Your Fussy Baby

chapter 1

Common Fussiness and Crying

Some of the things we know about ordinary, brief, or common fussing and crying shed light on extreme fussiness/colic. This information is often comforting to parents who are distressed by their child's fussing or crying. (If you have skipped the Introduction, you may want to go back and read it now. The Introduction explains how to use the book and describes what I mean by "fussiness.")

As a pediatrician, parents often ask me why their babies fuss or cry—and often during such inconvenient hours! While it is true that babies often "melt down" during the evening and sleeping hours, these behaviors also occur during the day. During the day, though, their fussing is less bothersome, making less of an impression. Step number one in understanding your baby's fussiness is to try to become sensitive to all of your child's fussy times and even to gradations between the best and worst fussing or crying. It might be worthwhile to keep a detailed diary so that you can separate your child's actual behavior from your perceptions, which can be affected by your own tiredness and frustration. And even the fussiest babies have good times, too, which may also be helpful to record.

I admit it can be hard to be objective about fussing and crying. Crying is an irritating sound. It seems to suggest misery and pain. It is virtually impossible to ignore. There is something about it that, as one mother put it, "poisons the atmosphere." You cannot sleep, enjoy a meal, or concentrate on anything else when you can hear a baby crying. Crying might be a survival mechanism that developed in the process of human evolution. It certainlyseems to be nature's way of making sure a baby gets the attention she needs.

What Does Crying Mean?

Tennyson wrote in "In Memoriam":

But what am I?

An infant crying in the night;

An infant crying for the light;

And with no language but a cry.

Of course, crying is one of the only ways a newborn infant can communicate. But the meaning of a baby's crying is open to interpretation. We think that a crying baby is hurting, frightened, or angry; this crying is taken as a form of criticism, loneliness, or tension.

There is something in each of us that identifies with a baby's crying. Who has not felt alone in a strange world, cold, confused, and unable to communicate? We project onto the sobbing child all the despair of the human condition. But it is important to recognize that we really do not know what a baby's crying means. Though babies do cry when they have been hurt or frightened, it is incorrect to assume that a crying infant is either hurt or scared. We cannot even be certain a crying baby is unhappy. Some researchers have observed that stress hormones do not increase during some spells of crying as they do during, for example, circumcision or the drawing of blood from an infant. On the basis of this they concluded that during extreme fussiness, babies were not experiencing pain. Perhaps there is some truth to the folk wisdom which claims that babies cry "to exercise their lungs" or because it's one of the few things they know how to do. Birds fly, babies cry.

Whatever the case (and we will return to the important problem of why babies cry), remember that a screaming infant is not "doing a number" on you. Infants do not cry to manipulate, influence, punish, control, or intentionally annoy you. Infants of one to four months do not realize that their crying can get results. They do not even know that they are a separate person from you. They are just crying. And they may not even realize that!

What Should Parents Do About Crying?

A well-known British pediatrician, Dr. Illingworth, once claimed that one cause of crying is fatigue. This might suggest that you should let a crying baby alone to sleep. But Illingworth also added, categorically, that during the first few weeks of life an infant should be consoled rather than left alone. He claimed that picking up a baby when he or she cries results in less crying later on. This claim was later verified in a direct observational study by American researchers Silvia Bell and Mary Ainsworth at John Hopkins University. They disproved the notion that continually responding to a newborn's cry encourages crying behavior.

You Cannot Spoil Your Newborn

Bell and Ainsworth focused on twenty-six middle-class infant-mother pairs. Data were gathered by observing these mothers and children at home. First, observers confirmed that all infants have some crying spells. They noted the number of crying episodes that a mother ignored, the number she responded to, the length of time it took her to respond, what kind of response she made, and the overall effectiveness of her response. Picking up the baby and holding him proved to be the most effective way to terminate crying. Talking to him or gesturing at him from a distance was the least effective.

Bell and Ainsworth observed that, during the first few months, some mothers were deliberately unresponsive when their babies cried because they feared they might spoil their babies. Data over an entire year, however, showed that mothers who consistently and promptly responded to their infant's crying were rewarded at the age of one year with infants who cried less frequently, and for shorter durations, than those infants whose mothers ignored crying or delayed responding.

The authors of the study concluded, therefore, that infant crying is so disagreeable or "changeworthy" to adults that it probably serves a useful evolutionary function. They added that infant crying should be viewed as an "attachment" or "proximity-promoting" behavior because most often it served to bring a parent closer to a child. Furthermore, Bell and Ainsworth acknowledged the extreme difficulty of a mother or father ignoring a baby's crying. They recommended that a mother not struggle to overcome the natural impulse to comfort her crying child. An infant less than three months of age is, according to their study, at no risk of being spoiled.

