A support package for parents of excessively crying infants: development and feasibility study.

BACKGROUND: Around 20% of 1- to 4-month-old infants cry for long periods without an apparent reason. Traditionally, this was attributed to gastrointestinal disorder ('colic'), but evidence shows that just 5% of infants cry a lot because of organic disturbances; in most cases, the crying is attributable to normal developmental processes. This has led to a focus on the impact of the crying on parents. Parental vulnerabilities influence how parents evaluate and respond to the crying and predict adverse outcomes. By developing evidence-based services that support parents, this study was designed to take the first steps towards national health services that enhance the coping and well-being of parents whose babies excessively cry. Related aims were to improve these infants' outcomes and how NHS money is spent. OBJECTIVES: To develop a novel intervention package to support parents of excessively crying infants and to examine the feasibility of delivering and evaluating it in the NHS. DESIGN: Stage 1 of this study aimed to (1) complete a literature review to identify example support materials, (2) obtain parents' guidance on the support needed when a baby cries excessively, together with their evaluation of the example materials, and (3) develop a support package based on the results. Stage 2 aimed to (1) recruit 60 parents whose babies were currently excessively crying, (2) assess parents' and NHS professionals' willingness to complete a study of the support package, (3) measure the use and evaluation of the package components, (4) estimate the package component costs and (5) provide evidence on the feasibility and methods for a large-scale trial. SETTING: Primary health care. PARTICIPANTS: Stage 1: 20 parents of previously excessively crying infants and 55 health visitors (HVs) or specialist community public health nurses (SCPHNs). Stage 2: 57 parents of currently excessively crying infants and 124 HVs/SCPHNs. INTERVENTIONS: The support package included a website, a printed booklet and a programme of cognitive-behavioural therapy-based sessions delivered to parents by a qualified practitioner. MAIN OUTCOME MEASURES: (1) Demographic data, (2) figures for parents' use of the package components and continuation in the study, (3) parents' and HVs'/SCPHNs' ratings of the package components and suitability for NHS use, (4) questionnaire measures of parental well-being and infant health and (5) costs. RESULTS: Most parents (95%) accessed the website or printed materials and half (51%) attended the practitioner sessions. All 52 parents and 85% of HVs/SCPHNs providing data would support the inclusion of the package in the NHS. It was associated with reduced parental frustration, anxiety, depression, reported infant crying and contacts with health professionals and increased knowledge about crying. Methods for a full trial and figures for the cost of excessive infant crying for the NHS and each package element were identified. LIMITATIONS: No control group was included. Most of the recruited parents were white, well educated and in stable relationships. CONCLUSIONS: Parents and HVs/SCPHNs recognise the need for NHS provisions that support parents of excessively crying babies and consider the materials developed to meet that need. A full-scale randomised controlled trial is feasible and desirable. TRIAL REGISTRATION: Current Controlled Trials ISRCTN84975637. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 56. See the NIHR Journals Library website for further project information.

INTRODUCTION: This study is a first step in developing evidence-based NHS services to support parents whose babies cry excessively. BACKGROUND: Around one-fifth of babies cry a lot without an apparent reason. This 'excessive' infant crying used to be known as 'colic' and was blamed on indigestion pain. Recent evidence suggests that only 5% of infants taken to the doctor because of excessive crying are actually unwell. The crying peak and 'unsoothable' crying bouts that alarm parents in early infancy usually stop by themselves once the baby is 5 months old and are probably attributable to normal developmental processes. Although most babies who cry a lot are well, the crying can distress parents and lead to poor consequences; these include overfeeding, stopping breastfeeding, maternal depression, poor parent­child relationships, problems with child development and, in extreme cases, infant abuse. By developing NHS services that support parents to manage excessive infant crying, this project aimed to improve parents' well-being, long-term outcomes and how NHS money is spent. FINDINGS: In stage 1 of the study (development of an intervention package), the research evidence was reviewed and parents whose babies previously cried excessively and NHS health visitors (HVs) and specialist community public health nurses (SCPHNs) were involved to develop evidence-based support materials. These included a website, a printed booklet and support sessions with a qualified practitioner. In stage 2 (a feasibility study of package implementation in the NHS), HVs/SCPHNs helped to recruit 57 parents whose babies were currently excessively crying. On average, these babies cried for 6.9 hours per day. Most parents accessed the website or booklet and half attended the practitioner sessions. The package was associated with reduced parental anxiety and depression, and all 52 parents and 85% of HVs/SCPHNs who gave an opinion considered that it should be included in the NHS. Findings for the cost of each package element and suggestions for future services were provided.

