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The Phenomena of Early The Phenomena of Early Infant Crying and ColicInfant Crying and Colic
Ronald G. Barr, MDCM, FRCPCRoss Trust Seminar
Infant crying: causes, challenges and long-term outcomes
Centre for Community Child HealthRoyal Children’s Hospital
Melbourne, AustraliaMarch 2, 2009
The Phenomena of Early The Phenomena of Early Infant Crying and ColicInfant Crying and Colic
Or, why I hope my next child has colic!Or, why I hope my next child has colic!
Ronald G. Barr, MDCM, FRCPCRoss Trust Seminar
Infant crying: causes, challenges and long-term outcomes
Centre for Community Child HealthRoyal Children’s Hospital
Melbourne, AustraliaMarch 2, 2009
Infants cryingInfants crying: : ““photographs made by the photographs made by the instantaneous processinstantaneous process””
Darwin, The Expression of Emotion in Animals and Man, 1872 The The ““ArgumentArgument””
Clinical crying problems are:a. Costlyb. Not explained by “pathology” in the infant or
the caregiverc. Should be reconceptualized as a
manifestation of normal behavioral development
The Argument The Argument (cont(cont’’d)d)
The phenomena of early infant crying may be adaptive (from the point of view of evolutionary behavioral ecology).
This understanding of early increased infant crying (and colic) as “normal” has some implications for clinical approaches to early infant crying problems.
The The ““CostCost”” of Early Infant Cryingof Early Infant Crying
2
Crying concerns in the health Crying concerns in the health care systemcare system
Early increased cryingis used as anadvertisement for theQuebec telephone call-inservice.It accounts for about30% of all calls.
© Ronald G. Barr, MDCM, FRCPC 2009
Maternal Emotional Distress and Maternal Emotional Distress and ““ColicColic””Miller, Barr et al (1993) Pediatrics 92: 551Miller, Barr et al (1993) Pediatrics 92: 551--558558
Mothers who had infantswith colic (modifiedWessel’s criteria) hadelevated levels ofemotional distress,despite equivalentdistress levels in 3rdtrimester
The The ““costcost”” of cryingof cryingSleep and St. James-Roberts, 1998
• Cost of health professional time for cry and sleep complaints in the first 3 months (salary only): $CDN 46.08/baby
• Annual cost for NHS: $CDN 35,304,652• Equivalents:
a. 775 full time nursesb. 4238 hip fracturesc. 270 patients with HIV treated for life
© Ronald G. Barr, MDCM, FRCPC 2009
What is colic?What is colic?Defining featuresDefining features
(Gormally & Barr, 1997)
1. Age-dependent crying patterns (peak during 2nd month).These are due to changes in the amounts of crying that cluster during the evening.
2. Associated behaviors (prolonged cry bouts, unsoothability, “pain facies”)
3. “Paroxysmal” (unpredictable)
© Ronald G. Barr, MDCM, FRCPC 2009
WesselWessel’’s s ““Rule of 3Rule of 3’’ss””An infant has colic when s/he cries:
> 3 hours/day> 3 days/week> 3 weeks
© Ronald G. Barr, MDCM, FRCPC 2009
Assumption:Assumption:Colic is an abnormality,Colic is an abnormality,or or ““something wrongsomething wrong””
with the infantwith the infant
3
The Argument Against The Argument Against PathologyPathology
• Non-pathological mechanisms can account for all primary features of colic
• Good outcome
© Ronald G. Barr, MDCM, FRCPC 2009
““ColicColic”” is not explained by is not explained by pathology in the infant or in pathology in the infant or in
the caregiverthe caregiver
The Lamp PostThe Lamp Post
Anthropology
PsychobiologyNonlinear dynamic systems (catastrophe)
Clinical
© Ronald G. Barr, MDCM, FRCPC 2009
What is colic?What is colic?Defining featuresDefining features
((GormallyGormally & Barr, 1997)& Barr, 1997)
