gms | German Medical Science

Excessive crying belongs to regulatory problems of babies and small infants (from birth to three years). There is a differentiation between the often temporary crying in the first three months (three-months colic) and a longer-lasting persistent regulatory problem. Excessive crying is a serious threat and danger for child development, for the psychic health of children and for the well-being of a child in general. To avoid long-term negative effects for children and their parents an early identification of overstrained families and adequate support services are needed. The functioning cooperation of paediatrists, hospitals, advice services, youth offices and communal intervention services is regarded as necessary to provide support, especially as “early help”.

Crying babies are newborns and infants who cry more than three hours for more than three days for a period of at least three weeks (according to a definition of the US paediatrist Morris Wessel). There are different scientific explanations for the excessive crying of babies which lead to different intervention approaches. Excessive crying is regarded either as infant colic of the immature gastro-intestinal system or as a symptom of a kinematic imbalance due to suboccipital strain (KISS syndrome) or as an infantile regulatory problem which is closely linked to the parent-child situation. Usually, oral interventions and acupuncture are used to treat the infant colic. Chiropractice is taken for the treatment of the KISS syndrome. Psychotherapeutic approaches are used for the treatment of regulatory problems. The causes of infantile regulatory problems are multifactorial. They are neither purely medical nor purely psycho-social. The development of the symptoms is complex and can be caused by biological risk factors at the side of the child, by psychosocial conditions at the side of the parents or by missing support of the social environment. In most of the cases excessive crying is caused by an interaction between risk and protective factors. Primary care services offer parents looking for advice diagnostics and counselling for the care of the child and the – in most of the cases – tensioned family situation.

• How effective are psychosocial, psychiatric, sociomedical and/or complimentary medical interventions for crying babies and their parents?
• How effective are interventions in “Schreiambulanzen” (primary care services) compared to other settings?

• Which costs are caused by the care for crying babies?
• Which cost savings can be reached by early interventions?

• In how far are the provision and access to care for crying babies and their parents assured?
• What has to be done to improve the provision? Which general conditions have to be developed?

A systematic electronic database research has been conducted in 32 databases (e. g. EMBASE, MEDLINE, PubMed) using key search words like crying, babies, crying infants, regulatory problem. Only intervention or therapy studies have been selected which had a sample >30, were published in German or English, not before the year 2001. The evidence classification of the Oxford Centre of Evidence-based Medicine was used for the evidence judgement. The methodological quality of the studies was evaluated by the check lists of the German Scientific Working Group Technology Assessment for Health Care.

18 studies from nine countries (including five from USA and five from UK) deal with oral, chiropractice, acupuncture, psychotherapeutic or behaviour related therapeutic interventions. The studies have a high evidence level, 14 studies have evidence levels between 1A and 2B. The oral interventions show that excessive crying is significantly reduced by a standardized extract of fennel, melissa and camomile or by a fennel seed oil emulsion or by a hydrolised formula or by a temporary strict maternal avoidance of cow’s milk products. Two Swedish studies suggest that minimal acupuncture shortens the duration and reduces the intensity of the crying of babies with colic. Only from UK and USA were studies available concerning the efficacy of chiropractice/tactile stimulation which show contradictory results. The efficacy of behaviour related therapeutic interventions for the reduction of excessive crying and the stresslevel of the parents is proven. The decisive factor seems to be the personal support by the advice giving professional. There are no concrete results concerning the efficacy of “Schreiambulanzen” (primary care services) because they are only analyzed in one review. The review covers studies with paediatricians from 1984 to 1994.

There is only one study from UK which covers explicitly cost-effectiveness. The study is methodologically weak, the results are not transferable to the German situation.

Three studies deal with ethical and social aspects of infantile regulatory problems. One of them describes the situation in Germany concerning early psychosocial interventions. The two other studies try to find out which risk factors favor the development of excessive crying. The German study shows that the number and the character of the early interventions differ strongly by region. Furthermore, there is a high discrepancy between the average coverage of 1.2% and the prevalence rate of infant regulatory problems (2.5% to 16.6%). The results concerning the risk factors are controversial. According to a Swiss study infantile regulatory problems are linked to the physical and psychic state and the social circumstances of the mother whereas an English study does not find any relation.

Despite the high evidence level of the majority of the studies many of them have methodological weaknesses. Excessive crying is not always defined by the Wessel criteria. The comparability of intervention and control groups is often limited, in part control are missing completely. The dropout rate is in several studies quite high. Predominantly are only a few studies included in the reviews, the selection criteria are not always comprehensible. There are no subgroup analyses by different age months of the babies reported. In several studies it is questionable whether the effects are to attribute to the intervention or to a Hawthorne effect.

Overall the studies cope the complexity of infantile regulatory problems and excessive crying only insufficiently. Current studies are missing which compensate these shortcomings and – moreover – address the efficacy of interventions in “Schreiambulanzen” (primary care services).

The state of research regarding the efficacy of interventions for crying babies has considerable gaps. But there is sufficient evidence for the effectiveness of treating infant colic by oral intervention with fennel or hydrolised cost or minimal acupuncture. Individual personal therapeutic intervention (in-door, out-door, at home) reduces also effectively excessive crying. There are not enough valid data/studies for a solid evaluation of the effectiveness of primary care services and the cost-benefit-efficacy of interventions for crying babies and their parents. Access to and supply with interventions and primary care services for crying babies and their parents are not assured in relation to the estimated need in Germany. A qualitative upgrading of the training and post-education of professional care providers in this field and low-threshold access to interventions and services is needed to improve the situation of crying babies and their parents.

The authors declare that they have no competing interests.

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