Parental and health professional evaluations of a support service for parents of excessively crying infants.

BACKGROUND: The 'Surviving Crying' study was designed to develop and provisionally evaluate a support service for parents of excessively crying babies, including its suitability for use in the United Kingdom (UK) National Health Service (NHS). The resulting service includes three materials: a website, a printed booklet, and a Cognitive Behaviour Therapy (CBT) programme delivered to parents by a qualified professional. This study aimed to measure whether parents used the materials and to obtain parents' and NHS professionals' evaluations of whether they are fit for purpose. Parents were asked about participating in a randomised controlled trial (RCT) to evaluate the materials fully in health service use. METHODS: Participants were 57 parents with babies they judged to be crying excessively and 96 NHS Health Visitors (HVs). Parental use and parents' and HVs' ratings of the Surviving Crying materials were measured. RESULTS: Thirty four parents reported using the website, 24 the printed booklet and 24 the CBT sessions. Parents mostly accessed the website on mobile phones or tablets and use was substantial. All the parents and almost all HVs who provided data judged the materials to be helpful for parents and suitable for NHS use. If offered a waiting list control group, 85% of parents said they would have been willing to take part in a full RCT evaluation of the Surviving Crying package. DISCUSSION AND CONCLUSIONS: The findings identify the need for materials to support parents of excessively crying babies within national health services in the UK. The Surviving Crying support package appears suitable for this purpose and a full community-level RCT of the package is feasible and likely to be worthwhile. Limitations to the study and barriers to delivery of the services were identified, indicating improvements needed in future research. TRIAL REGISTRATION: Study Registration no. ISRCTN84975637 .

Parenting the Crying Infant.

Crying conveys evidence about an infant's state and neurological health which, when carefully assessed, can provide diagnostic information for parents and clinicians. When crying is inconsolable or judged to be excessive, it can stress parents, disrupt parenting and, in rare cases, place an infant at risk for abuse. Research has revealed physiological and neural responses to crying that may predispose some adults to maltreat infants. Although this work suggests that parental vulnerabilities contribute to insensitive or aggressive reactions, there is a growing recognition that exposure to large doses of crying may be a challenge for all adults. Support programmes that inform parents about infant crying, enhance parenting, and improve parental wellbeing and coping, are under development with promising initial findings.

Video evidence that parenting methods predict which infants develop long night-time sleep periods by three months of age.

Aim To examine two hypotheses about the longitudinal relationship between night-time parenting behaviours in the first few postnatal weeks and infant night-time sleep-waking at five weeks, three months and six months of age in normal London home environments. BACKGROUND: Most western infants develop long night-time sleep periods by four months of age. However, around 20-30% of infants in many countries continue to sleep for short periods and cry out on waking in the night: the most common type of infant sleep behaviour problem. Preventive interventions may help families and improve services. There is evidence that 'limit-setting' parenting, which is common in western cultures, supports the development of settled infant night-time behaviour. However, this evidence has been challenged. The present study measures three components of limit-setting parenting (response delay, feeding interval, settling method), examines their stability, and assesses the predictive relationship between each of them and infant sleep-waking behaviours. METHODS: Longitudinal observations comparing a General-Community (n=101) group and subgroups with a Bed-Sharing (n=19) group on infra-red video, diary and questionnaire measures of parenting behaviours and infant feeding and sleep-waking at night. Findings Bed-Sharing parenting was highly infant-cued and stable. General-Community parenting involved more limit-setting, but was less stable, than Bed-Sharing parenting. One element of General-Community parenting - consistently introducing a short interval before feeding - was associated with the development of longer infant night-time feed intervals and longer day-time feeds at five weeks, compared with other General-Community and Bed-Sharing infants. Twice as many General-Community infants whose parents introduced these short intervals before feeding in the early weeks slept for long night-time periods at three months of age on both video and parent-report measures, compared with other General-Community and Bed-Sharing infants. The findings' implications for our understanding of infant sleep-waking development, parenting programmes, and for practice and research, are discussed.

Descriptive figures for differences in parenting and infant night-time distress in the first three months of age.

