturbed gastrointestinal function could also be a disturbance of the child’s metabolism in connection with passive smoking . A statistical connection ( correlation ) between excessive crying of the baby and nicotine consumption of the parents could be demonstrated. In infants with three-month colic, increased levels of the gastrointestinal hormone motilin were found in some cases . Since there is still a correlation between increased motilin concentrations and nicotine consumption, based on these findings, a connection between maternal nicotine consumption during pregnancy and secondhand smoke with the development of colic-like symptoms is being discussed. The thesis that colic is the cause of the cry disorder also supports a new study that examined the intestinal flora of infants. The infants who became suspicious of crying more often also had more Proteobacteria in their stools. These also include gas formers, which could trigger painful flatulence.

Genetic and constitutional factors acquired due to prenatal stress are discussed as further favorable causes. Some authors speak of abnormalities in neuromotor development, which suggest an immaturity of the organization of the brain.

Therapy and prognosis

The therapeutic measures in the practices of paediatricians, in which low-threshold and timely treatment is possible due to the preventive examinations, in the crying outpatient departments - such as in the family center at the Potsdam University of Applied Sciences - and in the family day clinics aim in addition to the treatment of excessive crying itself on the relief of the parents and the support of a sustainable relationship for parents and child. Education, advice on helpful behavioral measures and psychotherapy and family therapy are the focus of the therapeutic measures. The type and intensity of the respective treatment measures depends on the individual case and should take into account the stress factors and resources of the family recorded in the diagnosis. Drug therapy is not recommended. In the vast majority of infants, the disorder disappears after three to six months.

Counseling, behavioral measures and psychotherapy

Parent-child counseling and parent-child psychotherapy are effective means of treatment. In counseling, the main focus is on parent-child interaction, i.e. the social interplay between the child and his or her parents. In most cases, parent-child counseling with one to five counseling sessions is considered sufficient. The parents are advised on the child's level of development and they are offered alternatives in the interpretation of children's signals. This is intended to strengthen the parents' intuitive abilities. Appropriate counseling can also help in coming to terms with any parental guilt feelings. The midwife can also be asked for advice in postpartum care.

In addition, the reduction of stimuli has proven to be effective. It is also helpful to avoid child fatigue and to structure the daily routine in a predictable way for the child, with regular sleep phases during the day and joint games and dialogues during the waking phases. Short periods of time out (time-out phases) are also important for the primary caregiver in the event of severe overload. In critical phases with great tension, exhaustion or rising anger, parents are advised to first put the child down in a safe place, to come to rest themselves in the next room and only then to calm the child.

Parent-child psychotherapy is indicated for more severe disorders, such as when crying goes beyond the age of three months and further disorders exist or develop in other areas of interaction such as sleeping and feeding. This is also indicated if there are interaction patterns (mutual behaviors) that suggest a mismatch of the parents to the disorder. This includes, for example, actions by parents that are intended to calm the baby, but ultimately involuntarily lead to the baby's crying and the excessive demands on the parents being maintained and intensified.

Psychotherapy is also justified if significant stresses and disorders in the parent-child relationship can be identified. Mental disorders of the mother such as postnatal depression are also indications for psychotherapy. This can have a psychoanalytic , attachment-theoretical , behavioral or systemic-family therapeutic orientation. Treatment approaches based on psychoanalysis assume that the parents' interaction with the child can be improved by clarifying the projective attribution of meaning to the child. The life history experiences of the parents can also be included. But direct advice and support in the different interaction situations can also be used as a measure. In behavior therapy, interaction is supported and the parents are helped to apply their intuitive skills. In most cases, this form of intervention takes up to ten sessions. Psychotherapy or counseling can be supported by video recordings made by parents and children in certain game scenes. In retrospect, these serve as the basis for advice on the interaction and enable the parents to clearly understand the mutual reactions between them and their child.

Inpatient psychotherapy includes the admission of the mother and child to a hospital and is mainly indicated in the case of mental illnesses in the caregivers. In the case of particularly severe psychosocial stressful situations, severe mental disorders of the caregivers and an existing risk of child abuse, the child may need to be temporarily removed from the family. In such a case it is important to support the development of the relationship between the mother or parents and the child or birth parents, the foster parents and the child therapeutically.

If the family is under severe psychosocial stress, it can make sense to set up services that relieve the burden on the family, such as child care or child care . Also socio-educational family assistance Support may be in different psychosocial stressful situations.

The general effectiveness of psychotherapy for early regulatory disorders has been proven. In addition to the recognized psychotherapeutic procedures, behavioral therapy and psychoanalysis, the importance of a systemic-family therapeutic perspective is pointed out. Difficulties in the evaluation result from the high spontaneous remissions , i.e. the development-related disappearance of the symptoms with increasing age.

In infants suffering from excessive crying because of early childhood brain damage, settled by spitting the writing time significantly reduced compared to the massage. Swaddling in connection with daily structuring also reduced the screaming phases. It was shown here that swaddling caused an additional reduction in the crying phases up to the eighth week of life, but not beyond this age. Another study on healthy, 6-16 week old infants showed that swaddling increased the duration of deep sleep phases and decreased the frequency of spontaneous awakenings. The development of a malformation of the hip joint caused by wrapping the baby's legs too tightly is mentioned as a possible undesirable effect of swaddling .

In recent years, alternative medical methods such as chiropractic , cranio-sacral therapy or osteopathy have also been discussed as treatments. However, their usefulness is questionable.

Medication

The effectiveness of two drugs for treating three-month colic has been studied in several studies.

Dicyclomin , an active ingredient from the group of anticholinergics , unfolds its effect via receptors in the autonomic nervous system . It inhibits the activity of the part of the vegetative nervous system known as the parasympathetic nervous system and thus leads to reduced bowel activity. Although two systematic reviews of several controlled studies confirmed a specific effect of the drug on screaming phases and duration, at the same time slight side effects such as drowsiness, loose stools, constipation and rarely severe side effects such as breathing disorders and epileptic seizures were found. Therefore, dicyclomine is not recommended for the treatment of three-month colic. Dicyclomine is not available in Germany and has no approval in the USA or Canada for the crucial age group under six months.

The second substance investigated in several studies is simeticon . This active ingredient reduces the surface tension of the food pulp in the intestinal tract and is said to accelerate the discharge of gases in the case of flatulence. Two systematic reviews evaluating three controlled studies found no specific efficacy of simeticon compared to placebo . Therefore, the active ingredient is not recommended for the treatment of three-month colic.

A 2013 study shows that daily administration of probiotics can reduce the duration of daily infant colic. Apparently this improves the intestinal flora , which in so-called baby babies often only has low concentrations of Bifidobacteria and Lactobacilli. However, this study was funded by the probiotic manufacturer BioGaia. An earlier meta-analysis came to a rather cautious result with regard to the effectiveness of probiotics, even if certain effects were sometimes discernible. This study suggests several conflicts of interest. One of the authors receives funding from Nestlé. Above all, the lack of studies on the long-term effects of probiotics is viewed critically.

further reading

  • Mechthild Papoušek, Michael Schieche, Harald Wurmser (eds.): Regulatory disorders in early childhood. 3. Edition. Huber, Bern 2007, ISBN 978-3-456840-36-9 .
  • Christiane Ludwig-Körner: Parent-Infant-Toddler Psychotherapy . Vandenhoeck & Ruprecht, Göttingen 2016, ISBN 978-3-525-40560-4 .

See also

Web links

Wikibooks: Baby Book: Screaming  - Learning and Teaching Materials

Individual evidence

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This version was added to the list of articles worth reading on June 9, 2009 .