A prospective study on the persistence of infant crying, sleeping and feeding problems and preschool behaviour

Early childhood multiple or persistent regulatory problems and diurnal salivary cortisol in young adulthood

BACKGROUND

Early childhood multiple or persistent regulatory problems (RPs; crying, sleeping, or feeding problems) have been associated with a risk of behavioural problems in young adulthood. It has been suggested that this may be due to the possible influence of early RPs on the functioning of the hypothalamic-pituitary-adrenal (HPA) axis. However, associations between early RPs and HPA-axis activity in young adulthood remain unexplored. Thus, the aim of the current study was to investigate whether early childhood multiple or persistent RPs are associated with diurnal salivary cortisol in young adulthood.

METHODS

At the ages of 5, 20 and 56 months, RPs of 308 children from the Arvo Ylppö Longitudinal Study were assessed via standardized parental interviews and neurological assessments. Multiple RPs were defined as two or three RPs at the age of 5 months and persistent RPs as at least one RP at 5, 20 and 56 months. At the mean age of 25.4 years (SD= 0.6), the participants donated saliva samples for cortisol at awakening, 15 and 30 min thereafter, 10:30 am, at noon, 5:30 pm, and at bedtime during one day. We used mixed model regressions, and generalized linear models for testing the associations, controlling for important covariates.

RESULTS

Of the 308 children, 61 (19.8%) had multiple or persistent RPs in early childhood: 38 had multiple, and 27 had persistent RPs. Persistent RPs were associated with significantly higher cortisol peak and output in the waking period, and cortisol awakening response. On the other hand, multiple RPs were not associated with salivary cortisol.

CONCLUSION

Children displaying persistent RPs throughout early childhood show, over two decades later, increased HPA axis activity in response to awakening stress. This may be one physiological mechanism linking early childhood RPs to adulthood behavioural outcomes.

The longitudinal association of combined regulatory problems in infancy and mental health outcome in early childhood: a systematic review

Co-occurring regulatory problems in infancy, RPs, including excessive crying, feeding-eating and sleeping, have been found associated with mental health problems in school ages. Still, an overview is needed on trajectories of co-occurring or combined RPs, and mental health problems in early childhood. The aim of this review is to systematically review the literature on longitudinal community-based studies of combined RPs measuring mental health outcomes in early childhood. Following the PRISMA guideline, we systematically reviewed the literature published 2000-2020, in which combined RPs are assessed in infancy, and mental health is examined using standardised measures at ages 1-7 years. The search was performed in four databases MEDLINE, EMBASE, PsycINFO and Scopus. A protocol is published on PROSPERO. Based on 1978 screened articles, 42 papers were screened for eligibility, of which six were included, comprising data on two or more RPs investigated among a total of 20,675 children. Assessment of risk of bias in the studies showed overall good quality in five of the six papers. The literature reviewed suggests that combined RPs in infancy are early markers of mental health problems during early childhood, and highlights that community studies exploring the longitudinal associations of combined RP and mental health problems in preschool and early school age are still scarce. Overall, the review points to the need of research into preventive intervention targeting early manifestations of childhood dysregulation, such as RPs.

The association of early regulatory problems with behavioral problems and cognitive functioning in adulthood: two cohorts in two countries

BACKGROUND

Regulatory problems (RPs; excessive crying, sleeping, or feeding difficulties) that co-occur (i.e., multiple) or are persistent have been associated with cognitive and behavioral problems in childhood. However, it remains unknown if multiple or persistent RPs are associated with cognitive and behavioral problems in adulthood.

METHODS

This large prospective longitudinal study (N = 759) was conducted in two cohorts in Germany (N = 342) and Finland (N = 417). RPs were assessed at 5, 20, and 56 months via the same standardized parental interviews and neurological examinations. In young adulthood, questionnaires were used to assess behavioral problems. Cognitive functioning was assessed with IQ tests. We examined the effects of multiple or persistent RPs on the outcomes via analysis of covariance tests and logistic regression controlled for the influence of cohort.

RESULTS

Of 163 participants with RPs, 89 had multiple and 77 had persistent RPs. Adults who had early multiple or persistent RPs (N = 151) reported more internalizing (p = .001), externalizing (p = .020), and total behavioral problems (p = .001), and, specifically, more depressive (p = .012), somatic (p = .005), avoidant personality (p < .001), and antisocial personality problems (p = .006) than those who never had RPs (N = 596). Participants with multiple or persistent RPs were more likely to receive any ADHD diagnoses (p = .017), particularly of hyperactive/impulsive subtype (p = .032). In contrast, there were no associations between multiple or persistent RPs and IQ scores in young adulthood.

CONCLUSIONS

The results indicate long-lasting associations between multiple or persistent RPs and behavioral problems. Thus, screening for early RPs could help to identify children who are at risk for later behavioral problems.

Can a parental sleep intervention in an individual setting improve the maternal and paternal sense of competence and parent-child interaction in parents of young sleep-disturbed children? findings from a single-arm pilot intervention study

BACKGROUND

In early childhood sleep and regulatory problems, parental factors are often impaired but essential to overcoming them. This study aims to examine, in parents of young sleep-disturbed children, whether mothers' and fathers' sense of parenting competence were increased and dysfunctional parent-child interactions reduced with a parental sleep intervention, whether these changes were sustained over a 12-month follow-up period and if children's symptomatic parameters could be related factors.

METHODS

A total of 57 families with sleep-disturbed children aged 6 months to 4 years entered this single-arm pilot study. Each parent pair participated in six weekly individual face-to-face sessions of a multimodal cognitive-behavioral sleep intervention. The Parenting Sense of Competence Scale, Parental Stress Index Short Form, Child's Sleep Diary and Child's Questionnaire on Crying, Eating and Sleeping were obtained pre-, post-, 3, 6 and 12 months after the intervention.

RESULTS

Maternal sense of competence and dysfunctional mother-child interaction improved significantly up to 6 months after the intervention. Factors related to lower maternal competence were the child's more frequent nightly food intake and more crying due to defiance; factors related to dysfunctional mother-child interaction were more frequent crying episodes, more crying due to defiance and more eating difficulties; factors related to increased maternal competence were less duration of child's night waking, less bed-sharing and lower frequency of crying episodes; factors related to increased paternal competence were less child's nightly food intake and fewer episodes of unexplained and unsoothable crying; and factors related to improved father-child interaction were less frequent child's night waking and fewer unexplained and unsoothable crying episodes.