1.1. AgeAge--dependent crying patterns dependent crying patterns (peak during 2nd month).(peak during 2nd month).
2. Associated behaviors (prolonged cry bouts, unsoothability, “pain facies”)
3. “Paroxysmal” (unpredictable)
© Ronald G. Barr, MDCM, FRCPC 2009
The The ““crying curvecrying curve””((BrazeltonBrazelton, 1962), 1962)
Large differences
from infant to infant
© Ronald G. Barr, MDCM, FRCPC 2009
““Peak PatternPeak Pattern”” of Early of Early Crying BehaviorCrying Behavior
Hunziker & Barr, Pediatrics 1986
4
© Ronald G. Barr, MDCM, FRCPC 2009
!Kung San Gathering!Kung San Gathering(Photos by Marjorie (Photos by Marjorie ShostakShostak))
!Kung San Mother & Infant!Kung San Mother & Infant(Photo by Marjorie (Photo by Marjorie ShostakShostak))
© Ronald G. Barr, MDCM, FRCPC 2009
!Kung San Mother & Infant!Kung San Mother & Infant(Photo by Marjorie (Photo by Marjorie ShostakShostak))
© Ronald G. Barr, MDCM, FRCPC 2009
Western Western CaregivingCaregiving StylesStyles
© Ronald G. Barr, MDCM, FRCPC 2009
CaregivingCaregiving ContextsContexts !Kung San Western Contact Constant Intermittent
Carry Constant Response to cry
Feeding “Continuous” “Pulse”
Posture Upright Supine
Responsivity Universal Occ. Non-response
© Ronald G. Barr, MDCM, FRCPC 2009
Hourly Hourly Cry/Fret DurationCry/Fret Duration in !Kung in !Kung San Infants in Early MonthsSan Infants in Early Months
Barr, Barr, KonnerKonner et al DMCN 1991et al DMCN 1991
Large infant to infant
differences
5
© Ronald G. Barr, MDCM, FRCPC 2009
Hourly Cry/Fret Hourly Cry/Fret FrequencyFrequency in !Kung San, in !Kung San, Dutch, and USA InfantsDutch, and USA Infants
Hourly Cry/Fret Hourly Cry/Fret DurationDuration in !Kung in !Kung San vs. Dutch InfantsSan vs. Dutch Infants
© Ronald G. Barr, MDCM, FRCPC 2009
AgeAge--related Crying Patterns in related Crying Patterns in Preterm InfantsPreterm Infants
(Barr, Chen, Hopkins et al DMCN)
© Ronald G. Barr, MDCM, FRCPC 2009
NN--shaped curves in other shaped curves in other biological functionsbiological functions
Age-related changes in headhead--turning to turning to rattle soundsrattle sounds.
Less “turning towards” and more “no turns” at 2 months.
Field, Muir et al, Child Dev, 1980
© Ronald G. Barr, MDCM, FRCPC 2009
NN--shaped curve in caloric intakeshaped curve in caloric intake
© Ronald G. Barr, MDCM, FRCPC 2009
““Distress CurvesDistress Curves”” have been found have been found in all nonin all non--human mammalian (i.e. human mammalian (i.e.
breast feeding) species breast feeding) species investigated.investigated.
• Guinea pig pups (Pettyjohn, 1979)
• Infant rat pups (Hofer et al, 1999)
• Chimpanzees (Bard, 2000)
• Free-living Rhesus macaques (Barr et al, 2005)
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© Ronald G. Barr, MDCM, FRCPC 2009
Parental Responses to Infant Parental Responses to Infant Chimp DistressChimp Distress
(Bard K, In Barr et al ((Bard K, In Barr et al (edseds) 2000)) 2000)
© Ronald G. Barr, MDCM, FRCPC 2009
Evidence that the Evidence that the ““Crying CurveCrying Curve””is a Behavioral Universal of Infancyis a Behavioral Universal of Infancy
There is a similar pattern and timing in:1. All samples of Western infants2. Cultures with radically different caregiving styles3. Prematures4. A wide variety of human infant biological & behavioral functions5. Non-human species
© Ronald G. Barr, MDCM, FRCPC 2009
What is colic?What is colic?Defining featuresDefining features
(Gormally & Barr, 1997)
1. Age-dependent crying patterns (peak during 2nd month).
2. Associated behaviors (prolonged cry Associated behaviors (prolonged cry bouts, bouts, unsoothabilityunsoothability, , ““pain pain faciesfacies””))
3. “Paroxysmal” (unpredictable)
© Ronald G. Barr, MDCM, FRCPC 2009
UnsoothableUnsoothable Crying BoutsCrying Boutsin London, Copenhagen, and with a in London, Copenhagen, and with a ““proximalproximal””
form of careform of careInfants with Bouts of Unsoothable Crying
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
10 days 5 weeks 12 weeks
Age of Infants
Perc
enta
ge o
f Inf
ants
London CommunityCopenhagen CommunityProximal Care
St James-Roberts, I., Alvarez, M., Csipke, E., Abramsky, T., Goodwin, J., Sorgenfrei, E. Infant crying and sleeping in London, Copenhagen, and when parents adopt a 'proximal' form of care. Pediatrics,2006.
