Dr. Karp lecture notes: The Happiest Baby

Harvey Karp, MD, Asst Prof Pediatrics, UCLA School of Medicine

A New Perspective

A mind once stretched to a new idea never returns to its original size.” – Oliver Wendell Holmes

  • Crying – What is it? How does it affect us?
  • New ideas to ↑ calm and ↑ sleep: The 4th Trimester…The Calming Reflex…The 5S’s

New parents have two main jobs: feed their baby successfully & calm crying

Until recently, there wasn’t much hope offered to parents of crying babies

  • What To Expect – “…you may not be able to quiet the screaming…live with it.”
  • Brazelton – Touchpoints – “…babies in my practice cry for 1-1.5 hours a day.”
  • In 1972, we prescribed sedatives/opium!
  • Story of the !Kung San – “!Kung babies have same frequency of crying , but parents reported to calm the cries w/i 30 sec 90% of time (60% of episodes are stopped w/i 5 sec).” – Konner 2005; Barr, Konner 1991

The Crying Reflex – One of > 70 neonatal reflexes…nature’s built-in smoke alarm!

Colic and the Rule of 3s – Brazelton, Peds, 1962

Crying is rough!
Exhaustion…Nursing failure…Marital stress…Depression…SIDS…Child abuse

Exhaustion and Insecurity
Baby’s cry = lawnmower (100 dB), triggers stress reaction in adults

Interferes with Nursing
↓ Latch… ↓ Production… ↓ Let down… ↓ Confidence in milk & self… ↓ Family support… Bernal
(10% of parents of fussy babies stopped breastfeeding in response to crying – van der Wal AJDC 1998)
(1323 women ~50% stopped breast b/c “baby not satisfied” or “too little milk” – Li Pediatrics 2008)
(>50,000 #1 reason >4w/o stopped breast “baby not satisfied” – Ahluwalia Pediatrics 2005)

Marital Stress
91% of parents with colicky babies had severe marital stress
Levitzky and Cooper, Clin Peds, 2000

Postpartum Depression

  • PPD is highly correlated with infant colic and maternal fatigue on postpartum day 14.
    Howell et al, Matern Child Health J, 2006; Corwin, et al, J Ob Gyn NN Nursing 2005
  • 45% at colic clinic – mod/severe PPD – Maxted et al, Infant Mental Health Journal, 2005
  • 188 pregnant women high risk for PPD….39% → PPD
    #1 predictor of PPD – 25% fussiest babies! #2 predictor – unsupportive spouse! – Murray and Cooper, J&J Roundtable 2001

SIDS

  • 50-82% of prone sleepers are put in that position because of excessive crying or restless sleeping
    - Van Sleuwen et al, J Peds, 2006, Willinger JAMA 2000
  • 5/222 SIDS deaths occurred when parents let baby continue to cry at night for the 1st time. – DeJonge et al
  • Routine back sleepers who roll to the stomach have a 7-19x ↑ SIDS rate Li Am J Epi 2003, Mitchel APAM 1999

Shaken Baby Syndrome

  • ~ 1500 hospitalizations/yr (avg. age 4 mo)
  • 22% die…62% permanent damage
  • 80% attackers men (45% fathers)
  • 95% incidents triggered by crying – Sandberg M, Barr R. NCSBS, 2002
  • 2.6% of parents reported shaking baby under 2 yrs to stop cry – Theodore et al, Peds, 2005
  • 5% of Dutch parents shook baby under 3 months to stop cry (6-12% of very fussy babies) – van der Wal AJDC

However, if you can easily soothe the crying… it’s not upsetting!

What causes colic?
GI problems? Brain Immaturity? Maternal Anxiety? Difficult Temperament?

Is it a GI problem?

  • Colic = “intestinal” (Greek)
  • There are several good reasons people thought it might be intestinal – pain-like screams, pass gas, cry after eating, noisy stomach and anti-spasm drugs ↓ crying (but these work because they are also sedating)

Tiny Tummy Troubles – Gas, cramps, constipation

Gas theory is 97%…Hot Air

  • Stops after 3 months
  • Delayed in preemies (begins 2 weeks after due date)
  • X-rays – ↑ gas not at beginning of crying BUT after crying is over!! – Illingsworth, Arch Dis Child, 1954
  • Simethicone = plain water placebo – Danielsson, ACTA Ped Scan, 1985 Metcalf, Peds, 1994
  • Babies calm in car, sling or swing…how would these make bad pain go away?
  • Colic absent in some cultures…yet they pas gas, burp and poop, too! – Barr, Dev Med Ch Neuro, 1991

Big Tummy Troubles – Food allergy/sensitivity, GE reflux

What about foods?