CONCLUSION

For parents of sleep-disturbed young children, an intervention that addresses the child's sleep could be promising to increase the parental sense of competence and reduce dysfunctional parent-child interactions, especially for mothers. Child symptomatic parameters may change, together with the parental sense of competence and parent-child interaction of both parents, after the intervention. Mothers with children with more severe symptomatology perceive their parenting competence as lower on average and their mother-child interaction as more dysfunctional. Future research with a larger sample and a randomized controlled design is needed.

TRIAL REGISTRATION

The study was retrospectively registered at the German Clinical Trials Register (ID: DRKS00028578; registration date: 21.03.2022).

A single-arm pilot study: can a parental sleep intervention for sleep-disturbed young children in individual settings improve children's sleep, crying, eating, and parental distress in mothers and fathers?

Background

Early sleep problems co-occur with crying, eating problems, and parental distress. This study investigates the impact of a parent-focused intervention to improve child sleep with the following aims: (1) To assess the impact on child sleep (sleep onset latency, frequency and duration of nighttime awakenings, frequency of bed-sharing, and nighttime food intake, total nighttime sleep duration, and sleep efficiency), child crying (frequency of crying episodes, of unexplained and unsoothable crying and of crying out of defiance), child eating difficulties, and parental distress of mothers and fathers. (2) To assess the maintenance of any changes in these areas longitudinally, at 3-month, 6-month, and 12-month follow-ups. (3) To explore at the within-subjects level, how children’s sleep, crying, eating, and parental distress changed together across all study measurement points.

Methods

In this single-arm pilot study, the parents of 60 children participated in six individual sessions of a parent-focused multimodal age-adjusted cognitive-behavioral intervention to improve child sleep. Parents of 39 children (46% girls, age in months M = 22.41, SD = 12.43) completed pre- and at least one measure after the intervention. Sleep diary, questionnaire for crying, feeding, sleeping, and parental stress index (short-form) were assessed pre, post, three, six, and 12 months after the intervention.

Results

Significantly, sleep (decreased sleep onset latency, frequency, duration of nighttime awakenings, bed-sharing, nighttime food intake; increased total nighttime sleep duration, sleep efficiency), crying (reduced frequency of crying episodes, unexplained and unsoothable crying), and parental distress (reduced) changed, which remained partially stable over follow-up. The frequency of crying episodes decreased with fewer nighttime awakenings; morning crying with increased nighttime feeding; unexplained and unsoothable crying with higher sleep efficiency; crying due to defiance with more nighttime awakenings, sleep efficiency, and bed-sharing. Eating problems decreased with shorter night awakenings and time; maternal distress with fewer nighttime awakenings, paternal with less child’s nighttime feeding, unexplained and unsoothable crying, and time.

Conclusions

A parental sleep intervention for sleep-disturbed young children could be promising to reduce children’s sleep problems, crying, eating problems and parental distress. Future studies should consider more personal contact during the follow-up to reduce the drop-out rate and a randomized-controlled design.

Trial registration

The study was retrospectively registered at the German Clinical Trials Register (ID: DRKS00028578, registration date: 21.03.2022).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-022-03631-5.

Impact of baby behaviour on caregiver's infant feeding decisions during the first 6 months of life: A systematic review

Caregivers are often concerned about baby behaviours. Without adequate counselling, parental response can lead to altering infant feeding and jeopardizing breastfeeding. We conducted a systematic review to assess the evidence about the influence of baby behaviours perceived as problematic (crying, sleep waking and posseting) on infant feeding decisions during the first 6 months of life (self‐reported milk insufficiency, breastfeeding duration and introduction of formula). The review focused on quantitative studies published in English, Portuguese or Spanish without date restriction. The search was designed with the support of a medical librarian and conducted in seven databases. Data were managed in Covidence and risk of bias was assessed through the Johanna Briggs Institute critical appraisal checklists. Synthesis of the literature was guided by a conceptual model of the impact of baby behaviours on caregivers feeding practices. We retrieved and reviewed 4312 titles/abstracts and selected 22 for review; 10 were purely descriptive and 12 were cross‐sectional, prospective and quasi‐experimental studies. Although studies from diverse regions were included in the review, more than half were from high‐income countries. All studies reported that baby behaviours affect feeding decisions, the most common baby behaviours studied were crying and fussiness, and the studies suggested relationships with lactation problems and reports of milk insufficiency, maternal breastfeeding confidence, breastfeeding duration and discontinuation, and introduction of formula. There are many factors that lead to perceiving baby behaviours as problematic and there is a need to provide anticipatory guidance to parents and caregivers, starting in pregnancy and counselling through well‐trained health providers.

Although normal infant behaviour is highly variable, caregivers often perceive infant fussing/crying, posseting and sleep to be problematic.

How caregivers interpret such ‘problems’ is critical in shaping how they deal with them and the impacts they have on infant feeding practices.

Developing baby behaviour is not routinely included in training of health care staff, who often misinterpret baby behaviours and advise changes in feeding strategies.

There is a need for large‐scale studies addressing such issues, as well as clearer guidelines for health professionals and caregivers about common baby behaviours and how to cope with them.

Physical and Psychological Childbirth Experiences and Early Infant Temperament

Objective

To examine how physical and psychological childbirth experiences affect maternal perceptions and experiences of early infant behavioural style (temperament).

Background

Unnecessary interventions may disturb the normal progression of physiological childbirth and instinctive neonatal behaviours that facilitate mother-infant bonding and breastfeeding. While little is known about how a medicalised birth may influence developing infant temperament, high impact interventions which affect neonatal crying and cortisol levels could have longer term consequences for infant behaviour and functioning.

Methods

A retrospective Internet survey was designed to fully explore maternal experiences of childbirth and her postnatal perceptions of infant behaviour. Data collected from 999 mother-infant dyads were analysed using Pearson's correlations and multiple analyses of covariance, employing the Bonferroni method of correction to establish initially significant variables. Multiple linear regressions were conducted to determine major perinatal contributors to perceived early infant temperament.

Results

Multiple regression analyses on each of the eight Mother and Baby Scales outcome variables indicated that early infant behavioural style (0-6 months) was largely predicted by subjective maternal states during and post-childbirth, postnatal depression scores, maternal personality traits and infant age. For example, infant age (Beta = 0.440, p = 0.000) was the most significant predictor of Alert-Responsive infant behaviour, followed by maternal Postnatal Positive experience (Beta = 0.181, p = 0.000). In contrast, depression (EPDS) scores (Beta = 0.370, p = 0.000) were the most significant predictor of Unsettled-Irregular infant behaviour, followed by Anxious-Afraid Birth Emotions (Beta = 0.171, p = 0.000) and infant age (Beta = -0.196, p = 0.000). Mothers also perceived their infants as more Alert-Responsive (Beta = 0.080, p = 0.010) and Easier overall (Beta = 0.085, p = 0.008) after a Supported birth experience.