Aim To provide descriptive figures for infant distress and associated parenting at night in normal London home environments during the first three months of age. BACKGROUND: Most western infants develop long night-time sleep periods by four months of age. However, 30% of infants in many countries sleep for short periods and cry out on waking in the night: the most common type of infant sleep behaviour problem. Preventive interventions may help families and improve services. There is evidence that 'limit-setting' parenting, which is common in western cultures, supports the development of settled infant night-time behaviour. However, a recent review has challenged this and argued that this form of parenting risks distressing infants. This study describes limit-setting parenting as practiced in London, compares it with 'infant-cued' parenting and measures the associated infant distress. METHODS: Longitudinal infrared video, diary and questionnaire observations comparing a General-Community (n=101) group and subgroups with a Bed-Sharing (n=19) group on measures of infant and parenting behaviours at night. Findings General-Community parents took longer to detect and respond to infant waking and signalling, and to begin feeding, compared with the highly infant-cued care provided by Bed-Sharing parents. The average latency in General-Community parents' responding to infant night-time waking was 3.5 min, during which infants fuss/cried for around 1 min. Compared with Bed-Sharing parenting, General-Community parenting was associated with increased infant distress of around 30 min/night at two weeks, reducing to 12 min/night by three months of age. However, differences in infant distress between General-Community subgroups adopting limit-setting versus infant-cued parenting were not large or statistically significant at any age. The figures provide descriptive evidence about limit-setting parenting which may counter some doubts about this form of parenting and help parents and professionals to make choices.

Childhood Functional Gastrointestinal Disorders: Neonate/Toddler.

In 2006, a consensus concerning functional gastrointestinal intestinal disorders (FGIDs) in infants and toddlers was described. At that time little evidence regarding epidemiology, pathophysiology, diagnostic work-up, treatment strategies and follow-up was available. Consequently the criteria for the clinical entities were more experience than evidence based. In the past decade, new insights have been gained in the different FGIDs in these age groups. Based on those, further revisions have been made to the criteria. The description of infant colic has been expanded to include criteria for the general pediatrician and specific criteria for researchers. The greatest change was the addition of a paragraph regarding the neurobiology of pain in infants and toddlers, including the understanding of the neurodevelopment of nociception and of the wide array of factors that may impact the pain experience.

The Surviving Crying study: progress report for the first stage of research.

The term 'infant colic' has been used to refer both to 'prolonged' infant crying (a measure of crying) and to parents'concern thatexcessive'crying is a sign that something is wrong with their baby. There is growing evidence that the terms need to be distinguished, so that the traditional focus on the crying is balanced by an equal focus on the impact of the crying on parents. The Surviving Crying study is a first step towards developing and evaluating routine NHS services to support parents who are worried about their baby's excessive crying. This report summarises the study's overall aims and methods and describes the first stage, designed to develop this parental support package. The package comprises a website, printed materials for parents who do not use the internet and a CBT-based programme manual for delivering direct one-to-one or small-group support sessions to parents. Stage two of the study, designed to provide an initial evaluation of the package and its suitability for use in the NHS, is underway. An email address exists for practitioners and researchers who wish to be kept informed.

Video Evidence That London Infants Can Resettle Themselves Back to Sleep After Waking in the Night, as well as Sleep for Long Periods, by 3 Months of Age.

OBJECTIVE: Most infants become settled at night by 3 months of age, whereas infants not settled by 5 months are likely to have long-term sleep-waking problems. We assessed whether normal infant development in the first 3 months involves increasing sleep-period length or the ability to resettle autonomously after waking in the night. METHODS: One hundred one infants were assessed at 5 weeks and 3 months of age using nighttime infrared video recordings and parental questionnaires. RESULTS: The clearest development was in sleep length; 45% of infants slept continuously for ≥5 hours at night at 3 months compared with 10% at 5 weeks. In addition, around a quarter of infants woke and resettled themselves back to sleep in the night at each age. Autonomous resettling at 5 weeks predicted prolonged sleeping at 3 months suggesting it may be a developmental precursor. Infants reported by parents to sleep for a period of 5 hours or more included infants who resettled themselves and those with long sleeps. Three-month olds fed solely breast milk were as likely to self-resettle or have long sleep bouts as infants fed formula or mixed breast and formula milk. CONCLUSIONS: Infants are capable of resettling themselves back to sleep in the first 3 months of age; both autonomous resettling and prolonged sleeping are involved in "sleeping through the night" at an early age. Findings indicate the need for physiological studies of how arousal, waking, and resettling develop into sustained sleeping and of how environmental factors support these endogenous and behavioral processes.

Preventing early infant sleep and crying problems and postnatal depression: a randomized trial.

