COLIC? Bore Your Baby to Sleep!

I’ve been a newborn baby doctor for the last 40 years. After about two of them I lost count of the number of babies I was seeing with so-called ‘colic’. So many endless nights, so many tears, so much screaming … and that was just the parents.

Because of these tired, stressed families, I developed a lifelong obsession to talk to them about this disorder. This information is laid out in the evolutionary biology and medical literature, and it’s also known by a large number of parents whose babies have been through it and who have learned by experience how to prevent it.

But the start of any discussion about the behaviour of babies must be made in the light of their evolution.

Humans, after they started to walk in an upright posture,  developed an athletic pelvis with a narrow birth canal as a consequence. Later humankind also developed a big brain. In order to give birth successfully through this narrow pelvis, their big-brained babies had to be delivered when still small, way earlier in pregnancy than before. We had to birth our babies prematurely.

Biologists call our babies  “exterio-gestate foetuses”. That is, they are foetuses on the outside. I’m sure you have heard of the ‘fourth trimester’ of pregnancy. Three in womb, and another in your arms.

This tells us what babies expect of us. They are the most immature of all placental mammals. They are so helpless they cannot even cling and hold on to their mother efficiently. They need to be held and protected; they need security and love, they need feeding frequently and on demand. We produce for them a dilute easily digested milk, designed for frequent feeding. We are a continuous contact species and have not evolved to be separated from our parents’ bodies for very long.

You can see how this might impact on babies’ crying behaviour.

But first, you need to make sure that the baby is not crying because they are hungry. Remember this ‘continuous contact’ milk is designed for frequent, even hourly, feeding. Their stomach can empty in 30 minutes. So if they are upset, try feeding them again.

Second, studies were done where large groups of parents were given diaries to record how much unsettledness, fussing and crying their babies had.  The results were remarkable and consistent.  Most babies start to become more unsettled at about 2-3 weeks of age, they are at their noisiest at 6 weeks, and then there is a gradual improvement until 3 months, when crying levels drop rapidly.  Most of the crying was in the evening.

How much the baby cried and fussed depended on two factors.

  • How closely the baby was held and where s(he)spent the day. Babies close to their parents cried less (and fed more), and those separated in cots and prams, cried more.
  • The temperament of the baby – either settled and calm, or sensitive and ‘wired’.

The average amount of crying/fussing (at which half of the population cry more, and half cry less) in a Western society is 3 hours a day at 6 weeks. The babies in the developing world (or with attachment parenting) crying less and Western routine-based babies, separated in prams or cots, crying more.

These are all normal babies and the curve that describes this population of babies is a bell-shaped or ‘normal’ curve. This means that there are 10% of babies that are crying a great deal more than 3 hours, sometimes 8 hours or more, a day.

The studies about ‘colic’ say that the condition occurs in about 10% of babies. But it has exactly the same pattern as ‘normal crying’ as above. So what causes it?  The vast majority of these babies have no pathology, no illness.

What this means is that these babies are merely on the highest centile for ‘normal crying’. They are still completely normal babies but they are more sensitive than average.  No wonder after decades of research, no one can find a unifying pathological diagnosis. There isn’t one.

It’s not pain…

Let’s clear up one misconception right off. Colic has never been about pain in the abdomen or anywhere else for that matter. There is no question that the baby looks like he or she is in excruciating tummy pain. The baby doubles up, knees in chest, and screams like there’s a knife twisting in his gut. But it’s not about pain, it’s about stress and overstimulation of the poor baby’s sensory nervous system.

“Six O’Clock Colic”

The situation of babies screaming in distress primarily in the evening (“six o’clock” or “evening” colic) has been described for hundreds of years. As in the studies, it usually gets going when babies are around four to six weeks of age (though for some particularly sensitive babies, it can start from birth). It then increases in intensity to reach a maximum over the following couple of weeks then settles slightly before ceasing, often abruptly, at about three months of age (hence why it is also called “three-month colic”).

Premature babies have it earlier and more intensely. It was through the study of just this group of babies that developmental psychologists started to unravel the problem in the full-term. As premature babies near term they can become very distressed when their environment presents them with even minimal increases in stimulation. If you pick up such a baby, look at him and talk to him, he will often start stressing out, straining, crying and arching his back as his nervous system overloads with your input on his senses. With such as him, you can either pick up, or you can look at him, or you can speak to him. You just can’t do all of them at once.

The psyche of full-term babies is much more resilient than that. But they still have their limits. But let’s start at the end, and work backwards.