Conclusion

Maternal and infant outcomes were influenced by multiple physical and psychological perinatal variables. The mother's subjective experience appeared to be of equal significance to more objective factors (e.g. birthplace/mode). Social support enhanced the mother's childbirth experience, benefitting her perceptions of her baby's early temperament. These findings provide further support for current World Health Organisation intrapartum guidelines (2018) on the importance of making childbirth a 'positive experience' for women.

Trajectories of dysregulation in preschool age

Dysregulation of emotions, behaviour and attention is involved in several areas of childhood psychopathology, but knowledge about early developmental trajectories remains scarce. This study aims to explore continuity and associations of dysregulation in preschool age. Dysregulation was measured at age 2½ years and again at 5 years in a community-based birth cohort of 1099 children using the Child Behavior Checklist, preschool version (CBCL1½-5), answered by mothers. Based on the Dysregulation Profile (CBCL-DP) score, we defined four trajectory groups, using the 75th percentile from the Danish norm material as a cut-off. Associations between the four CBCL-DP trajectory groups and potential covariates, including child, parental and family factors, were analysed using univariate and multiple multinomial logistic regression. Nearly half (54%) of the children showed persistent low scores of CBCL-DP, 17% displayed continuing dysregulation problems, 13% had problems that increased from 2½ years to 5 years, whereas 16% of the children showed reduced problems across preschool age. Persistent dysregulation was associated with maternal postpartum depressive symptoms RRR = 2.20 (95% CI 1.29-3.75), low maternal educational level RRR = 1.69 (95% CI 1.08-2.66), and mothers' smoking during pregnancy RRR = 2.87 (95% CI 1.09-7.55). Persistent problems of emotional, behavioural and attention regulation in children aged 2½ years to 5 years is influenced by maternal educational level and post-partum depression symptoms. The study draws clinical attention to early symptoms of dysregulation and to the importance of addressing the specific needs of mentally vulnerable parents in intervention planning.

Feeding Problems Including Avoidant Restrictive Food Intake Disorder in Young Children With Autism Spectrum Disorder in a Multiethnic Population

We examined feeding problems, including Avoidant Restrictive Food Intake Disorder (ARFID), in preschool children with Autism Spectrum Disorder (ASD). Data were collected from a prospective longitudinal study of 46 children with ASD in a multiethnic, low resource area in Gothenburg, Sweden. Feeding problems were found in 76% of the children with ASD, and in 28%, the criteria for ARFID were met. The study highlights early onset age, the heterogeneity of feeding problems, and the need for multidisciplinary assessments in ASD as well as in feeding problems, and also the need for further elaboration of feeding disorder classifications in children.

Recognizing Early Regulation Disorders in Pediatric Care: The For Healthy Offspring Project

Background

Regulation disorders are already apparent in infancy. The For Healthy Offspring Project was the first Hungarian study aimed at building an effective model for screening and examining the prevalence and complex (medical and psychosocial) background of classic behavior regulation disorders (excessive crying, feeding, and sleep problems) in infancy.

Material/Methods

Data were collected from families of 0- to 3-year-old children in a pediatric hospital and its neighboring areas through questionnaires, medical examinations, and individual and small-group consultations.

Results

In the questionnaire study about their children’s behavior (n=1133), 15% of mothers reported excessive crying, 16% reported feeding problems, and 10% reported sleep problems. In a subsample (n=619) in which medical examinations were also conducted, the prevalence of medical diagnoses was 15.0% for excessive crying, 15.2% for sleep disorders, 10.3% for breastfeeding difficulties, and 14.8% for feeding disorders. Children who were referred to the screening program (n=183) had significantly more behavior regulation disorders than the other children in our study. Regulation disorders were found to be comorbid with other health conditions in some cases.

Conclusions

We developed a complex model to screen for regulatory problems in early childhood. This study adds more information about the relationship between regulation problems and other health conditions. The general incidence (5–15%) of early childhood regulation disorders in other countries is likely similar to that found in Hungary. In order to effectively recognize early regulation disorders, diagnostic instruments widely used in the international field should be adapted in general Hungarian pediatric care.

The effects of infant behavioural sleep interventions on maternal sleep and mood, and infant sleep: A randomised controlled trial

Infant sleep problems are one of the first challenges for parents, negatively influencing infants and mothers. The present study examined the effects of preventive behavioural sleep intervention (BSI) on infant sleep patterns, maternal sleep quality, and depression. A clinical randomised multicentre controlled trial was conducted involving 82 mothers and their infants aged 2-4 months in Iran from August 2018 to April 2019. The intervention group received BSI, which included one individual 90-min class session, booklet, voice messages, and follow-up calls; while the control group received training on general infant safety. Details of infant sleep, maternal sleep quality, and postnatal depression were measured through the sleep diary, Pittsburgh Sleep Quality Index, and Edinburgh Postnatal Depression Scale, respectively, before and at 8 weeks after the training. In the intervention group, both the mean infant "night-time sleep period" and infant "longest self-regulated sleep period" were 81 min longer than the controls (p < .001). With an improvement of 160 min, the mean infant bedtime was decreased to 22:20 hours in the intervention group, substantially earlier than the controls (00:30 hours). The mean infant "night-time awakenings with signals" did not significantly change (2.6- and 2.5-times in the intervention and control groups, respectively). The intervention led to a significant improvement in maternal sleep quality and depression (p < .05). The present study acknowledges the positive effects of an early preventive infant BSI on infant sleep, maternal mood, and maternal sleep. Our present results also imply the importance of considering sleep patterns differences and cultural-based intervention's design.

Behavioral Regulatory Problems Are Associated With a Lower Attentional Bias to Fearful Faces During Infancy

To investigate the role of early regulatory problems (RP), such as problems in feeding, sleeping, and calming down during later development, the association between parent-reported RP at 3 months (no-RP, n = 110; RP, n = 66) and attention to emotional faces at 8 months was studied. Eight-month-old infants had a strong tendency to look at faces and to specifically fearful faces, and the individual variance in this tendency was assessed with eye tracking using a face-distractor paradigm. The early RPs were related to a lower attention bias to fearful faces compared to happy and neutral faces after controlling for temperamental negative affectivity. This suggests that early RPs are related to the processing of emotional information later during infancy.

Occurrence and determinants of parental psychosocial stress and mental health disorders in parents and their children in early childhood: rationale, objectives, and design of the population-based SKKIPPI cohort study

PURPOSE

The postnatal period is a vulnerable time for parents and children but epidemiological and health care utilisation data for Germany on parental mental health during early childhood is scarce. This protocol describes the rationale, aim and study design of a population-based cohort study to assess the occurrence and determinants of psychosocial stress and mental health disorders, as well as the use and cost of health care and social services in early childhood.