© Ronald G. Barr, MDCM, FRCPC 2009
Uniqueness of Uniqueness of UnsoothableUnsoothableCrying Bouts to Early CryingCrying Bouts to Early Crying
0
10
20
30
40
Min
utes
/day
(mea
n +
1 SD
)
Age
Daily Unsoothable Cry
Non-colic
Colic
6 Weeks 5 Months
By 5 months, the mean amount of
unsoothable crying is 1-3 minutes/day
in all infants.
Barr, Paterson et al, JDBP, 2005
© Ronald G. Barr, MDCM, FRCPC 2009
The early cry is a The early cry is a gradedgradedsignal, not a typological signal, not a typological
sign or signalsign or signal
Gustafson: Can we hear the causes of
infant crying?
“He sounds just like a porpoise”
In Barr, Hopkins, Green: Crying as a Sign, a Symptom and a Signal, London: MacKeith Press, 2000
7
© Ronald G. Barr, MDCM, FRCPC 2009
““If you were a good mother, If you were a good mother, you wouldyou would…”…”
• Listen carefully to the cry and learn to read what the cause of the crying is so that you address the needs of your baby…
• Learn the right way to soothe your infant so that s/he can be calmed and not cry…
© Ronald G. Barr, MDCM, FRCPC 2009
One is crying following a painOne is crying following a painstimulus, one crying before a feed.stimulus, one crying before a feed.
Can you tell which is which?Can you tell which is which?
© Ronald G. Barr, MDCM, FRCPC 2009
What is colic?What is colic?Defining featuresDefining features
((GormallyGormally & Barr, 1997)& Barr, 1997)
1. Age-dependent crying patterns (peak during 2nd month).These are due to changes in the amounts of crying that cluster during the evening.
2. Associated behaviors (prolonged cry bouts, unsoothability, “pain facies”)
3. 3. ““ParoxysmalParoxysmal”” (unpredictable)(unpredictable)
““ClassicClassic”” colic: Paroxysmalcolic: Paroxysmal
• Unpredictable• Begins and ends apparently
unrelated to anything in the environment
• May begin or end “suddenly”
Basic Phenomenon in Basic Phenomenon in ““Well behavedWell behaved””Chaotic Systems: the Lorenz AttractorChaotic Systems: the Lorenz Attractor
NonNon--linear phase transitionslinear phase transitions
GAS
LIQUID
SOLID
Temperature
8
NonNon--linear Phase Transitions in linear Phase Transitions in Behavioral SystemsBehavioral Systems
NonNon--linear Phase Transitions in linear Phase Transitions in Behavioral SystemsBehavioral Systems
Concept of Infant Behavioral Concept of Infant Behavioral StatesStates (Wolff, 1987)(Wolff, 1987)
Infant behavioral states as a linear continuum of “arousal”
Infant behavioral states as distinct, nonlinear, and discontinuous, organizations of behavior.
The The ““ShapeShape”” of Nonof Non--linear linear TransitionsTransitions
““ExplainingExplaining”” Prolonged Crying Bouts, Prolonged Crying Bouts, Resistance to Soothing and Resistance to Soothing and Paroxysmal Crying BoutsParoxysmal Crying Bouts
X1 = soothing attempt while in stable state.
X2 = soothing attempt while in transitional state
Summary re: Summary re: ““ParoxysmalParoxysmal””Crying BoutsCrying Bouts
No pathologic or abnormal mechanism need be postulated to explain unpredictable, paroxysmal, “unexplained” nature of crying bouts.
They are most likely to be classical state transitions in infants functioning as “well-behaved” non-linearly organized behavioral systems.
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““Colic:Colic:”” a a reconceptualizationreconceptualizationRather than thinking of colic as distinctdistinct,
qualitatively differentdifferent, and due to underlying pathophysiologypathophysiology or pathopsychologypathopsychology…
Perhaps we should think of it as continuouscontinuouswith normal behavior, qualitatively similarsimilar, and due to infants acting as as they shouldthey should, or were designed to, act.