  • 10-15% of colic = milk allergy – Lucassen, BMJ, 1998/li>
  • Food sensitivity – caffeine, others

What about reflux?

  • Many babies have reflux (50% > 1/d)…we just call it spitting up…and, they are fine!
  • Main misdiagnosis – Gastro-colic reflex → cry & arch after eating (this is why many babies fuss after food)
  • Reflux peaks at 4 months (reflux primary symptoms are vomiting and poor weight gain…rarely crying)

Reflux is over-diagnosed

  • Only 1/50 crying babies seen in Denver ER had reflux – Poole, Peds, 1991
  • Only 1/24 crying infants <3 mo seen by peds GI had reflux - Heine, Arch Dis Ch, 1995
  • Omperazole given to infants with reflux. It ↓ acid but does not ↓ crying – Moore, J Peds, 2003
  • GERD unlikely in crying/back arch without >5 vomitus or feeding difficulty – Heine, J Paed Ch H 2006
  • No benefit of H2 blocker+propulside vs placebo in “colic” patients – Jordan, J Paed Ch H, 2006

The 4th Trimester a Unifying Theory for Colic

  • Our babies are “evicted” 3 months early. If they stayed inside until more mature they might get stuck and die!
  • Newborn humans not like baby horses

Turning on the Calming Reflex with the 5 S’s

  • Stimulation 24/7 (“Womb service”)
  • CR is a fetal reflex that probably evolved to lessen risk of breech or transverse lie
  • 5 S’s activate the “CR”- Swaddling, Side/Stomach position, Shushing, Swinging, Sucking

The 1st S – Swaddling

  • Cornerstone of calming (See – Van Sleuwen, Franco, Gerard, Lipton, Brackbill, Giacoman)
  • Snug, arms at sides (may resist), hips flexed (See Mahan and Kasser Peds 2008, Karp Peds 2008)
  • No loose wraps…no overheating…during the first weeks…no swaddling in prone…wake to nurse 8-12/day
  • When infants have been swaddled and sleep supine, their risk of dying from sudden infant death syndrome (SIDS) is reduced with an odds ratio of 0.64 to 0.69. (Franco 2004, Ponsonby 1993)

The 2nd S – Side/Stomach

  • Back triggers Moro
  • Roll towards stomach
  • Don’t let the baby sleep on the side or stomach

The 3rd S – Shushing

  • As loud as crying (Womb is louder than a vacuum)
  • Shushing is the only universal learned sound
  • Over-stimulation is not nearly as big a problem as under-stimulation! Babies miss the rhythmic, hypnotic sounds and movement. Being in a quiet room is weird for them.
  • Sound at 60-80dB significantly increases quiet sleep and decreases active sleep (SIDS occurs most during active sleep)
  • (See – Walker, Smith, Brackbill ’66,’71,‘75, Birns, Smith, Kramer, Spencer)

The 4th S – Swinging

  • Tiny and fast (jiggle not shake…ALWAYS support the head and neck)
  • Follow her lead
  • Dads are great! Once we get over our initial fears of handling a new baby, we usually feel more comfortable than moms doing the “Jell-O” head jiggle!
  • May need swing on fast speed for hours (avoid if premie or muscular weakness…ask MD)
  • Never in anger!!!! If you’re getting really frustrated …get some back-up or take a break.
  • (See – van den Daele, Brackbill, Pederson, Kramer, Hunziker, Elliott, Korner, Korner, Gatts)

The 5th S – Sucking

  • Other cultures nurse 50-100 times/day, Reverse psychology, Avoid nipple confusion
  • (See – Campo)

The 6th S – Sleep

  • All babies fall asleep nursing…it’s normal!
  • After ~3w/o…after baby falls asleep in your arms/at breast, wake her up a tiny bit when you put her down to sleep

The 6th S – Sleep

  • Back to sleep
  • Adding swaddle + strong white noise usually leads to 1-2 hours ↑ sleep/night

The 5 S’s are not just “old info”

  • Promote paramount importance of the 4th trimester
  • Discovery of the calming reflex (CR)
  • Clarify need to do 5 S’s:
    • exactly right (Karp J Peds 2007)
    • with just enough vigor
    • in combo (some respond best to a specific S, others need multiple S’s simultaneously – Brackbill, Brazelton)
  • Takes vigor to turn on the CR, and continued mild stimulation to keep it on

See bibliography

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