METHODS

As part of the collaborative SKKIPPI project, we will contact a random sample of 30,000 infants listed in the residents' registration offices of three German towns and we expect to include 6,000 mother-child pairs. Both parents are invited to fill out an online screening questionnaire. Mothers with indications of psychosocial stress will be interviewed to assess mental health disorders, regulatory problems of their children, as well as health care and social services utilisation, with a follow-up assessment after 6 months.

RESULTS

After description of sociodemographic and health data, we will analyse occurrences, patterns, and potential determinants (maternal age, social status, household factors, migration status etc.) of psychosocial stress and mental health disorders in the mothers and their children in early childhood.

CONCLUSIONS

Our study will identify potential risk and protective factors for postnatal mental health and health care utilization of psychosocially burdened families. This will help to improve prevention and treatment strategies to strengthen the parent-child relationship, to reduce persisting vulnerability of children, and to improve health care and social services.

TRIAL REGISTRATION

The study has been registered in the German Clinical Trial Registry on February 8th 2019 (DRKS-ID: DRKS00016653).

Helping Families of Infants With Persistent Crying and Sleep Problems in a Day-Clinic

Excessive crying and sleep problems affect up to 30% of infants and often coexist. Although usually benign and self-limiting, persistent crying, and sleep problems exceeding 6 months of age need attention as they may impair the mental health of the infant and its family. The source and the impact of these persistent regulatory problems is often not restricted to the infant, but extends to the parents and the parent-infant relationship. Clinical practice needs interdisciplinary and multi-method interventions focusing beyond regulatory problems of the infant but also on parental self-regulation and parent's co-regulatory responses toward the infant. Treating clinicians may encounter limitations of home-visits, outpatient, and pediatric residential settings when working with families in distress. We describe an infant mental health day-clinic treatment, drawing attention to this viable future direction. It offers a therapeutic climate based on forming a triangle of co-regulation between clinician, parent and infant to first help the parent and the infant settle down. This stress reduction restores parent-infant connectedness and parental learning and reflecting capacity. Clinicians then use established therapeutic modalities to support parental self- and co-regulatory skills which is important for the development of self-regulation in the infant. Experience with this treatment program suggests that a day-clinic setting facilitates interdisciplinary and integrative multi-method intervention, infant and parental stress reduction and integration of parental self- and co-regulatory skills in daily family life, improving overall outcomes. This perspective warrants further investigation.

Self-Reported Psychosocial Stress in Parents With Small Children

BACKGROUND

Psychosocial stress in early childhood can impair children's health and development. Data on the prevalence of psychosocial stress in families with infants and toddlers in Germany are lacking. Such data could be used to determine the need for prevention and to plan the appropriate preventive measures.

METHODS

In 2015, a representative cross-sectional study called Kinder in Deutschland- KiD 0-3 was conducted by questionnaire in pediatricians' practices across Germany. Parents taking their children to the U3-U7a child development checks were asked to self-report information about stress in their families. The data were analyzed with descriptive statistics and chi-square tests.

RESULTS

Data from 7549 families went into the analysis. Stressful situations commonly reported by the parents included unplanned pregnancy (21.3%), parenthoodrelated stress (e.g., self-doubt as to parenting competence, 29.6%), and lack of familial and social support for problems and questions arising in relation to the child, as well as for temporary child care (19.7%). Most types of psychosocial stress varied as a function of the child's age group, as categorized by the particular examination for which the child was presenting at the time of the survey (U3-U7a). Couple distress, lack of social support, signs of depression or anxiety symptoms, or inner anger were more commonly reported by parents attending the later examina - tions. Such problems could be addressed by supportive measures (e.g., parent counseling, early child intervention).

CONCLUSION

Psychosocial stress affects a large percentage of the parents of small children. A large proportion of parents of small children suffer from psychosocial stress. This should be monitored for accumulation and stability across child development checks and addressed as appropriate. Family practitioners and pediatricians are important partners for effective cooperation between the social system and the health-care system, and for the provision of preventive measures where appropriate.

The association of infant crying, feeding, and sleeping problems and inhibitory control with attention regulation at school age

Regulatory problems in infancy and toddlerhood have previously been associated with an increased risk of developing attention problems in childhood. We hypothesized that early regulatory problems are associated with attention problems via reduced inhibitory control. This prospective study assessed 1,459 children from birth to 8 years. Crying, feeding, and sleeping problems were assessed at 5 and 20 months via parent interviews and neurological examinations. At 20 months, inhibitory control was tested with a behavioral (snack delay) task. Attention regulation was assessed at 6 and 8 years using multiple instruments and informants. Detrimental effects of crying, feeding, and sleeping problems on attention regulation were partly mediated by children's ability to inhibit unwanted behaviors (β = -0.04, p = 0.013). Accounting for cognition diminished this indirect effect (β = -0.01, p = 0.209). Instead, the effects of crying, feeding, and sleeping problems on attention regulation were fully mediated by children's cognitive functioning (β = -0.10, p < 0.001). These results support that inhibitory control abilities partly mediate effects of crying, feeding, and sleeping problems. However, these effects may be accounted for by children's general cognitive abilities. Early regulatory problems may set infants on a course of under control of behavior into school age, and such trajectories are highly associated with general cognitive development.

Emotional-Behavioral Functioning, Maternal Psychopathologic Risk and Quality of Mother-Child Feeding Interactions in Children with Avoidant/Restrictive Food Intake Disorder

The literature on food intake disorder (ARFID) in early childhood has evidenced psychopathologic difficulties in both children and their mothers and a poor quality of feeding interactions. Only a few studies have focused on three different ARFID subtypes: irritable/impulsive (I/I), sensory food aversions (SFA) and post traumatic feeding disorder (PTFD). The aim of this study was to explore possible differences between the three groups in children’s emotional-behavioral functioning, maternal psychopathologic risk and the quality of mother–child feeding interactions, comparing these clinical groups with a control group. The sample consisted of 100 child–mother dyads, of which 23 children with I/I, 25 children with SFA, 27 children with PTFD and 27 children with no diagnosis. The mothers primarily filled out questionnaires assessing their psychopathologic symptoms and children’s emotional-behavioral functioning. Then, all dyads were videotaped during a main meal. Results revealed significant differences between the study groups in relation to children’s emotional–adaptive functioning, mothers’ psychological profile and mother–child interactions during feeding. These findings are relevant for the development of target intervention programs to treat specific ARFID disorders.