The Three Month Old Baby

At and beyond three months of age babies usually develop the ability to calm and regulate themselves more successfully. You can see this at work in a four to five month-old baby who is fed and happy and sitting in a little prop-up chair. He wants to play with his mother so he gazes at her across the room, chuckles and waves his arms to attract her. She can’t resist and approaches him, their eyes lock and soon they are talking nonsense, looking deeply into each other’s eyes and are totally engrossed in one another. The intensity of their so-called ‘serve and return’ interaction rises. The stimulation then increases to a level that makes the baby uncomfortable. There’s just too much stress in the game for him.

So he suddenly he looks away, switches off and totally ignores his mother.

He looks at the ceiling or at his hands in his lap as his mother wanders off. There he sits, his shoulders tense, his eyes downcast. Then over the next few minutes he calms and relaxes and starts to throw glances at his mum.

As he relaxes more his gazes last longer and longer.

Then the cycle starts again. He laughs and waves his hands to attract her, and back she comes.

The baby has learnt that when he gets over-aroused, stressed and uncomfortable, if he looks away and ignores it, he can calm himself down. This is an invaluable lesson, the first element of a regulatory system that gives him control over the sensory input from his environment. It is also the start of the ability to concentrate undistracted on a task.

The Six Week Old Baby

Now, back to the beginning. The colic syndrome starts at four to six weeks of age. Before this, the boundaries of his attention do not stray much beyond his mother’s body and breasts, of its warmth and smell. But now his eyes can focus further and his horizons expand and he starts to take in his surroundings. It is about a week before he smiles.

Once he starts smiling, he attracts people around him like a magnet.  Evolution has made the contours of his face and body specifically designed to make people around him want to nurture and care for him. They gaze at him and he gazes back. He watches the curtains flapping by the window. Then grandma visits and she can’t take her eyes off him. With this new attention, his excitement rises to a level that makes him uncomfortable but, alas, he has not yet developed the ability to decrease his attentiveness and calm himself. As the stimulation and stress levels rise he starts to get distressed. He becomes tense and begins to strain and groan, especially late in the day.

His parents become anxious, “Is he constipated? Why does he writhe and arch his back?” Soon his distress level makes him cry and scream. He is picked up and passed hand-to-hand around the family who gaze at him, trying to fathom the cause of his discomfort. The parents ask advice from Google to Hospital Emergency Departments and the cascade of advice starts.

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Colic - The Six Week Old Baby

HELPFUL ADVICE

He is diagnosed as suffering from “wind”, stomach spasms, gastro-oesophageal reflux, lactose intolerance, and food sensitivity. To fix it, he is given everything from anti-reflux drugs to chamomile tea, Mother is advised to stop dairy in her diet, or stop breast-feeding completely. She is advised to wind him properly all the way through to massaging his stomach (in a clockwise direction) with warm olive oil. And proffered the worst piece of advice possible: “Just you let him cry it out”!

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Sucking To Calm

What’s a baby to do?

SUCKING

Upset babies find sucking calms them down and no doubt it does. Neuro-chemists tell us that when a baby sucks, his brain secrets ‘beta endorphin’ (a opiate-like neurotransmitter). So our baby starts to feed frequently, sucking, sucking, sucking in an effort to calm himself down. Despite having a full stomach after a good feed the sucking and milk intake continues and in combination with the straining, soon becomes reflux vomiting. His parents take him to the hospital where is given a barium meal, or an oesophageal pH probe study and diagnosed with GORD (gastro-oesophageal reflux disease) and treated with Zantac (and H2-antogonist drug), Losec (a proton Pump inhibitor drug), and/or taken off the breast because “the flow is too fast”.

WIND

After birth, babies swallow lots of air, which passes to the stomach. The valve between the oesophagus (gullet) and the stomach is a ring of muscle, which in babies is hopelessly incompetent and hangs open: it can hardly trap a feed (hence most babies posset/vomit), let alone trap an air bubble.  So if the baby swallows air, he can easily burp it up. Hence:

  • All babies reflux. Studies show that stomach contents are refluxed up into the oesophagus on average about 20 times a day.
  • Babies don’t need burping. That is not to say babies do not like to be sat up and patted (at maternal heart rate) but they are doing it for comfort, not to help them burp.

Crying ‘colicy’ babies swallow more air– so if you pick them up they may burp. But he’s not crying because he needs burping – he’s burping because he’s crying…

And at the other end, once babies start milk feeding, the germs in the large bowel ferment the lactose to produce litres of hydrogen gas as a by-product. This fills the lower bowel, and hence babies tend to fart like troopers (apologies to our Armed Forces). The bowel is a long fleshy tube open at each end, filled with liquid contents. No pain, no distension. All babies are windy. But they don’t SUFFER from it.