OBJECTIVE: To evaluate a prevention program for infant sleep and cry problems and postnatal depression. METHODS: Randomized controlled trial with 781 infants born at 32 weeks or later in 42 well-child centers, Melbourne, Australia. Follow-up occurred at infant age 4 and 6 months. The intervention including supplying information about normal infant sleep and cry patterns, settling techniques, medical causes of crying and parent self-care, delivered via booklet and DVD (at infant age 4 weeks), telephone consultation (8 weeks), and parent group (13 weeks) versus well-child care. Outcomes included caregiver-reported infant night sleep problem (primary outcome), infant daytime sleep, cry and feeding problems, crying and sleep duration, caregiver depression symptoms, attendance at night wakings, and formula changes. RESULTS: Infant outcomes were similar between groups. Relative to control caregivers, intervention caregivers at 6 months were less likely to score >9 on the Edinburgh Postnatal Depression Scale (7.9%, vs 12.9%, adjusted odds ratio [OR] 0.57, 95% confidence interval [CI] 0.34 to 0.94), spend >20 minutes attending infant wakings (41% vs 51%, adjusted OR 0.66, 95% CI 0.46 to 0.95), or change formula (13% vs 23%, P < .05). Infant frequent feeders (>11 feeds/24 hours) in the intervention group were less likely to have daytime sleep (OR 0.13, 95% CI 0.03 to 0.54) or cry problems (OR 0.27, 95% CI 0.08 to 0.86) at 4 months. CONCLUSIONS: An education program reduces postnatal depression symptoms, as well as sleep and cry problems in infants who are frequent feeders. The program may be best targeted to frequent feeders.

Distinguishing infant prolonged crying from sleep-waking problems.

OBJECTIVE: Infants who cry a lot, or are unsettled in the night, are common sources of concern for parents and costly problems for health services. The two types of problems have been linked together and attributed to a general disturbance of infant regulation. Yet the infant behaviours involved present differently, at separate ages and times of day. To clarify causation, this study aims to assess whether prolonged crying at 5-6 weeks (the peak age for crying) predicts which infants are unsettled in the night at 12 weeks of age (when most infants become settled at night). METHODS: Data from two longitudinal studies are analysed. Infant crying data were obtained from validated behaviour diaries; sleep-waking data from standard parental questionnaires. RESULTS: A significant, weak relationship was found between crying at 5-6 weeks and 12-week night waking and signalling in one study, but not the other. Most infants who met the definition for prolonged crying/colic at 5-6 weeks were settled during the night at 12 weeks of age; they were not more likely than other infants to be unsettled. CONCLUSIONS: Most infants who cry a lot at 5-6 weeks of age 'sleep through the night' at 12 weeks of age. This adds to evidence that the two types of problematic behaviour have different causes, and that infant sleep-waking problems usually involve maintenance of signalling behaviours rather than a generalised disturbance.

Infant crying and sleeping: helping parents to prevent and manage problems.

This article summarizes the current understanding of infant crying and sleeping problems, together with the implications of this understanding for services and research, with a focus on the first months of infancy.

Infant crying and sleeping in London, Copenhagen and when parents adopt a "proximal" form of care.

OBJECTIVE: Western parents are given conflicting advice about whether to introduce a "scheduled" approach to infant care or to follow their infants' demands. Attempts to address this issue using randomized, controlled trials have been unsuccessful. This comparative study collected evidence about methods of parenting and associated infant crying and sleeping in 2 communities with substantially different approaches to infant care (London, United Kingdom, and Copenhagen, Denmark) and in a "proximal care" group, where parents planned to hold their infants > or =80% of the time between 8 am and 8 pm, breastfeed frequently, and respond rapidly to infant cries. METHODS: Validated behavior diaries were used to measure parental behavior and infant crying and night waking longitudinally at 8 to 14 days, 5 to 6 weeks, and 10 to 14 weeks of age. Feeding and sleeping practices were measured by questionnaire. RESULTS: Proximal care parents held infants for 15 to 16 hours per 24 hours and coslept with them through the night more often than other groups. London parents had 50% less physical contact with their infants than proximal care parents, including less contact when the infants were crying and when awake and settled. London parents also abandoned breastfeeding earlier than other groups. Copenhagen parents fell in between the other groups in measures of contact and care. These differences in caregiving were associated with substantial differences in several aspects of infant crying and settled behavior at night. London infants cried 50% more overall than infants in both other groups at 2 and 5 weeks of age. However, bouts of unsoothable crying occurred in all 3 of the groups, and the groups did not differ in unsoothable bouts or in colicky crying at 5 weeks of age. Proximal care infants woke and cried at night most often at 12 weeks. Compared with proximal care infants, Copenhagen infants cried as little per 24 hours, but woke and cried at night less often at 12 weeks of age. CONCLUSIONS: "Infant-demand" care and conventional Western care, as practiced by London parents, are associated with different benefits and costs. As used by proximal care and Copenhagen parents, infant demand parenting is associated with less overall crying per 24 hours. However, the proximal form of infant-demand parenting is associated with more frequent night waking and crying at 12 weeks of age. Copenhagen infants cry as little per 24 hours as proximal care infants but are settled at night like London infants at 12 weeks of age. Colicky crying bouts at 5 weeks of age are unaffected by care. The findings have implications for public health care policy. First, they add to evidence that bouts of unsoothable crying, which are common in early infancy, are not much affected by variations in parenting, providing reassurance that this aspect of infant crying is not parents' fault. Second, the findings provide information that professionals can give to parents to help them to make choices about infant care. Third, the findings support some experts' concerns that many English parents are adopting methods of care that lead to increased crying in their infants. There is a need for informed debate among professionals, policy makers, and parents about the social and cultural bases for the marked differences between London and Copenhagen parents' approach to care.