© Ronald G. Barr, MDCM, FRCPC 2009
““ColicColic”” has a good outcomehas a good outcome
© Ronald G. Barr, MDCM, FRCPC 2009
Outcome of Outcome of ““coliccolic”” in Infantsin Infants(Lehtonen, Gormally and Barr, 2000)
• Wt. Gain delay Transient• Allergy None• Crying Much reduced• Behavior disturbance None• Temperament difficult None• Sleep problems None• Negative reactivity None
© Ronald G. Barr, MDCM, FRCPC 2009
There are 3 curves, not 1There are 3 curves, not 1
1 2 3 4 5
Wessel’s criteria
© Ronald G. Barr, MDCM, FRCPC 2009
There are 3 curves, not 1There are 3 curves, not 1
1 2 3 4 5
Wessel’s criteria
Persistent mother-infant distress
syndrome (Papousek et al)
#1
#2
© Ronald G. Barr, MDCM, FRCPC 2009
There are 3 curves, not 1There are 3 curves, not 1
1 2 3 4 5
Wessel’s criteria
“Difficult”infant
#3
10
© Ronald G. Barr, MDCM, FRCPC 2009
Clifford et al: Clifford et al: SequelaeSequelae of of Infant ColicInfant Colic
Arch Arch PediatrPediatr AdolescAdolesc Med (2002) 156:1183Med (2002) 156:1183--11881188• Diaries at 6 weeks and 3 months of age• Modified Wessel’s criteria• Of those with colic at 6 weeks:
a. 86.3% did not have colic at 3 months: 13.7% still did (“persistent” colic)
• At 3 months, 6.4% had colic:a. Of these, 50% did not have colic at 6
weeks (in other words, 50% with colic at 3 months “developed” it)
© Ronald G. Barr, MDCM, FRCPC 2009
There are 3 curves, not 1There are 3 curves, not 1
1 2 3 4 5
Wessel’s criteria
Persistent mother-infant distress
syndrome
“Difficult”infant
6.4%6.4%
© Ronald G. Barr, MDCM, FRCPC 2009
Although early increased Although early increased crying (crying (‘‘coliccolic’’) has no long ) has no long term negative outcomes, term negative outcomes,
persistent or repeated elevated persistent or repeated elevated crying crying afterafter 33--4 months 4 months doesdoeshave longhave long--term predictability term predictability
to later poorer outcomesto later poorer outcomes
© Ronald G. Barr, MDCM, FRCPC 2009
LongtermLongterm Effects of Effects of ““PostPost””Curve Crying Curve Crying
• Papousek, Wurmser, von Hofacker: Clinical perspectives on unexplained early crying: challenges and risks for infant mental infant mental healthhealth and parentparent--infant relationshipsinfant relationships. In Barr, St. James-Roberts, Keefe MR (eds) New evidence on unexplained early infant crying: its origins, nature and management, 2001 (289-316)
• Wolke, Rizzo, Woods: Persistent infant crying and hyperactivityhyperactivityproblems in middle childhood. Pediatrics 2002: 109(6):1054-1060.
• Rao MR, Brenner RA, Schisterman EF, Vik T, Mills JL: Long term cognitive developmentcognitive development in children with prolonged crying. Arch DisChild 2004:89:989-992.
• Wake M, Morton-Allen E, Poulakis Z, Hiscock H, Gallagher S, Oberklaid F: Prevalence, stability and outcomes of crycry--fussfuss and sleep problemssleep problems in the first 2 years of life: prospective community-based study. Pediatrics 2006: 117:836-842.
© Ronald G. Barr, MDCM, FRCPC 2009
Typical Assumption:Typical Assumption:Colic is an abnormality,Colic is an abnormality,
or or ““something wrongsomething wrong”” with the with the infant infant
The Argument Against The Argument Against PathologyPathology
Non-pathological mechanisms for primary features:
a. Crying curveb. Unsoothable crying boutsc. Paroxysmal crying
Good outcomea. For infants with classical colic (first 3-4
months)b. Less good for infants with “post-curve”
persistent elevated crying
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© Ronald G. Barr, MDCM, FRCPC 2009
Current EvidenceCurrent Evidence--based based Assumption:Assumption:
Colic and early increased Colic and early increased crying are crying are normalnormal,,
and there is and there is nothing wrongnothing wrongwith the infant with the infant
© Ronald G. Barr, MDCM, FRCPC 2009The Period of PURPLE Crying is a registered trademark and all content is copyright protected. All rights reserved, Ronald G. Barr, MDCM and the National Center on Shaken Baby Syndrome (2004-2008)
In SummaryIn Summary“Colic” is a manifestation of normal behavioral development
“Colic” is the upper end of a continuumof crying behavior in normal infants (like height: some infants are taller and some are shorter)
“Colic” is not an indication of disease in the infant.