The conclusion of this study is similar to others that suggest that conditioning or training an infant is extremely difficult even in a carefully controlled laboratory environment. Spoiling, after all, is simply encouraging an undesirable behavior. But babies under a few months of age cannot "learn" a crying habit because they are not neurologically mature enough (neurological maturity is a necessary precursor to what later becomes psychological development). After all, at three weeks of age a baby is not even neurologically mature enough to learn to smile specifically at her mother. This suggests that it takes time for a baby's brain to develop before it can recognize you and respond to this recognition (and melt your heart with her fantastic smile). Specific social smiling at parents normally develops at about six weeks (in premature deliveries, this occurs at about six weeks after the expected date of delivery). The logic follows: If you cannot teach a baby to smile before she is neurologically ready, why assume you can teach her to cry? Actually, during the first several weeks of life, babies do smile when they are asleep. But this is not a socially responsive smile. Interestingly, they can cry when they are asleep as well.

However, studies performed after the Bell and Ainsworth study strongly suggest that you can teach a crying habit to children over six months of age by indiscriminately responding to all vocalizations—always picking them up and/or soothing them. These children—having reached a sufficient level of neurological maturity—learn to cry for attention. For infants over six months of age (in contrast to newborns), parents who respond only to cries that appear to be intense or related to hunger or soiling and do not respond to quiet whimpers, mild calls, and other types of low-level whining sounds have children who at one year of age cry less. By the way, many parents do not realize that even the best babies may exhibit quiet whimpers, mild calls, low-level whining, or whimpering sounds while they remain sound asleep!

Frequent and Infrequent Criers

Bell and Ainsworth also concluded that in children between nine and twelve months of age, frequency of crying (how often a crying spell occurred) was a sign of "individual stability." Babies under nine months of age displayed fewer patterns of crying, but after nine months a baby could be identified as a frequent/long or infrequent/brief crier, an identification that often held as the child grew older. Logical conclusions from this study are, then, that infrequent criers after nine months of age were those babies whose mothers responded promptly to crying during their early months, becoming increasingly discriminate as they matured. These conclusions may, however, be too simple. Might there be biological differences among certain groups of babies that cause some to cry less and others, more? To begin to investigate this question, more background is necessary.

Similarities Between Common Fussiness/ Crying and Extreme Fussiness/Colic

Several studies of common fussing/crying show that the line between normal fussiness and extreme fussiness/colic is indistinct. Specifically, common fussiness mimics patterns associated with extreme fussiness/colic in five fundamental ways.

1. All Babies Cry Some of the Time

Crying in infants was studied intensively by a group of researchers at the Mayo Clinic. In their first study, they observed seventy-two babies in a newborn nursery. They worked in shifts so that each baby was observed twenty-four hours a day. The observers recorded start times of any and all crying as well as the duration. They attempted in each case to attribute a cause to the crying—wet or soiled diapers, hunger, cramped positions, chilling, and the like—if one was apparent. These researchers found that most of the newborns cried between one and eleven minutes per hour. The average daily total duration of crying was about two hours for these seventy-two babies.

Observation continued as the babies experienced normal postpartum life in the nursery for eight days—the recommended hospital stay at that time. Observing these babies around the clock during these eight days, researchers found that the minimum amount of crying time per day was 48 minutes. The maximum amount of crying time per day was 243 minutes (4 hours and 3 minutes). To clarify, all of the infants cried some of the time—at least 48 minutes per day. The average amount of crying was about two hours per day.

2. Some Crying Cannot Be Attributed to an Obvious Cause

The researchers then attempted to classify the causes of crying into the following categories: hunger, vomiting, wet or soiled diapers, being cold, being in an uncomfortable position, and unknown reasons. For example, if the baby was crying and sucking at common feeding intervals and was calmed by feeding, the crying was attributed to hunger. They found that hunger was the cause of crying 36 percent of the time spent crying. A wet diaper caused 21 percent of this group's crying, and soiled diapers about 8 percent. Interesting, however, is that a full 35 percent of all crying minutes were attributed, by this study, to "unknown reasons." The researchers were surprised that over one-third of all the minutes crying for these infants could not be explained by an apparent cause. In other words, if you cannot figure out why your baby is crying, you are in good company!

Next, these researchers evaluated their data from the perspective of frequency, the number of separate bouts of crying. Each spell of crying was recorded once, regardless of how long it lasted. In these tallies, they found that the number of bouts of crying for "unknown reasons" was greater than for any other cause, including hunger.

Their conclusions, then, were that the group's total amount of time spent crying caused by hunger was only slightly higher than the total amount of time spent crying caused by "unknown reasons," but that the number of bouts of crying caused by "unknown reasons" was greater than the number of bouts of crying caused by hunger. If these conclusions are accurate and pertain to the population at large, they make a rather important point. Babies have more separate crying spells for unknown reasons than they do for known reasons such as being hungry, wet, or soiled.