Attention development in 10-month-old infants selected by the WILSTAAR screen for pre-language difficulties.

BACKGROUND: WILSTAAR comprises a programme for identifying and treating 8-10-month-old infants who are at risk of language and cognitive difficulties. It has been adopted by health trusts, and included in Sure Start intervention schemes, throughout the UK. This study addresses one of the main queries raised by critics of the programme, by providing evidence about the psychological abilities of infants who fail the WILSTAAR screening assessment. METHODS: Thirty 10-month-old infants who failed the screen ('at-risk' infants) and 30 gender- and age-matched infants who passed the screen ('not-at-risk' infants) were assessed using a standard, validated measure of attention, the Distractibility Task. RESULTS: The at-risk infants were found to have poorer focused attention, and were more distractible, than the not-at-risk infants. The not-at-risk infants were quicker in deducing that distractor slides included in the task were of little importance, spent more sustained periods of time in focused attention on toy play, and were quicker in learning to use the information available in the task. CONCLUSIONS: The findings contribute to knowledge about infants' psychological development and provide partial support for the thinking underlying WILSTAAR. Evidence was found to support concerns about the accuracy of the WILSTAAR screening assessment, and issues about the trade-off between assessment age and the inclusion of WILSTAAR in routine services are discussed.

Do pregnancy and childbirth adversities predict infant crying and colic? Findings and recommendations.

Bouts of unexplained crying in 1- to 3-month-old infants are a common problem for parents and health services. One proposed explanation has linked the crying to preceding adversities, such as maternal stress and cigarette smoking during pregnancy and complications during childbirth. In the first part of this review, we argue that studies of these links have methodological shortcomings, and make recommendations about the safeguards needed to overcome these shortcomings. In part two, we present a study that assesses the relations between adversity indices and validated measures of crying in two separate cohorts of infants. Four indices of childbirth adversity predicted infant crying separately and cumulatively in cohort 1, but not in cohort 2. We conclude that there is a need for further research that includes replication and other safeguards. Infant crying is a highly emotional issue for many parents. Before researchers add to their burden by claiming that maternal prenatal anxiety, cigarette smoking, or labour medication, contribute to their baby's crying, we need to be sure of our grounds.

Individual differences in responsivity to a neurobehavioural examination predict crying patterns of 1-week-old infants at home.

Unexplained crying in infants aged 1 to 3 months is a common concern for Western parents and health services. This study examined the hypothesis that the crying is due to high infant responsivity, and provides evidence about the types of stimulation that trigger crying in infants who present with high responsivity. The sample included 93 eight-day-old infants from a community sample (47 females, 46 males; mean birthweight 3457g; mean gestation 39.4 weeks; mean Apgar scores 8.28 at 1 minute and 9.59 at 5 minutes). Infants were tested for their response to two standard, mildly challenging, procedures: a neurobehavioural test involving undressing, putting down, and handling, and the Guthrie test, involving a painful heel prick to obtain a blood sample. The infants' crying over 24 hours was recorded in parental diaries. Newborn infants who exhibited high responsivity during the neurobehavioural assessment cried, rather than fussed, the most at home. High responsivity during the neurobehavioural assessment also predicted those infants who cried a lot and met a definition of 'colic' at home. The findings support the responsivity hypothesis and show that infants with high responsivity are upset by undressing, putting down, and sustained handling. Explanations for this and implications for the management of infant crying and colic are discussed.