If you are here, things are probably a little desperate. Irritable infant is a term that does not really describe the desperation that some parents feel regarding the incessant recurrent crying that you really did not sign up for when you thought it was a good idea to go ahead and multiply. Lack of sleep,conflicting advice, tears, and feeling worthless, guilty, and just plain miserable. These are how some parents, particularly Mothers feel when their infant, about 3 -4 weeks of age has a new default behaviour called screaming. Fathers are either ‘trying to fix it’ or have retreated to the safety of work, not really knowing what to say or do. Resentment towards the infant, the Father and even uncaring dismissive doctors is commonplace. So take a deep breath and lets try and make sense of what this infant is trying to say.
Irritable infant for all intents and purposes means that the normal fussing, crying and difficult sleep that comes with a new baby have escalated to out of control levels. The causes of irritable infants can be broken down to three groups, each of which may overlap. Various studies suggest about 20% of infants are irritable infants.
- Colic – common
- Food protein intolerance – less common
- Gastro-esophageal reflux disease – rare
The official definition of Colic (an old fashioned term) implies incessant crying for 3 hours per day, for three or more days per week for three weeks or more in an otherwise healthy infant between the ages of 2 weeks and 4 months. Not sure who made this up but many parents will look at this and wish for just that amount of crying. This definition was decided as a universal tool to allow World wide studies to be standardised. Well guess what, studies have been done and we are not really much closer to a ‘cure’. But they have helped dispel a few myths.
- Colic is nothing to do with the quality of the parenting or milk
- Infants with colic will be normal healthy children with a vastly normal array of temperaments and personalities
- Good days will outnumber bad days by about 4 months, and by 5-6 months things are significantly better.
Note that the definition implies an ‘otherwise healthy infant’. This is very important as it rules out a cause for crying that maybe medically based. A healthy infant means good weight gain, feeding well, and developing according to age appropriate guidelines.
So what do these infants do ?
Firstly the behaviour of these infants tends to be consistent. They are easily startled, a noise will move them from sleep to screaming in seconds. Their lips shudder, they continue crying despite being picked up, with gasping breaths between each cry, and this waxes and wanes over minutes to hours. They have difficulty falling asleep and easily wake. Parents desperately wanting to help will ‘try anything’ to gain some relief. Tonics, white noise, (you can get an app for this), oral stimulation, feed changes, environment change, may temporarily appear to help but a day later many are back to square one. They tend to be ‘at their worst’ between 4pm to 8pm and during the night they sleep reasonably requiring couple of feeds.
What causes colic ?
Not sure. Here are the usual thoughts
- Gut – Clenching fists, arching of back, passing wind, suggests the cause is from the gastrointestinal tract. This has resulted in many studies and attempts at alleviating ‘gut discomfort’. There has been some small studies that have suggested giving probiotics such as Lactobacillus Reuteri have helped compared to placebo. Nestle infant comfort ® formulas has this added. The medications for colic sold in supermarkets and chemists have never shown any improvement when studied compared to placebo, despite their claims on the bottle.
- Some sort of ancestral reason – This implies that colic is a defense mechanism to be ‘looked after better’. These infants are better fed, and better looked after (they are rarely put down), than an infant who is quiet. The so called squeaky wheel gets the oil. Colic is seen in every culture, race, and country, and has been mentioned in literature throughout the ages. A study in 2002 analysed heart rates, calorie intake and stress hormone levels of cortisone, and found no difference between those who are ‘colicky’ and those who are ‘angels’. So the screaming is attention seeking !! Not much help to parents.
- Temperament – The nature of the infant. Again this is not the most useful explanation and is obviously hard to prove. The good news on this front is that colicky difficult infants do not grow up to be similar children. There is no real prospective or retrospective evidence that colic is a sign ‘of things to come’. I guess this is reassuring.
What can you do for colic ?
As there is obvious medical cause then the goal is to cope as best as possible counting down to when good days tend to outweigh the bad. The peak period is around 6 weeks to 2 months. Here are some suggestions to get you through this period.
- carry in a front sling or back pack
- wrap snugly in a blanket ( swaddling mimics the womb)
- keep motion in an infant swing
- place near continuous noise or vibrations from household appliances like the dishwasher, vacuum cleaner, washer-dryer, or smart phone app.