The Spectrum of Sleep Disorders Among Children: A Cross-sectional Study at a South Indian Tertiary Care Hospital

Introduction

Sleep problems during infancy and early childhood are fairly common and rarely recognized in pediatric practice. These are mostly related to the initiation and maintenance of night-time sleep. Understanding sleep patterns and disorders associated with sleep is challenging, especially in the pediatric age group. This study was done to estimate the magnitude of sleep disorders in children and to evaluate the associated risk factors.

Methods

This cross-sectional study was carried out among 450 children visiting the pediatric outpatient department of Sri Ramachandra Institute of Higher Education and Research, Chennai, India between November 2018 and June 2019. Children with chronic illnesses and a history of physical or mental trauma in the past six months were excluded. The Sleep Disturbance Scale for Children (SDSC) was used to gather information regarding sleep disorders.

Results

It was observed that a majority of the participants (72.2%) slept 9-11 hours per day. Among 46.2% of the participants, the time lag between bedtime and sleep time was less than 15 minutes. Overall, sleep problems were present in 34% of the participants. History of sleep problems in infancy, absence of siblings, and parental presence while sleeping emerged as statistically significant risk factors for childhood sleep disorders (p: <0.05).

Conclusion

We believe our study provides a basis for exploring the pattern and problems associated with sleep behavior among children. There is a need for setting up routine screening measures in pediatric outpatient departments to facilitate early detection of sleep disorders in order to avoid complications.

Problems of feeding, sleeping and excessive crying in infancy: a general population study

OBJECTIVE

To study regulatory problems (RPs) of feeding, sleeping and excessive crying in infancy, and explore the influence of maternal mental health problems and parent-child relationship problems.

DESIGN AND SETTING

Data were collected in the general child health surveillance delivered to infant families by community health nurses (CHNs). Information on CHNs' assessments and conclusions were obtained on 2598 infants and merged with data from national registers. Descriptive statistics and logistic regression models were used to study RPs in early and late infancy, and the influences due to child, family and parent-child relationship problems.

RESULTS

Combined RPs (C-RPs), defined as two or more simultaneous problems of feeding, sleeping or excessive crying, was identified in 2.9% and 8.6% of the population between age 2-6 and 8-11 months, respectively. Low maternal schooling and immigrant parents were associated with an increased risk of late C-RPs, but RPs in early infancy stand out as the main predictor of late C-RPs OR 3.4 (95% CI 1.8 to 6.6), and the effect of early maternal mental health problems and parent-child relationship problems seem to be mediated by early C-RPs.

CONCLUSIONS

Combined problems of feeding, sleeping or excessive crying may exist throughout infancy independently of exposures to maternal mental health problems and parent-child relationship problems. The results indicate that infants with RPs exceeding age 2 months need special attention, in clinical as well as community settings. Suggested intervention includes specific guidance to the parents to help them understand and regulate their infant's sensitivity and reactions.

Reliability and validity of the neonatal feeding assessment scale (NFAS) for the early identification of dysphagia in moderate to late preterm neonates

Background

A clinical feeding assessment instrument to assist with early identification of oropharyngeal dysphagia (OPD) in neonates was developed.

Objective

To investigate the validity and reliability of the Neonatal Feeding Assessment Scale (NFAS) in comparison to the modified barium swallow study (MBSS) as gold standard.

Method

A within-subject design was implemented. A group of 48 late premature neonates (mean gestational age 35.5 weeks) were sampled in the neonatal intensive care unit.

Results

The NFAS consists of six subsections, including physiological stability, infant state, stress cues, screening of muscle tone and control, oral peripheral examination and feeding/swallowing assessment. 93% of participants (14/15) received confirmatory diagnosis of OPD on MBSS. The NFAS presented with high sensitivity (78.6%) and specificity (88.2%) scores. The positive predictive value was 78.6%. Subsequently the accuracy of the NFAS to identify the presence of OPD accurately was 85.4% when compared to MBSS. Inter-rater reliability was determined on 35% of the sample. The inter-rater agreement on overall instrument outcome was substantial beyond chance.

Conclusion

The NFAS may be of use to clinicians to support the early identification of OPD in this population, especially in resource constrained settings working without access to MBSS and to reach under served neonates.

Temporal Patterns of Infant Regulatory Behaviors in Relation to Maternal Mood and Soothing Strategies

This study investigates the temporal patterning of infant self-regulatory behaviors (crying/fussing, sleeping) in relation to both infant (age, sex, regulatory problems) and maternal variables (soothing behaviors, mood). Self-regulatory and soothing behaviors were assessed in 121 mother-infant dyads (4-44 weeks) by the Baby's Day Diary at 5 min intervals over 3 days. Further infant characteristics and maternal mood were assessed by questionnaires (DASS, CES-D, STAI) and the Diagnostic Interview for the Assessment of Regulatory Problems in Infancy and Toddlerhood. Data were analyzed using generalized additive mixed models. Negative maternal mood was associated with a deviant course of crying/fussing during the day. Body contact was associated with reduced variability in the 24 h course of sleep. Mother-infant transactional processes-above and beyond known relationships with overall levels of crying/fussing and sleeping-might play out on the temporal dimension of infant regulatory behaviors.

The consequences of having an excessively crying infant in the family: an integrative literature review

BACKGROUND

The consequences of having an excessively crying infant in the family are acknowledged in research, yet to our knowledge, no literature review has been made regarding the overall consequences to the family and infant. This integrative review fills the gap with the aim to review and synthesise current research.

AIMS

To identify, describe and synthesise previous studies on the consequences of having an excessively crying infant in the family.

DESIGN

An integrative review of literature published between January 2008 and April 2018. The search was conducted in the following databases: MEDLINE, CINAHL, PsycINFO, Medic and Journals@Ovid. Empirical literature reporting the consequences of having an excessively crying infant in the family was eligible for inclusion. Quality appraisal was performed using CASP tools and JBI checklists. The extracted data were analysed using thematic analysis.

FINDINGS

Thirty-one articles were included in the review. Ten themes were identified: The consequences of having an excessively crying infant in the family create desperation. It ruins everyday life, impairs breastfeeding, isolates and casts parents into loneliness, strains and breaks family relationships with feelings of failure as a parent. The excessively crying infant in the family brings a struggle that can lead to physical and mental exhaustion. The infant may have problems later in childhood. Parents are actively trying to solve the problem and to adjust. Time allows survival with traces of negative symptoms, feelings and memories.

CONCLUSIONS

The consequences of having an excessively crying infant in the family are harmful to relationships and health. Caring for the crying infant can lead to exhaustion, which might escalate into abuse. These findings help professionals understand this complex phenomenon and encourage actions for concrete support. Further research is required to explore evidence-based interventions that can help excessively crying infants and their families.