However there is a reasonable chance that someone will suggest your windy baby is suffering from ‘lactose intolerance’ and you should stop breastfeeding and start a lactose-free formula. Take no notice of this advice unless your baby has had a recent bout of viral gastroenteritis, only then is it possible. That is not to say that your baby’s poos aren’t explosive and gassy. They often are in normal breastfeed babies. Lactose is nearly the only sugar in mammalian milks and if you have great supply there may be too much for the baby’s gut to absorb. It spills into the colon and ferments, producing lots of hydrogen gas and liquid poos. It’s normal.

DAIRY SENSITIVITY

Nowadays it is also likely that it will be suggested that your baby might be sensitive or allergic to cows milk protein. True, 5% of babies develop this but most of them are formula fed (with cows milk formula). Occasionally however breastfed babies can react to small parts of the dairy protein in the mother’s diet which is secreted into the breastmilk. So it is reasonable to try a period of a couple of weeks avoiding dairy products.

“Medicalising Normality”

There was an editorial in the Australian Paediatric and Child Health Journal titled
“Medicalising Normality” aptly describing what is happening here. All these medical diagnoses tend to flow from a series of vicious cycles triggered by the extra sucking and the baby’s behaviour, but all downstream from the true cause of the distress.

There is a condition I call “Christmas Colic” when babies do this in spades.  Too many relatives, too many parties, too much excitement leading to lots of screaming babies in Emergency Departments in late December.

How do we fix the problem? It is simple in principle and tough in practice. We have to reduce the level of, especially visual stimulation, in the babies environment to a level he can cope with, and do it for long enough to calm his active stress response.

In a phrase we have to “Bore Him to Sleep”.

CALMING THE BABY REGIME

  • If the grandparents insist on winding your baby up, send them home. Otherwise get them to help you by joining in with this plan. Alternatively, if you have a toddler,  they would be delighted to help by looking after her.

  • Stick a note on the front door saying that you are out.

  • Go into her room, draw the blinds and make the light in the room dim. Put on some quiet, restful music; that’s for you, but babies do like a background of ‘family sounds’ rather than silence.

  • Get the baby and take her into the room with you. NEVER leave her on her own.

  • Feed her on demand in the dim light, avoiding long periods of intense eye contact with her (obviously you can look at her – but make your gaze calming).

  • Put her on your chest with her ear against your heartbeat and cuddle her until she settles. This reminds her of the sounds and feel of the womb. It may take some time. Be patient.

  • You can now wear her on your chest for as long as you both like.

  • Lie down with her on the bed, making sure that if you fall asleep that there are no risk factors for SIDS in your sleeping arrangements. Check out the risk factors beforehand.

IF YOU NEED TO GET AWAY FOR A SHORT WHILE:

  • An inconsolable baby can press all your buttons. It can be quite overwhelming. It’s okay to get someone else to take over from you. They can take over the cuddling, calming and holding.

IF THERE IS NO-ONE TO HELP YOU AND YOU NEED TO GET AWAY:

  • Wrap him firmly in a sheet. Wrap him with his back rounded and his limbs contained – this will also remind him of the containment of the womb and help him feel secure. He may want to have his arms free, but it is preferable to contain them.

  • Then place him in his cot. Pat him gently on the bottom at about 70 pats to the minute (mother’s heart rate) and just …

BORE YOUR BABY TO SLEEP
  • If it helps, give him a dummy.

  • If he gets upset (and he probably will), rewrap him and put him back on your chest, continue cuddling, or feeding.

  • If you’re both going crazy, pick him up and cuddle him for a while. You can then try the cot again.

  • Continue this until he settles. Do not leave the baby to cry, but you can leave the room when he finally sleeps.

  • Generally the early hours are hard, but if you persevere, things will improve. He will eventually start to, as the psychologists say, ‘return to base’.

  • By the second day he will be calmer. Do not take him out of the room, even though he appears improved. Give it another day, to be sure he loses some of his fatigue and stress.

  • The more he sleeps, the less opportunity there is for him to be stimulated, and the more he will sleep. This is a good cycle, not a vicious one. When he’s calm and sleepy, you can return him to the family room.

  • You then need to keep the activity and stimulation in his environment down to a level that he can handle. If he develops jerky movements, or looks stressed, return to the calm room.

How much stimulation your baby can cope with depends on his basic temperament. All babies are different.

There are a few babies who are calm from the moment they’re born. These babies can be taken to your workplace and meet a hundred people and not get upset. Most babies though, have a limit,  – you need to find out where your baby’s is, and keep the level under that.

Some super-sensitive babies find life difficult if they aren’t clamped to their mother’s chest for the first three months of their life. Don’t worry; they won’t suffer from sensory deprivation. They are learning their most important lesson: how to keep themselves calm and feel secure.

I wish you good luck (and enough sleep)!

Updated May 2019