Archive for December, 2011

December 15, 2011

Gone With the Wind

I was recently asked by a newly graduated midwife for any better tips on “winding” babies. I asked the midwife what she had been taught in university on this subject, she thought about it and replied “nothing”. We talked about why the university had not taught her how to ‘wind a baby’ and where our knowledge on this subject comes from. We often do things because they have been instilled in us by our mothers, aunties and grandmas and we come to accept it as fact. It may be quite confronting correcting old wives tales. The truth is I doubt any university in the 21st Century teaches student midwives about wind, colic or how to burp babies because there is no substantive evidence to support what we have been telling new parents all these years.

The First Two Weeks:

Parents are often very shocked when their baby has kept them awake all night in the first few days and often want the midwife to take the baby for a few hours rest. “All she wanted to do was feed and if she wasn’t feeding she was crying. She looked as if she was in so much pain; pulling her legs up, I didn’t know what to do.”

Very frequent feeding in these early days is normal and an evolutionary process to  ensure a baby’s stomach is not over distended too soon. Colostrum is perfectly designed to be small in quantity and gentle on baby’s gut therefore not increasing cortisol (stress hormone) levels.

The evidence shows that crying is a normal sign of vigour. A mother will often describe the intense feeling of hurt, pain and love she feels when her baby cries which leads to an uncontrollable urge to soothe her baby.  A mother’s powerful response to her crying baby evolved to ensure she continued to care and bond with her baby.

Normal vigorous crying, constant feeding and the need to be held almost all night long mixed with lack of knowledge and obsessions with wind can lead parents on a path to listen to any advice and try every potion there is on the market in order to find the answer, while ignoring powerful maternal instincts to listen to her baby.

Two Weeks to Three Months:

From two weeks of age babies who may have previously been “good” babies will often have a change in behaviour. The amount of crying tends to escalate up until its peak around 6 weeks. This often occurs mostly in the late evening and may last from 2-5 hours. These babies may have twisted faces and piercing wails. This can be extremely distressing for many new parents when the crying starts with no prior warning, often increasing in pitch and intensity until all of a sudden baby stops crying. About 15% of newborn babies will cry more than 3 hours per day from 2 weeks to 3 months. By 3-4 months almost all babies have stopped these crying episodes.

Studies of infants around the world indicate that unsoothable and unpredictable crying is a natural phase of early infant development due to the fact that humans are born so much earlier than our mammalian counterparts.

Over the last several million years our human brain has grown so much that we could no longer accommodate birthing our babies at the equivalent gestation of other mammals. Mammals are born with functioning brain capacity at 80% compared to a newborn brain which is only 20% developed at birth and takes a further 12 months to develop to 80% function. Within the first 3 months our sensory system can be easily overloaded and caused stress. Babies are designed to be held closely to their mother for long periods, just like our primate cousins. When babies are held in close proximity, it allows for the numerous benefits; oxytocin inducing and soporific effects of frequent feeding, baby and mother fall in and out of restful sleep together, mother responds effectively to her baby, frequent unrestricted breastfeeding is the norm and baby cries much less.

The most commonly used definition of Colic syndrome originated in 1954 by Wessel, who describes colic syndrome by using the “rule of three”: crying for more than three hours per day, for more than three days per week, and for more than three weeks in an infant that is otherwise healthy. The word colic itself is derived from the Greek word kolikos, meaning large intestine or colon as it was believed that intestinal pain caused the distress, but evidence confirms that crying behaviours in newborns is a normal process and not an “illness” that we need to cure. Even infants in primitive tribes who are held 24 hours a day and breast-feed constantly show the same pattern in peak inconsolable crying in these early weeks.

Evidence shows that in the last 10 years more and more babies are being incorrectly diagnosed as having a disorder, exposing them inappropriately to medication.  As there is no evidence that acid-suppressive drugs help in treating unsettled behaviour, medications should surely be avoided. Yet research and experience in practice points to a much higher percentage than the actual 5% of babies who do have an organic disorder, being misdiagnosed and ‘treated’ for gastro-oesophageal reflux disease (GERD), food allergies and lactose intolerance. Treatment ranges from medications, hospital admission, ceasing breastfeeding or introducing lactose-free formula milk and dietary eliminations for the mother regardless that the evidence does not support this thinking.

Promoting a normal phenomenon as a medical problem invariably leads parents to have little or no understanding at all about why their child cries so much. For many parents it can severely impact on their life and their ability to bond and connect with their baby, putting them at greater risk for postnatal depression, premature cessation of breastfeeding, long-term psychological disturbance, and child abuse.

The eternal “wind” problem

Not all types of crying and unsettled behaviour fit the “colic” mould and they are often exacerbated by our Western culture of raising babies. For years we have been told not to spoil babies by picking them up too much, midwives have told mums to burp their babies and to take them off the breast before the fall asleep. We’re told to play with babies and communicate, but rarely are mums told about the infant states or how much is too much play for a newborn. Baby massage is recommended for babies now but slap dash classes may be given which teach the strokes but ignore the essence of real baby massage; which is teaching mothers to effectively communicate with their baby and pick up on enjoyment/love/early tired signs/distress and disorganised state signals.