© Ronald G. Barr, MDCM, FRCPC 2009
The Phenomena of Early The Phenomena of Early Increased Crying May Be Increased Crying May Be
AdaptiveAdaptive
© Ronald G. Barr, MDCM, FRCPC 2009
The Phenomena of Early The Phenomena of Early Increased Crying May Be Increased Crying May Be
Adaptive:Adaptive:1.1. They contribute to survivalThey contribute to survival
2. They have the properties of an 2. They have the properties of an ““honest signalhonest signal””
© Ronald G. Barr, MDCM, FRCPC 2009
How Crying Signals May Have How Crying Signals May Have Functioned in our Evolutionary Past Functioned in our Evolutionary Past
(after (after BowlbyBowlby))
© Ronald G. Barr, MDCM, FRCPC 2009
Cry as a Stimulus for Milk Cry as a Stimulus for Milk Letdown Letdown (after Lind et al)(after Lind et al)
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© Ronald G. Barr, MDCM, FRCPC 2009
CryCry--Feed Relationship Among Feed Relationship Among !Kung San !Kung San ((KonnerKonner))
Probability of nursing following cry/fret in !Kung San infants, from direct observations
Months of age
Percentage
© Ronald G. Barr, MDCM, FRCPC 2009
Crying promotes motherCrying promotes mother--infant attachment and infant attachment and
““bondingbonding””
Thanks to Pilyoung Kim and colleagues (James Swain, Gary Evans)
© Ronald G. Barr, MDCM, FRCPC 2009
The limbicThe limbic--hypothalamichypothalamic--midbrain circuits called midbrain circuits called ‘‘Maternal CircuitsMaternal Circuits’’ overlap with the overlap with the mesocorticolimbicmesocorticolimbic dopaminargicdopaminargic reward pathwaysreward pathways..
Swain et al. (2007)© Ronald G. Barr, MDCM, FRCPC 2009
Febo, Numan, Ferris, 2005
Rodent mothers have greater activations in the reward circuits while nursing.
© Ronald G. Barr, MDCM, FRCPC 2009
10 sec
Rest
Rest
Rest
Rest
Rest
OwnBabyCry
OtherBabyCry
OwnBabyNoise
OtherBabyNoise
30 sec 30 sec 30 sec 30 sec
Mothers were exposed to Mothers were exposed to cries cries andand picturespictures of their of their own and othersown and others’’ babies.babies.
Own baby Other baby© Ronald G. Barr, MDCM, FRCPC 2009
Insula DLPFC
AmygdalaPeriaqueductal Gray Precuneus
Substantia nigra
Breastfeeding mothers had greater activations in the Breastfeeding mothers had greater activations in the mesocorticolimbicmesocorticolimbic reward circuitreward circuit in response to in response to own own baby crybaby cry at at 22‐‐4 weeks4 weeks postpartum. postpartum.
p<.05, corrected
Also, hypothalamus, VTA, OFC, Putamen
13
© Ronald G. Barr, MDCM, FRCPC 2009
Thalamus
Visual CortexSubstantia nigra Head of Caudate
DL Prefrontal Cortex
Insula
Precuneus
p<.05, corrected
Breastfeeding mothers had greater activations in the mesocorticolimbic reward circuit in response to own baby cry at 3‐4 months postpartum.