Infant regulatory behavior problems during first month of life and neurobehavioral outcomes in early childhood

Whether infant regulatory behavior problems already in the first month of life indicate an increased risk of childhood neurobehavioral problems, and whether maternal depression in the postpartum and early childhood underpins these associations remain unclear. Altogether, 2049-2364 mothers from the Prediction and Prevention of Pre-eclampsia and Intrauterine Growth Restriction (PREDO) study completed the Neonatal Perception Inventory on regulatory behavior problems at the infant's age of 15.6 days (SD 3.2, range 1-30), the Infant Behavior Questionnaire-Revised on temperament at 6.5 months (SD 0.9, range 4.2-12.4), and the Ages and Stages Questionnaire-3 on developmental milestones and the Child Behavior Checklist on behavioral problems at 3.5 years (SD 0.7, range 1.9-6.0). Maternal depressive symptoms were measured by the Center for Epidemiological Studies Depression Scale (infancy follow-ups) and Beck Depression Inventory-II (childhood follow-up). Father-rated infant temperament and paternal depressive symptoms were also available (n = 1474). Higher levels of infant regulatory behavior problems predicted higher levels of mother- and father-rated negative affectivity temperament (0.13 SD units per SD unit, 95% confidence interval 0.09-0.17; and 0.09, 0.04-0.14, respectively), lower levels of mother-rated orienting/regulation temperament (- 0.09, - 0.13 to - 0.05) and problem-solving skills (- 0.12, - 0.21 to - 0.04), and higher levels of Externalizing (0.07, 0.03-0.11) and Total behavioral problems (0.07, 0.03-0.11). Regulatory behaviors partially mediated the effect of maternal depressive symptoms. Regulatory behavior problems already during the first month of life predict neurobehavioral outcomes, and partially mediate the effect of maternal depressive symptoms. Our study may inform design of interventions aimed at timely prevention in children at risk.

The link between infant regulatory problems, temperament traits, maternal depressive symptoms and children's psychopathological symptoms at age three: a longitudinal study in a German at-risk sample

BACKGROUND

Difficult conditions during childhood can limit an individual's development in many ways. Factors such as being raised in an at-risk family, child temperamental traits or maternal traits can potentially influence a child's later behaviour. The present study investigated the extent of regulatory problems in 6-month-old infants and their link to temperamental traits and impact on externalizing and internalizing problems at 36 months. Moderating effects of maternal distress and maternal depressive symptoms were tested as well.

METHODS

In a quasi-experimental, longitudinal study, a sample of 185 mother-infant dyads at psychosocial risk was investigated at 6 months with SFS (infants' regulatory problems) and at 3 years with CBCL (children's behavioural problems), EAS (children's temperament), ADS (maternal depressive symptoms) and PSI-SF (maternal stress).

RESULTS

A hierarchical regression analysis yielded a significant association between infants' regulatory problems and both externalizing and internalizing behaviour problems at age 3 (accounting for 16% and 14% variance), with both externalizing and internalizing problems being linked to current maternal depressive symptoms (12 and 9% of the variance). Externalizing and internalizing problems were found to be related also to children's temperamental difficulty (18 and 13% of variance) and their negative emotionality. With temperamental traits having been taken into account, only feeding problems at 6 months contributed near-significant to internalizing problems at 3 years.

CONCLUSIONS

Our results underscore the crucial role of temperament in the path between early regulatory problems and subsequent behavioural difficulties. Children's unfavourable temperamental predispositions such as negative emotionality and generally "difficult temperament" contributed substantially to both externalizing and internalizing behavioural problems in the high-risk sample. The decreased predictive power of regulatory problems following the inclusion of temperamental variables indicates a mediation effect of temperamental traits in the path between early regulatory problems and subsequent behavioural problems. Our results support the main effects of a child's temperament, and to some degree maternal depressive symptoms, rather than the diathesis stress model of interaction between risky environment and temperamental traits. Trial registration D10025651 (NZFH).

A Developmental Cascade Model of Behavioral Sleep Problems and Emotional and Attentional Self-Regulation Across Early Childhood

This article documents the longitudinal and reciprocal relations among behavioral sleep problems and emotional and attentional self-regulation in a population sample of 4,109 children participating in Growing Up in Australia: The Longitudinal Study of Australian Children (LSAC)-Infant Cohort. Maternal reports of children's sleep problems and self-regulation were collected at five time-points from infancy to 8-9 years of age. Longitudinal structural equation modeling supported a developmental cascade model in which sleep problems have a persistent negative effect on emotional regulation, which in turn contributes to ongoing sleep problems and poorer attentional regulation in children over time. Findings suggest that sleep behaviors are a key target for interventions that aim to improve children's self-regulatory capacities.

Inter-rater reliability and acceptance of the structured diagnostic interview for regulatory problems in infancy

BACKGROUND

Regulatory problems such as excessive crying, sleeping-and feeding difficulties in infancy are some of the earliest precursors of later mental health difficulties emerging throughout the lifespan. In the present study, the inter-rater reliability and acceptance of a structured computer-assisted diagnostic interview for regulatory problems (Baby-DIPS) was investigated.

METHODS

Using a community sample, 132 mothers of infants aged between 3 and 18 months (mean age = 10 months) were interviewed with the Baby-DIPS regarding current and former (combined = lifetime) regulatory problems. Severity of the symptoms was also rated. The interviews were conducted face-to-face at a psychology department at the university (51.5 %), the mother's home (23.5 %), or via telephone (25.0 %). Inter-rater reliability was assessed with Cohen's kappa (k). A sample of 48 mothers and their interviewers filled in acceptance questionnaires after the interview.

RESULTS

Good to excellent inter-rater reliability on the levels of current and lifetime regulatory problems (k = 0.77-0.98) were found. High inter-rater agreement was also found for ratings of severity (ICC = 0.86-0.97). Participants and interviewers' overall acceptance ratings of the computer-assisted interview were favourable. Acceptance scores did not differ between interviews that revealed one or more clinically relevant regulatory problem(s) compared to those that revealed no regulatory problems.

CONCLUSIONS

The Baby-DIPS was found to be a reliable instrument for the assessment of current and lifetime problems in crying and sleeping behaviours. The computer-assisted version of the Baby-DIPS was well accepted by interviewers and mothers. The Baby-DIPS appears to be well-suited for research and clinical use to identify infant regulatory problems.

