User:Hertzelnoah

PUT THIS IN WIKI UNDER GERD TOO) Baby colic (also known as infant colic, three month colic, and Infantile colic) is a condition in which an otherwise healthy baby cries or screams frequently and for extended periods without any discernible reason. The condition typically appears within the first two weeks of life and almost invariably disappears, often very suddenly, before the baby is three to four months old. It is equally common in bottle-fed and breastfed babies.  The crying often increases during a specific period of the day, frequently this happens in the early evening (the so-called “witching hour”). The medical definition of colic, is a health baby with periods of intense, unexplained fussing/crying lasting more than 3 hours a day, more than 3 days a week for more than 3 weeks. However, many doctors consider that definition, first described by Dr. Morris Wessel, to be overly narrow and would consider some babies with sudden, severe, unexplained crying lasting less than 3 hours/day as having “colic” as well (so-called “non-Wessel’s” colic). Persistent infant crying is much more than a nuisance. Crying and the parental exhaustion associated with it can trigger significant problems and even death, such as marital stress, breastfeeding failure  , shaken baby syndrome (also known as abusive head trauma)       , postpartum depression       , excess visits to the doctor/emergency room , unnecessary treatment for acid reflux          and maternal smoking. And crying and exhaustion may also contribute to SIDS   , infant obesity , maternal obesity   and even automobile accidents. The total financial burden (medical costs, lost productivity, legal/penal, adverse long term health effects, etc) of the 500,000 infants/year in the United States with colic the ultimate cost may exceed $1billion dollars/year.