© Ronald G. Barr, MDCM, FRCPC 2009
Thalamus InsulaPosterior Cingulate
Amygdala
Breastfeeding mothers had greater activations in the Breastfeeding mothers had greater activations in the mesocorticolimbicmesocorticolimbic reward circuitreward circuit in response to in response to own own baby picturesbaby pictures at at 22‐‐4 weeks4 weeks postpartum.postpartum.
p<.05, corrected
Substantia Nigra
Also, OFC, VTA, Putamen, fusiform gyrus, precuneus
© Ronald G. Barr, MDCM, FRCPC 2009
CaudateAnterior Cingulate Prefrontal Corex
DifferencesDifferences in brain responses to in brain responses to own baby picture own baby picture among two groups decrease at 3among two groups decrease at 3‐‐4 months4 months postpartum postpartum became became smallersmaller. .
p<.05, corrected© Ronald G. Barr, MDCM, FRCPC 2009
Crying Levels and Crying Levels and ““AffectiveAffective””Caregiver Responses Caregiver Responses ((AceboAcebo & & ThomanThoman))
Higher levels of crying are associated with increased levels of positive interaction
Even the highest levels of crying are associated with more positive interaction than the lowest levels of crying
““ModelingModeling”” Adaptive Value of Cry Adaptive Value of Cry Functions: CryFunctions: Cry--FeedFeed 11stst PathwayPathway
““ModelingModeling”” Adaptive Value of Cry Adaptive Value of Cry Functions: CryFunctions: Cry--AttachmentAttachment
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© Ronald G. Barr, MDCM, FRCPC 2009
Summary: the Summary: the ““goodgood””• Early crying may be
advantageous for survival
Soltis J (2004) “The signal functions of early infant crying” Beh & Brain
Sciences, 27(4): 443-458
Barr RG (2004) “Infant crying as a behavioral state rather than a signal”
BBS 27(4), 460
© Ronald G. Barr, MDCM, FRCPC 2009
Some clinical implications Some clinical implications of the normality of early of the normality of early
increased cryingincreased crying
© Ronald G. Barr, MDCM, FRCPC 2009
1 2 3 4 5
Crying started to increase
Stopped breast-feeding; start Similac
Change to soy
Vitamins
Goat’s milk—success!
For the parent: Scott the For the parent: Scott the High CrierHigh Crier----MarilynMarilyn’’s Storys Story
Months of age © Ronald G. Barr, MDCM, FRCPC 2009
Clinical ImplicationsClinical Implications• If you do not take the curve into account,
therapeutic interventions can be misinterpreted as effective when they are not effective, or ineffective when they are effective
© Ronald G. Barr, MDCM, FRCPC 2009
Clinical ImplicationsClinical Implications
1 2 3 4 5
Wessel’s criteria
“False positive” effective
“False negative”ineffective
© Ronald G. Barr, MDCM, FRCPC 2009
Clinical ImplicationsClinical Implications• If you do not take the curve into account,
therapeutic interventions can be misinterpreted as effective when the are not effective, or ineffective when they are effective
• ALL infants experience the curve, and “organic causes” only move the infant “up” within the range of crying
15
© Ronald G. Barr, MDCM, FRCPC 2009
Clinical ImplicationsClinical Implications
1 2 3 4 5
Wessel’s criteria
© Ronald G. Barr, MDCM, FRCPC 2009
New York New York TimesTimes
July 8, 1944
“…who admitted that he had killed his 31/2 week old daughter because she cried too much…”
© Ronald G. Barr, MDCM, FRCPC 2009
The ShakingThe Shaking
• Weak Neck Muscles
• Normal Large Head to Body ratio
• Violent,sustainedshaking
© Ronald G. Barr, MDCM, FRCPC 2009
Intracranial Intracranial ““CascadeCascade”” from Shakingfrom Shaking
© Ronald G. Barr, MDCM, FRCPC 2009
Mechanical Stresses During Mechanical Stresses During Shaking & Eye LesionsShaking & Eye Lesions
© Ronald G. Barr, MDCM, FRCPC 2009
Outcomes of Hospitalized Outcomes of Hospitalized CasesCases
• 20-35% die• Of the survivors, 65-80% have
significant long term neurological and developmental abnormalities
16
© Ronald G. Barr, MDCM, FRCPC 2009
Why is crying in Why is crying in normalnormal infants infants relevant to Shaken Baby relevant to Shaken Baby
Syndrome?Syndrome?