James a 4 week old baby has just had a lovely 40 min breastfeed. He is starting to slow down at the breast while he enjoys the soporific and calming effect of the milk so Mum takes him off the breast. She has read how to correctly wind and play with your baby before sleep so James is then placed over mums shoulder while she bounces up and down and pats his back. After a few minutes of whining James does a burp so Mum brings him down for play time. For some minutes James is happy to stare into Mum’s face and smile and copy her facial expressions but soon he becomes tired and starts to look away to signal to her that he has had enough. As Mum has never been told about the infant states and relies on books that instil routines she misses those early signs and continues to smile and stare at him. James now becomes restless with jerky arm movements, he furrows his brow and even starts to pull his legs up and arch his back. To Mum these are signs of wind so she puts him back over her shoulder. James is now completely over stimulated and begins to cry. In response Mum jiggles him and pats him faster, he then cries louder. The more she jiggles the more he cries and the pitch and fever of the crying escalates. Mum now feels her stress building and James responds to it. James is now completely over wrought and screaming, he is red and squirming. He is unable to calm himself down at this primitive age, he needs his mum to swaddle him and calm him back to sleep. Eventually extra air swallowed from crying causes a loud burp. James is finally bought down for a cuddle, to which James miraculously stops crying and calms down!  “See”, says Mum, “I knew it was the wind pains upsetting you!”

Help for the Overstimulated Baby and Mother:

  • Listen. Parents are often seeking help from many other practitioners as well as you.  You may be the first person to not label their child with an illness, to describe this as normal.
  • Antenatal education ‘What to expect in the first few days’. Parents need to need to know why it is normal.
  • In the early days minimise visitors and separation of baby from mum.
  • Crying and unsettled behaviour is often hunger in the first 2 weeks. Parents are often told over-feeding is the cause of wind. We should inform mums that underfeeding will cause an unhappy irritable baby!
  • Encourage breastfeeding on demand; no set limits, no routines. Suckling is soothing for babies.
  • Breastfed babies do not need to be burped. Wind, flatus and burping will occur spontaneously, and often quite frequently, regardless.
  • Teach parents how to minimise everyday stimulation. Read Howard Chilton’s great article for parents here.
  • Teach parents early tired/overstimulated signs.
    • Loose eye contact or have difficulty focusing
    • Have jerky arm and leg movements
    • Have a worried look on his face
    • Close his fists
    • Pulling at his ears
    • Yawn
    • Grizzle or whinge
    • Pull legs up
    • Arch backwards
    • Crying – late sign!
  • Teach parents safe wrapping techniques, to reduce primitive startle reflex and mimic womb environment.
  • Movement – rocking, jiggling, bobbing, walking, swaying.
  • Slings are so helpful; the ultimate womb-like environment.
  • Teach parents how to transfer baby gently into the bassinet without waking. Think smell, sound, movement.
    • Often babies sleep well during the daytime in the lounge room where they can hear the hustle and bustle of life, just like they did in the womb.
    • Try using a slept-in pillow case as baby’s wrap or blanket.
    • Warming the mattress can make the transition from mum’s arms to bassinet easier.
    • “Shusshing” noise, white noise/metronome ticking. These are even in app form.
    • Rocking or jiggling the cot or bassinet gently will help remind baby that he is still in mum’s arms.
  • Dummy use!!!  (Only if it’s a choice between a mother giving up breastfeeding as she is so exhausted or distressed or occasional use of a dummy to help calm baby and herself). A Cochrane review concluded that in motivated mothers, dummy use in healthy term breastfeeding infants before and after lactation is established does not reduce the duration of breastfeeding up to four months of age.
  • The incidence of crying episodes in breastfed and bottle-fed infants is similar so changes in diet are not advisable for 95% of babies.
  • Assess for signs of illness – there will be 5% of babies where their crying is not normal. It is essential that any ‘red flags’ have an urgent medical review.
  • Although early crying has no long-term negative outcomes, persistent or repeated elevated crying after 3-4 months is linked with long-term poorer outcomes and requires medical review.
  • It is very important to assess the mother-infant relationship, maternal fatigue, anxiety and depression and ensure appropriate support.
  • Admission to a parenting centre (day stay or overnight stay) may be appropriate for 24 hour support, (depending on their philosophy).
  • Safety for parents is important. A plan must be discussed on how to manage infant crying.
  • Give parents support helplines.
  • Reassurance and time to talk. Parents need to know that their baby is healthy and this period in their lives has no long-term adverse effects for their baby.
The Period of PURPLE Crying (Barr M & Barr R) 
  • Try to talk to parents about PURPLE  an alternative way to describe what parents and their babies are going through. See link here.
From here
In order to help parents ease more peacefully into their role as new parents a paradigm shift is required in our thinking. We need to see ‘wind’ and ‘colic’ as normal behaviours due to infants acting as they should, or were designed to, act rather than due to underlying pathophysiology or pathopsychology.
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