Causes Over the decades, researchers have offered various hypotheses for colic including the exposure to cigarette smoke,   insufficient melatonin production (which does not begin until 12 weeks of age, about the time colic seems to disappear) , circadian rhythms  , and stress of the mother in the third trimester. It has also been said that babies cry because they sense their mother’s anxiety, but this is highly unlikely. Newborns lack the ability to tell whether a mother is anxious, depressed, frustrated, etc. After all new babies even need help to burp! In fact, it has been shown that a couple’s later children are as likely to be colicky as their first,2 even though parental anxiety is markedly reduced with successive children. It is plausible, however, that anxiety may have some relationship to crying through a more circuitous route. Anxious parents tend to lack confidence and may jump from one calming intervention to another without doing anything long enough for it to be effective. For thousands of years, the number one belief of worried parents, grandparents and doctors has been that colicky crying was provoked by abdominal pain from intestinal spasm or trapped gas. In fact, the word “colic” comes from the ancient Greek word for intestine (sharing the same root as the word “colon”). This gastrointestinal (GI) theory of colic probably originated because fussy babies often: grunt/pass gas/double-up/cry after eating; have noisy stomachs; improve with tummy pressure, warmth or massage; may improve with pain medication (e.g. paregoric, or tincture of opium)  or sips of herbal teas used for stomach upset (e.g. mint, fennel). However, most doctors no longer believe colic is related to gas, cramps, or overfeeding. Research has shown that 85-90% of colicky babies have no evidence of a true GI problem. The prevailing view is that colic is just the extreme range of normal crying. In other words, all healthy babies cry, but the 10-15% loudest, most persistent, “shriekiest” criers are labeled as having “colic.” 1 There are many reasons why most experts have abandoned the idea that colic is usually a result of stomach upset: 1) Fussiness peaks at ~6 weeks and reliably ends by 3-4 months, yet older infants still experience plenty of burps, flatus, BMs, etc. 2) Premature babies are no more likely to suffer from colic than full term babies despite the fact that their intestines are immature. And, although they eat, poop, burp and “toot” every day, they rarely get colic until they reach their due date. (In other words, a baby born three months early has the same 10-15% chance of developing colic as a full term baby, but his/her fussing won’t even begin until after three months! ) 3) Contrary to the belief that babies cry from air in the stomach, research X-rays of crying babies reveal that colicky babies have much more air trapped in their stomachs at the end of crying episodes - when already calm - than at the start of the crying!  (This is because babies gulp air while crying.) 4) “Burp” drops (simethicone) are no better at reducing crying than drops of ordinary placebo (distilled water). 5) Car rides and vacuum cleaners often calm fussing, yet certainly don’t lessen GI pain. (Car rides and vacuums don’t soothe our stomachaches). In 90% of cases colic is unrelated to the type of milk consumed by the baby,   however occasionally it is triggered by GI upset from food allergy and may require a hypoallergenic formula (e.g. Pregestimil).    The most problematic foods are cow’s milk based formula and, for breastfeeding babies, dairy products in the mother’s diet. Other, less common allergens are wheat, soy and nuts. Breastfed babies may also become irritable from stimulants in the mother’s diet (see section on treatment).     One of the main reasons parents and doctors choose a soy formula is for the relief of colic. However, it is not clear that switching to soy reduces colic. 47  Unlike older children and adults who may have GI discomfort from lactose intolerance, there is little evidence that this is a cause of persistent crying in infants. Some reports have associated colic to changes in a baby’s intestinal bacterial. They suggest treating the crying with daily doses of probiotics (such as Lactobacillus acidophilus or Lactobacillus reuteri). In one study, 83 colicky babies given probiotics had reduced crying. After one week, treated babies had 10% less crying (159 min/day vs. 177 min/day). By 4 weeks treated babies had 65% less crying the (51min/day vs. 145 min/day). However, a more recent study found no reduction in colic in over 1000 babies who were given probiotics from birth. In 2009, a University of Texas study observed that colicky babies had a higher incidence of mild intestinal inflammation and a specific intestinal bacteria, Klebsiella. But, a commentary in the same journal, noted that the inflammation and bacteria were most likely just an exaggerated variation of normal. Over the past 15 years, increasing numbers of fussy babies have been put on medication under the presumption that their crying was a sign of pain from acid reflux, so-called gastro-esophageal reflux disease (GERD). In fact from 2000-2003 the number of babies treated with anti-reflux medicines increased 400%! 21 And the use of a popular liquid PPI formulated specifically for young children increased 16 fold from 1999-2004. In truth, most babies have mild reflux …we simply call it spiting up. It rarely requires treatment and almost invariably disappears within 4-6 months. Over the past 5 years, repeated studies have shown that GERD rarely causes infant crying. Even if the crying occurs during feeding and is accompanied by writhing and back arching it is rarely related to acid reflux unless the baby also has: 1) poor weight gain, 2) vomiting at least 5 times/day or 3) other significant feeding problems.16 17 1819 20 21 A multicenter study, organized by researchers at Pittsburgh Children’s Hospital, concluded that GERD medicine (proton pump inhibitors, or PPI’s) is no better than placebo at reducing infant crying. Surprisingly, 50% of fussy babies improved on the PPI…but so did 50% of fussy babies who received a mere placebo!22 A more logical explanation for why fussy babies worsen during feeding is that they are overreacting to a totally normal intestinal process called the gastro-colic (GC) reflex. When the stomach fills with food it sends a message to the colon to start tightening (to squeeze out the poop and make room for the coming new food). The GC reflex is an automatic response present in all babies and adults. In adults, it occurs peaks about an hour after eating, but in babies it happens within minutes of the start of a meal (often triggering a BM while the baby is still eating). Most infants have little or no awareness when the reflex is working, however some overly sensitive children do feel it and arch and cry as waves of mild squeezing move the partially digested food through the intestines. These cries are often sharp and severe and misdiagnosed as pain from acid reflux, gas cramps or overfeeding. But, it is easy to prove they are not the cries of pain because they usually quickly abate when parents correctly perform the “5 S’s.” (Babies who cry from the GC reflex are often the same sensitive infants who scream when startled by a sudden loud laugh or telephone ring.) The ability of many hyperirritable babies to be calmed by simple soothing maneuvers has given birth to an engaging new theory of colic, the “missing 4th trimester.” This theory, the basis of the work of California pediatrician, Dr. Harvey Karp    is now recommended by many leading pediatricians and parenting books. The “missing 4th trimester” is based on the observation that our newborns are very immature at birth. Baby horses, by comparison, can walk and even run on the very first day of life. However, since human fetuses have such large brains, they must be born before they are mature enough to stand or run…or even smile. Babies held inside longer to fully mature would have such large heads that they would never be able to squeeze through the birth canal and they (and their mothers) would likely die in childbirth. (The head of a newborn chimpanzee is ~90% of their mother’s pelvic outlet. On the other hand, a human baby’s head overfills the pelvic outlet and has to “mold” - squish into a cone head or banana shape – to fit out!) Contrary to outdated theories that babies cry from gas pains or from being over-stimulated, Dr. Karp’s theory suggests that infant crying is actually related to our under-stimulation of babies. In other words, babies cry because of their “eviction” from the womb with its rich symphony of rhythmic, entrancing sensations to the still, quiet world we create for them in our homes. In the womb, fetuses experience several potent and hypnotic stimuli (e.g. stroking against the soft uterus walls; frequent tiny, jiggly movements; constant warmth; and continual sound - louder than a vacuum cleaner - created by the whooshing of blood through the placental arteries). No wonder babies often fall asleep at crowded parties and noisy basketball games. Dr. Karp postulates that all babies are born with a “calming reflex” that is a relative “off-switch” for crying and “on-switch” for sleep. This unique response is activated when parents perform 5 techniques (the “5 S’s”), which closely mimic the rhythmic sensations in the uterus. Duplicating the baby’s womb experience and turning on the “calming reflex” is probably how traditional calming methods work (for example, car rides, vacuum cleaners, bouncy dancing, warm baths, carrying babies in slings, etc). Think of the “calming reflex” as analogous to the knee reflex. Knee reflexes are extremely predictable and can be activated hundreds of times in a row when triggered correctly. However, hit the knee 1 inch too high - or low - or hit it too softly and the reflex will never be triggered. Similarly, parents can turn on the “calming reflex” over and over again, but only when the “S’s” are done in a very specific way (see below - section on treatment). Babies who continue crying despite the “5 S’s” being done correctly may be hungry, flooded from a breast milk oversupply, uncomfortable or ill. Parents who are unable to soothe their baby’s crying should call their healthcare provider to make sure the baby is not sick. Fortunately, only 5% of cases of colic are caused by illness (the most common cause being intestinal allergy, described above). Parents should consider illness or pain as the cause of their baby’s fussing if the crying is accompanied by at least one of the following ten “red flag” symptoms: 62 1) Persistent moaning or weak crying 2) High-pitched, shrill cry (sharp and more dramatic than usual) 3) Vomiting (vomit that is green or yellow and/or more than 5/day) 4) Change in stool (constipation or diarrhea, especially with blood or mucous) 5) Fussing during eating (twisting, arching, or crying that begins during or just after a feed) 6) Abnormal temperature (a rectal temperature less than 97.0°F or over 100.2°F) 7) Irritability (crying all day with few calm periods in between) 8) Lethargy (excess sleepiness, lack of smiles or interested gaze, weak sucking lasting over 6 hours) 9) Bulging soft spot on the head (even when the baby is sitting up) 10) Poor weight gain (gaining less than ½ ounce a day)