© Ronald G. Barr, MDCM, FRCPC 2009
Questionnaire Study of Soothing Methods in Holland
van der Wal et al, Arch Dis Child, 1998
Techniques used to soothe infants:
1. Smother 2%2. Slap 3%3. Shake 5%
© Ronald G. Barr, MDCM, FRCPC 2009
Runyan.Runyan.TheThe challenges of assessing the challenges of assessing the incidence of inflicted traumatic brain injury: A incidence of inflicted traumatic brain injury: A
world perspective.world perspective.Amer J Prev Med 2008;34 (4S)
“The impact of these private acts must be further studied as there may be other long-lasting and serious intracranial impacts that have not been characterized.”
© Ronald G. Barr, MDCM, FRCPC 2009
The The ““crying curvecrying curve””(Brazelton, 1962) Hypothesis:Hypothesis: IF crying was a
significant stimulus for sbs, THEN the pattern of age-
related incidence of sbs should be similar to the age-related
properties of the crying curve
© Ronald G. Barr, MDCM, FRCPC 2009
AgeAge--specific incidence of specific incidence of hospitalizedhospitalized cases of SBScases of SBS
(Barr, Trent et al Child Abuse & Neglect 2006)
0
5
10
15
20
25
30
35
40
45
50
0 8 16 24 32 40 48 56 64 72 80
Age (weeks)
No.
of c
ases
© Ronald G. Barr, MDCM, FRCPC 2009
AgeAge--specific Incidence ofspecific Incidence ofPubliclyPublicly--reportedreported Cases of SBSCases of SBS
(Lee, Barr et al JDBP 2007)
0
20
40
60
80
100
120
0-4 5-8 9-12 13-16 17-20 21-24 25-28 29-32 33-36 37-40 41-44 45-48 49-52 53-56 57-60 61-64 65-68 69-72 73-76 77-80
Baby's Age (weeks)
No.
of C
ases
Crying Stimuli (n=166) All Stimuli (n=591)
17
© Ronald G. Barr, MDCM, FRCPC 2009
Curves of Early Crying and Curves of Early Crying and SBS IncidenceSBS Incidence
1 2 3 4 5Months of Age
Lag
Ons
et
Cry Curve
SBS Curve
© Ronald G. Barr, MDCM, FRCPC 2009
Sheets L et al.:Sheets L et al.:Sentinel injuries Sentinel injuries precede abusive precede abusive
head trauma in head trauma in infantsinfants
Presented Presented HelferHelfer Society, Society, Sept 2008, Tucson, AZSept 2008, Tucson, AZ
Used with permission from L. Sheets
© Ronald G. Barr, MDCM, FRCPC 2009
Pathways to ShakingPathways to Shaking
Crying
Threshold
Frustration ……….Anger
Shaking
© Ronald G. Barr, MDCM, FRCPC 2009
The Pathways to Prevention:The Pathways to Prevention:AppropriatenessAppropriateness
of Adviceof Advice
Crying
Threshold
Frustration ……….Anger
Shaking
AppropriateAccurateAdvice
© Ronald G. Barr, MDCM, FRCPC 2009
The Pathways to Shaking:The Pathways to Shaking:Wrong Advice?Wrong Advice?
Crying
Threshold
Frustration ……….Anger
Shaking
InaccurateInappropriate
WrongAdvice
••Must not result in Must not result in more harm than goodmore harm than good
© Ronald G. Barr, MDCM, FRCPC 2009
The Period of PURPLE The Period of PURPLE CryingCrying
PP Peak of CryingPeak of CryingUU UnexpectedUnexpectedR R Resists SoothingResists SoothingPP PainPain--like Facelike FaceLL Long LastingLong Lasting
EE EveningEvening
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© Ronald G. Barr, MDCM, FRCPC 2009
Five Things We Think We KnowFive Things We Think We Know• The “crying curve” (and “colic”) is a behavioral
universal of infancy• Unsoothable bouts are unsoothable!• Post-curve, persistent or repeated elevated
crying after 3-4 months is an important, but different, phenomenon, and has long-term predictability to later outcomes;
• The early cry is a graded signal, not a typological sign or signal
• The most important negative clinical consequence of “colic” for the infant is shaken baby syndrome or infant abuse
© Ronald G. Barr, MDCM, FRCPC 2009
Both Jack and I Both Jack and I thank youthank you
© Ronald G. Barr, MDCM, FRCPC 2009
How Do How Do ““Increasing Increasing Carry, Comfort, Walk Carry, Comfort, Walk
and Talk and Talk ResponsesResponses”” Work?Work?