- Go for a car ride or a walk outside
- Try a dummy (Despite the internet these are safe)
- take a shower together the warm water may be comforting[hr]
2. Food Protein intolerance
This represents a smaller but significant cause of irritability in infants. These infants are similar to the colic infants described above, but the difference is they struggle with feeding. They do not enjoy feeding, may pull off the breast or bottle, and swallowing appears an effort. They may regurgitate, sometimes have loose bowel actions and their weight gain is ‘just’. Irritability extends into the night. There maybe a family history of dairy or other intolerance. The culprits usually are the proteins in the dairy, and/or soy. These are past in breast milk and appear to affect the immature gut. This is not an allergy and hence there is no test that can be done.
- Breast fed – Many Mothers have already had a period off dairy and or soy and this makes a dramatic difference within 48 hours. The infant feeds better, does not regurgitate as much, and irritability lessens. Solids can be started as normal between 4 – 6 months but continue to avoid dairy (and or soy) until nearly 12 months. Around that time trial some yogurt and see what happens. If it is clear there is an ongoing tolerance wait a few months.
- Formula fed infants – If breast feeding has been unsuccessful and the infant is on formula then changing the protein will help. Current guidelines suggest trial of a soy based formula. Some parents would have trialed goats milk protein based formula and if the infant appears improved then this is fine to stay on. (This is not recommended for allergic infants as the Goats milk is just as allergic as cow’s milk). If the infant has similar symptoms on the soy based formula then consider Aptamil Allerpro®, which has the protein segments chopped up into small parts. This is similar to a script only formula called Pepti-junior®. Occasionally, more severely intolerant infants will need amino acid formulas called Neocate® or Elecare®. The last few are only available in consultation with allergist or paediatric gastroenterologist via your GP. The table below is a rough guide. It might be useful to print this table and show your GP.
TABLE OF FORMULAS.
¹ Hydrolysed means the proteins are chopped up.
If the infant responds crying will dramatically lessen, weight will improve, and bowel actions will become less ‘distressing’. Usually these infants can tolerate other proteins in solids. From 18 months to 2 years tolerance to these foods improves, but mild GIT symptoms may persist.[hr]
3. Gastro-esophageal Reflux Disease
Background – Irritable infant due to GORD
Reflux is common in infants and a certain amount of regurgitation is considered normal. Reflux disease means the infant is suffering due to this reflux, either due to poor weight gain or due to effect of the stomach acid on the oesophagus and the throat. During 70s and 80s many irritable infants were diagnosed with presumed reflux disease and placed on medication. If there was no vomiting, or regurgitation or signs of reflux then this was called ‘silent reflux’. Unfortunately this was probably not a true condition but is now entrenched in internet forums, websites and current folklore.
- Many of these infants were probably suffering from food protein intolerance, which is a more recent diagnosis.
- Reflux diagnosis using probes monitoring the refluxing into the lower end of the oesophagus found no difference between those who had been diagnosed with ‘silent reflux’ and healthy infants.
Nevertheless reflux medication is still used aggressively in irritable infants, due to the parents desperation, and the doctors desire to help. And sometimes, just sometimes there is improvement in symptoms to justify the occasional trial of medication.
Diagnosis and Management.
There are no simple tests to determine if reflux disease is present, so most clinicians rely on a trial of treatment. Traditional treatment for simple reflux is elevating the head and adding a thickening agent to breast milk or formula. The medications for reflux disease are designed to suppress the acid produced by the stomach. Their are some concerns that this is switching off a primary defence against some infectious diseases. Otherwise they are safe, well tolerated and are used temporarily.[hr]
What about all the other diagnosis for irritable infants ?
Desperate parents will no doubt search everywhere for some answers including the internet, family members, friends and alternative practitioners. Here are a few logical pointers.
- If there was any evidence that some of these treatments actually worked they would be part of mainstream medicine. This condition is very well researched and studied.
- Anecdotes such as testimonials can be invented from anywhere, and many celebrities make money endorsing products and making up testimonials. Anecdotes should not be mistaken for evidence
- Going on strict diets can sometimes be dangerous due to nutritionally compromising the infant and Mother. Many diets recommend going off dairy and gluten (poor old gluten) and apart from the infant who has dairy protein intolerance there is no evidence behind this.
- There is no such thing as an infant having a hip or shoulder joint ‘a bit out’ or ‘subluxed’. The manipulation of infants spines, neck and joints to treat vague conditions such as colic and reflux is quackery at its worst.
Finally, remember that this condition gets better, generally by 4 months or slightly after. Therefore taking this further 100% of all treatments will be successful by 4-5 months. See what I mean. Save your money.