The Roles of Maternal Depression, Serotonin Reuptake Inhibitor Treatment, and Concomitant Benzodiazepine Use on Infant Neurobehavioral Functioning Over the First Postnatal Month

OBJECTIVE

The purpose of this article was to systematically compare the developmental trajectory of neurobehavior over the first postnatal month for infants with prenatal exposure to pharmacologically untreated maternal depression, selective serotonin reuptake inhibitors or serotonin and norepinephrine reuptake inhibitors (collectively: SSRIs), SSRIs with concomitant benzodiazepines (SSRI plus benzodiazepine), and no maternal depression or drug treatment (no exposure).

METHOD

Women (N=184) were assessed at two prenatal time points to determine psychiatric diagnoses, symptom severity, and prenatal medication usage. Infants were examined with a structured neurobehavioral assessment (Neonatal Intensive Care Unit Network Neurobehavioral Scale) at multiple time points across the first postnatal month. SSRI exposure was confirmed in a subset of participants with plasma SSRI levels. General linear-mixed models were used to examine group differences in neurobehavioral scores over time with adjustment for demographic variables and depression severity.

RESULTS

Infants in the SSRI and SSRI plus benzodiazepine groups had lower motor scores and more CNS stress signs across the first postnatal month, as well as lower self-regulation and higher arousal at day 14. Infants in the depression group had low arousal throughout the newborn period. Infants in all three clinical groups had a widening gap in scores from the no-exposure group at day 30 in their response to visual and auditory stimuli while asleep and awake. Infants in the SSRI plus benzodiazepine group had the least favorable scores on the Neonatal Intensive Care Unit Network Neurobehavioral Scale.

CONCLUSIONS

Neonatal adaptation syndrome was not limited to the first 2 weeks postbirth. The profile of neurobehavioral development was different for SSRI exposure than depression alone. Concomitant benzodiazepine use may exacerbate adverse behavioral effects.

Excessive crying at 3 months of age and behavioural problems at 4 years age: a prospective cohort study

Background

Excessive crying in early infancy has been associated with behavioural problems among preschool children from high income countries but studies in low income and middle income countries are scarce.

Methods

The 2004 Pelotas Birth Cohort is a population-based study planned to enrol all live births occurring in Pelotas that year and comprises 4231 children who so far have been followed up at 3, 12, 24, 48 and 72 months of age. Several familial, maternal and child characteristics were gathered in every follow-up. At the 3-month follow-up, infants whose mothers perceived them as crying more than others of the same age were classified as ‘crying babies’. Child behavioural problems were assessed through the Child Behavior Checklist (CBCL) applied to the mother at the 48-month follow-up. Crude and adjusted ORs with 95% CIs were calculated by logistic regression.

Results

Prevalence of excessive crying at 3 months was 11.9% (10.9% to 13.0%). Among children with excessive crying at 3 months the proportion in the clinical range for CBCL total, internalising and externalising problems at 4 years of age was 31.2%, 12.9% and 37.5%, respectively, against 20.6%, 6.8% and 29.6%, respectively, among non-crying babies. After controlling for confounders crying babies presented increased risk of being in clinical range of CBCL total (OR=1.34; 1.03 to 1.74), internalising (OR=1.55; 1.09 to 2.21) and externalising problems (OR=1.29; 1.01 to 1.64) than infants without excessive crying.

Conclusions

Excessive crying in early infancy may represent one important risk factor for developing behavioural problems in later phases of early childhood.

Infant and toddler crying, sleeping and feeding problems and trajectories of dysregulated behavior across childhood

Infant and toddler regulatory problems (RPs) including crying, sleeping and feeding, are a frequent concern for parents and have been associated with negative behavioral outcomes in early and middle childhood. Uncertain is whether infant and toddler RPs predict stable, trait-like dysregulated behavior across childhood. We addressed this gap in the literature using data from the Avon Longitudinal Study of Parents and Children (ALSPAC). RPs at 6, 15-18, & 24-30 months and childhood dysregulated behavior at 4, 7, 8, & 9.5 years were assessed using mother report. Latent Class Growth Analysis (LCGA) indicated that trajectories of childhood dysregulated behavior were stable over time. All single RPs (i.e., crying, sleeping & feeding problems) were significantly associated with childhood dysregulated behavior. For example, crying problems at 6 months after controlling for confounders (Odds Ratios; 95% Confidence Intervals): Moderate dysregulated behavior: OR = 1.50, 95% CI [1.09 to 2.06], high dysregulated behavior: OR = 2.13, 95% CI [1.49 to 3.05] and very high dysregulated behavior: OR = 2.85, 95% CI [1.64 to 4.94]. Multiple RPs were especially strongly associated with dysregulated behavior. For example, the RP composite at 15-18 months: 1 RP, very high dysregulated behavior: OR = 2.79, 95% CI [2.17 to 3.57], 2 RPs, very high dysregulated behavior: OR = 3.46, 95% CI [2.38 to 5.01], 3 RPs, very high dysregulated behavior: OR = 12.57, 95% CI [6.38 to 24.74]. These findings suggest that RPs in infants and toddlers predict stable dysregulated behavior trajectories across childhood. Interventions for early RPs could help prevent the development of chronic, highly dysregulated behavior.

Sleep and Early Cortical Development

Sleep is increasingly recognized as a key process in neurodevelopment. Animal data show that sleep is essential for the maturation of fundamental brain functions, and growing epidemiological findings indicate that children with early sleep disturbance suffer from later cognitive, attentional, and psychosocial problems. Still, major gaps exist in understanding processes underlying links between sleep and neurodevelopment. One challenge is to translate findings from animal research to humans. In this review, we describe parallels and differences in sleep and development of the cortex in humans and animals and discuss emerging questions.

Mother-infant circadian rhythm: development of individual patterns and dyadic synchrony

BACKGROUND

Mutual circadian rhythm is an early and essential component in the development of maternal-infant physiological synchrony.

AIMS

The aim of this to examine the longitudinal pattern of maternal-infant circadian rhythm and rhythm synchrony as measured by rhythm parameters.

STUDY DESIGN

In-home dyadic actigraphy monitoring at infant age 4, 8, and 12 weeks.

SUBJECTS

Forty-three healthy mother-infant pairs.

OUTCOME MEASURES

Circadian parameters derived from cosinor and non-parametric analysis including mesor, magnitude, acrophase, L5 and M10 midpoints (midpoint of lowest 5 and highest 10h of activity), amplitude, interdaily stability (IS), and intradaily variability (IV).