Fuss Cry
F C
Increasing contact reduces distress Inconsolable Cry
But it does not reduce inconsolable crying
50% less
CrossCross--species species CaregivingCaregiving and and BreastmilkBreastmilk CompositionComposition
Blurton-Jones
© Ronald G. Barr, MDCM, FRCPC 2009
Infants with ColicInfants with Colicin London, Copenhagen, and with a in London, Copenhagen, and with a
““proximalproximal”” form of careform of careInfants with "Colic"
0%
2%
4%
6%
8%
10%
12%
14%
16%
18%
10 days 5 weeks 12 weeks
Age of Infants
Perc
enta
ge o
f Inf
ants
London CommunityCopenhagen CommunityProximal Care
*
* denotes χ2 test where p < 0.001
St James-Roberts, I., Alvarez, M., Csipke, E., Abramsky, T., Goodwin, J., Sorgenfrei, E. Infant crying and sleeping in London,Copenhagen, and when parents adopt a 'proximal' form of care. Pediatrics, 2006.
A counter-example or an explainable
variant?
© Ronald G. Barr, MDCM, FRCPC 2009
ReconceptualizationReconceptualization of of ““Colic:Colic:””Colic is a manifestation of normal Colic is a manifestation of normal
behavioralbehavioral developmentdevelopmentAll of the features of the crying definitive of
excessive crying (or “colic”) can be understood as manifestations of the upper end of a spectrum of crying behavior that is typical of normally normally developing infantsdeveloping infants rather than a distinct crying pattern indicative of underlying disease in the infant or psychopathology in the caregiver(s).
19
© Ronald G. Barr, MDCM, FRCPC 2009
Moderate Retinal Hemorrhage in Moderate Retinal Hemorrhage in Shaken Baby SyndromeShaken Baby Syndrome
Courtesy Alex Levin, MDCourtesy Alex Levin, MD
Guinea Pig Distress as a Function of Guinea Pig Distress as a Function of ““PlacePlace”” & Mother Presence & Mother Presence ((PettijohnPettijohn 1979)1979)
Levels of Levels of Description Description of Cryingof Crying
Barr (1990) Human Nature 1: 355-389
A proposed taxonomy for describing crying phenomena, in which “cycles,” “events” and “bouts” are related hierarchically in terms of the cry cycles and how they are related to each other
Events
Cycles
Bouts
Coded State Changes between Coded State Changes between CryingCrying and and AlertAlert
!Kung San Hunters!Kung San Hunters(Courtesy Marjorie (Courtesy Marjorie ShostakShostak))
© Ronald G. Barr, MDCM, FRCPC 2009
NN--shaped curves in habituation to shaped curves in habituation to visual stimulivisual stimuli
20
© Ronald G. Barr, MDCM, FRCPC 2009
Is there an Is there an ““early crying peakearly crying peak”” in freein free--ranging Rhesus macaques?ranging Rhesus macaques?
(Barr, Warfield, Catherine SRCD Apr 9, 2005)(Barr, Warfield, Catherine SRCD Apr 9, 2005)
0
5
10
15
20
25
30
35
0-6 7-12 13-18 19-24 25-30 31-36 37-42Age (Weeks)
Rat
e Di
stre
ss V
ocal
izat
ions
(dv/
hr) Mean
Median
Time Spent in Time Spent in ““CryingCrying”” or or ““AlertAlert””
States or States or ““In In transitiontransition””
Frequency histograms of % negative vocalizations in 10-second blocks, prior to (upper graph) and following (lower graph) taste administrations.
Negative Vocalizations:
CryingCrying = 100%
AlertAlert = 0%
TransitionTransition = 10-90%
Barr, Beek & Calinoiu, 1999
© Ronald G. Barr, MDCM, FRCPC 2009
Methodological Caveat for Methodological Caveat for Measuring CurvesMeasuring Curves
Principle:You must make enough measurements at the right times to capture the properties of the phenomenon you are measuring.
© Ronald G. Barr, MDCM, FRCPC 2009
Is there a "curve"?
0
20
40
60
80
100
120
140
160
180
w1 w2 w3 w4 w5 w6 w7 w8 w9w10
w11w12
Recording Week
Min
utes
/day
Dis
tress
Brazelton
Green diamonds includes St J-R (1999)
Symposium organized by M.
Alvarez, Stockholm
“6 weeks of age” is week 7 of life