Furthermore, other research among babies of different cultural upbringings, including the !Kung San in southern Africa, has demonstrated that the number of individual crying spells per day does not vary. American, Dutch, and !Kung San babies tend to cry about the same number of times per day. This additional research suggests that how often a baby cries is biologically driven. !Kung San babies, though, have been shown to have crying spells of shorter duration. In addition to the fact that hunger is all but ruled out as a cause for their bouts of crying because they are breast-fed regularly and often, the !Kung San babies are held continually, enabling mothers to respond to even the weakest fret within seconds. It has not been determined whether these shorter crying spells among the !Kung San result from frequent breast-feeding, continual holding, prompt responding, or all three. Of course, decreasing the duration of the same number of spells results in less total time overall spent fussing. This suggests that breast-feeding, holding, and prompt attention may decrease ordinary fussing from escalating into extreme fussiness/colic. I'll discuss this more later, but now let's return to the Mayo study.

The findings of the Mayo study, then, are that all babies cry during the newborn period and that much of this crying cannot be attributed to any obvious cause. The authors made some guesses about nonobvious causes: bright lights, cramping movements or stomach contractions as a part of digestion, loud noises, or loss of equilibrium. They added, almost as an afterthought, that perhaps an infant's crying expressed a need to be touched or rocked in a rhythmic motion. This is somewhat striking because unlike mothers today, the researchers did not assume that all babies have a need to be gently caressed in a tender, loving, or lingering fashion.

The authors continued the study on forty-two of the infants from the original sample, using as data detailed diaries recorded by individual mothers in their own homes. This data covered about twenty-one days at home after a nine- or ten-day stay in the normal newborn nursery. All of these babies had some crying spells. They averaged four crying spells per day. Fifty-five percent of these spells were attributed to hunger. Crying for "unknown reasons" occurred in 20 percent of babies. Here again, unknown reasons was second only to hunger as a cause of crying. Crying associated with vomiting, stooling, urination, overheating, bathing, chilling, lights, or noises (attributions made by their mothers) were individually less common than crying "for unknown reasons." In conclusion, all babies cry during the first few weeks of life, and often we do not know why.

3. Two to Three Hours of Crying Per Day Is Average

The well-known Cambridge pediatrician T. Berry Brazelton also performed his own important study on crying. Using diaries completed by parents to study crying in eighty infants, he concluded that fussiness and spells of crying that are unrelated to hunger or to wet or soiled diapers occurred in virtually all of his babies. Furthermore, only twelve of the eighty babies fussed less than one and a half hours per day. About half cried for about two hours per day, but this crying increased to an average of about three hours per day at the age of six weeks. Thereafter the amount of crying declined to about one hour per day by the age of twelve weeks. Brazelton's research is significant for two reasons. Not only did he confirm that all babies have spells of fussing/crying, but he also made the important observation that these spells increase and peak at six weeks of age. Such a six-week peak of crying has been documented subsequently by numerous others. In fact, the pattern of more crying during the first twelve weeks with a pattern of peaking at six weeks has even been documented among the !Kung San infants. It seems, therefore, safe to conclude that the following phenomena are not related to parenting styles but are instead biologically determined: (1) some varying degree of fussiness occurs in all babies but is not attributable to a known cause; (2) the number of fussy/crying spells per day; (3) higher frequency of fussy/crying spells in the first twelve weeks of life; and (4) a peak of fussy/crying behavior at six weeks of age. How can this be so?

4. Many Babies Have Evening Crying Spells

Brazelton also concluded that crying spells became much more focused or concentrated in the evening when the infants were about six weeks of age. At this age, very little crying occurred during the day. The spells of crying in the evening proved to be predictable and their onset was sudden. Regarding this rapid shift in behavior in the evening from a calm/quiet state to a crying state, Brazelton offered no explanation. The Japanese have a specific term for this behavior. It is "night crying."

5. Crying Decreases at About Three Months

As mentioned above, Brazelton found that, on average, crying decreased to about one hour per day by the age of twelve weeks. Another study undertaken by researchers at Harvard University verified Dr. Brazelton's observations using tape recordings of infants crying in their homes. These researchers observed the same time course: an increase in crying at about six weeks that decreased by about twelve weeks. This means that the natural history of unexplained fussing and crying runs the same time course as that of extreme fussiness/colic behavior. In both cases, babies calmed down at about three months of age. Also at this time a stable individual pattern of crying behavior that will hold true for at least the next year seems to develop. Also, as mentioned before, more crying during the first three weeks and a general pattern of increasing fussiness and crying peaking at about six weeks of age and then decreasing occurs in all babies, in all cultures.

This point cannot be overemphasized, so I want to repeat it. Even among cultures where babies are constantly held, breast-fed very frequently, and always responded to, there still existed a peak pattern of fussing and crying at about six weeks and more fussing and crying during the first three months. Because the caretaking practices are so different between !Kung San and American mothers and the fussing and crying patterns are so similar, it is likely that fussing and crying behavior reflect mainly the maturation of the baby's brain, not parenting practices. On the other hand, parenting might affect the duration of each individual crying bout.