RESULTS

Mothers experienced early disruption of circadian rhythm, with re-establishment of rhythm over time. Significant time effects were noted in increasing maternal magnitude, amplitude, and IS and decreasing IV (p<.001). Infants demonstrated a developmental trajectory of circadian pattern with significant time effects for increasing mesor, magnitude, amplitude, L5, IS, and IV (p<.001). By 12 weeks, infant phase advancement was evidenced by mean acrophase and M10 midpoint occurring 60 and 43 min (respectively) earlier than at 4 weeks. While maternal acrophase remained consistent over time, infants became increasingly phase advanced relative to mother and mean infant acrophase at 12 weeks occurred 60 min before mother. Mother-infant synchrony was evidenced in increasing correspondence of acrophase at 12 weeks (r=0.704), L5 (r=0.453) and M10 (r=0.479) midpoints.

CONCLUSIONS

Development of mother-infant synchrony reflects shared elements of circadian rhythm.

Long term follow up of high risk children: who, why and how?

BACKGROUND

Most babies are born healthy and grow and develop normally through childhood. There are, however, clearly identifiable high-risk groups of survivors, such as those born preterm or with ill-health, who are destined to have higher than expected rates of health or developmental problems, and for whom more structured and specialised follow-up programs are warranted.

DISCUSSION

This paper presents the results of a two-day workshop held in Melbourne, Australia, to discuss neonatal populations in need of more structured follow-up and why, in addition to how, such a follow-up programme might be structured. Issues discussed included the ages of follow-up, and the personnel and assessment tools that might be required. Challenges for translating results into both clinical practice and research were identified. Further issues covered included information sharing, best practice for families and research gaps.

SUMMARY

A substantial minority of high-risk children has long-term medical, developmental and psychological adverse outcomes and will consume extensive health and education services as they grow older. Early intervention to prevent adverse outcomes and the effective integration of services once problems are identified may reduce the prevalence and severity of certain outcomes, and will contribute to an efficient and effective use of health resources. The shared long-term goal for families and professionals is to work toward ensuring that high risk children maximise their potential and become productive and valued members of society.

The development of human female competition: allies and adversaries

Throughout their lives, women provide for their own and their children's and grandchildren's needs and thus must minimize their risk of incurring physical harm. Alliances with individuals who will assist them in attaining these goals increase their probability of survival and reproductive success. High status in the community enhances access to physical resources and valuable allies. Kin, a mate, and affines share a mother's genetic interests, whereas unrelated women constitute primary competitors. From early childhood onwards, girls compete using strategies that minimize the risk of retaliation and reduce the strength of other girls. Girls' competitive strategies include avoiding direct interference with another girl's goals, disguising competition, competing overtly only from a position of high status in the community, enforcing equality within the female community and socially excluding other girls.

Influence of early regulatory problems in infants on their development at 12 months: a longitudinal study in a high-risk sample

BACKGROUND

This study examined the extent to which regulatory problems in infants at 4 and 6 months influence childhood development at 12 months. The second aim of the study was to examine the influence maternal distress has on 4-month-old children's subsequent development as well as gender differences with regard to regulatory problems and development.

METHODS

153 mother-child dyads enrolled in the family support research project "Nobody slips through the net" constituted the comparison group. These families faced psychosocial risks (e.g. poverty, excessive demands on the mother, and mental health disorders of the mother, measured with the risk screening instrument Heidelberger Belastungsskala - HBS) and maternal stress, determined with the Parental Stress Index (PSI-SF). The children's developmental levels and possible early regulatory problems were evaluated by means of the Ages and Stages Questionnaires (ASQ) and a German questionnaire assessing problems of excessive crying along with sleeping and feeding difficulties (SFS).

RESULTS

A statistically significant but only low, inverse association between excessive crying, whining and sleep problems at 4 and 6 months and the social development of one-year-olds (accounting for 5% and 8% of the variance respectively) was found. Feeding problems had no effect on development. Although regulatory problems in infants were accompanied by increased maternal stress level, these did not serve as a predictor of the child's social development at 12 months. One-year-old girls reached a higher level of development in social and fine motor skills. No gender differences were found with regard to regulatory problems, nor any moderating effect of gender on the relation between regulatory problems and level of development.

CONCLUSIONS

Our results reinforce existing knowledge pertaining to the transactional association between regulatory problems in infants, maternal distress and dysfunctionality of mother-child interactions. They also provide evidence of a slight but distinct negative influence of crying and sleeping problems on children's subsequent social development. Easily accessible support services provided by family health visitors (particularly to the so-called "at-risk families") are strongly recommended to help prevent the broadening of children's early regulatory problems into other areas of behavior.

Neonatal brainstem dysfunction risks infant social engagement

The role of the brainstem in mediating social signaling in phylogenetic ancestral organisms has been demonstrated. Evidence for its involvement in social engagement in human infants may deepen the understanding of the evolutionary pathway of humans as social beings. In this longitudinal study, neonatal brainstem functioning was measured by auditory brainstem-evoked responses (ABRs) in 125 healthy neonates born prematurely before 35 weeks' gestational age. At 4 months, infants were tested in a set of structured vignettes that required varying levels of social engagement and cardiac vagal tone was assessed. Data show that neonates with a disrupted I-V waveform, evident mostly by delayed wave V, exhibit shorter latencies to gaze averts in episodes involving direct face-to-face interactions but engage gaze as controls when interacting with masked agents or with agents whose faces are partly veiled by toys. Analysis of variance of infants' social engagement with ABR, neonatal risk, maternal stress and cardiac vagal tone showed a main effect for ABR and an ABR by gestational age interaction. The integrity of brainstem transmission of sensory information during the final weeks of gestation may scaffold the development of social disengagement, thereby attesting to the brainstem's preserved evolutionary role in developing humans as social organisms prior to engaging in social encounters.

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.

The unsettled baby: crying out for an integrated, multidisciplinary primary care approach

Unsettled behaviour in the first few months of life is a common clinical problem, with the associated risks of postnatal depression, premature cessation of breastfeeding, long-term psychological disturbance, and child abuse. Parents of new babies complain of difficulty accessing appropriate care and receiving conflicting advice. Although organic disturbance is implicated in only 5% of cases, gastro-oesophageal reflux disease, food allergies and lactose intolerance are often mistakenly diagnosed in unsettled babies. There is no evidence that acid-suppressive medications help in treating unsettled behaviour and, until the hypothesis that proton-pump inhibitors may predispose to food allergies has been properly investigated, treatment with acid-suppressive medications should be avoided in this population. Although unsettled behaviour in infants is commonly a transient neurodevelopmental phenomenon that peaks at 6 weeks of age, failure to diagnose other correctable problems, including breastfeeding difficulty and cows milk allergy, risks entrenching anxiety and disrupted mother-infant interactions in the long term. In the current climate of health system reform, the design and evaluation of an integrated, evidence-based, multidisciplinary primary care approach to management of unsettled babies and their mothers is a priority.