Babies with persistent crying or any “red flag” symptoms should be checked by a healthcare professional to rule out illness. The top ten medical problems to consider in irritable babies with “red flag” symptoms are: 62 1) Infections (e.g. ear infection, urine infection, meningitis, appendicitis) 2) Intestinal pain (e.g. food allergy, acid reflux, constipation, intestinal blockage) 3) Trouble breathing (e.g from a cold, excessive dust, congenital nasal blockage, oversized tongue) 4) Increased brain pressure (e.g., hematoma, hydrocephalus) 5) Skin pain (e.g. a loose diaper pin, irritated rash, a hair wrapped around a toe) 6) Mouth pain  (e.g. yeast infection) 7) Kidney pain (e.g. blockage of the urinary system) 8) Eye pain (e.g. scratched cornea, glaucoma) 9) Overdose (e.g. excessive Vitamin D, excessive sodium) 10) Others (e.g. migraine headache, heart failure, hyperthyroidism)

Effect on the family Infant crying (and the parental fatigue that typically accompanies it) often have a serious impact on parents and babies. Crying and exhaustion can inflict enormous emotional strain causing parents to feel inadequate and overwhelmed. (Hours of tape-recorded infant shrieks are even used in Navy Seal training to test the sailor’s ability to withstand torture!) A baby’s cries may make parents feel that their baby doesn’t like them and trigger anxiety, stress, resentment and low self-esteem. Persistent infant crying has been associated with severe marital discord 5, postpartum depression (affecting 10-15% of new mothers 12-15 and many new dads  ), Shaken Baby Syndrome (the leading cause of child abuse fatalities), 8-11 SIDS (from agitated babies flipping onto their stomachs, frustrated parents placing fussy babies on the stomach to sleep, exhausted parents falling asleep in unsafe places - like couches or beds with bulky covers) 24,25, early termination of breastfeeding6 7, frequent visits to doctors (1 in 6 children are brought to the doctor/emergency rooms for evaluation of persistent crying),16 maternal smoking23 and over a quadrupling of excessive laboratory tests and prescription of medication for acid reflux. 21 Parents at especially high risk of experiencing a serious reaction to their infant’s crying, include: teens, drug addicts, military families, foster parents, parents of premies and parents of multiples. Families living in dense housing projects, such as apartment blocks, may also suffer strained relationships with neighbors and landlords if their babies cry loudly for extended periods of time each day.

TREATMENT In past decades, doctors recommended treating colicky babies with sedative medications (e.g. Phenobarbital, Valium, ethanol), analgesics (e.g. opium) or anti-spasm drugs (e.g. scopolamine, Donnatal, dicyclomine), but all of these have been stopped because of potential serious side-effect, including death. Currently, the first approach most commonly recommended in healthy babies (without any “red flag” symptoms) is to use non-medicinal, noninvasive treatments like emotional support   or the rhythmic calming of the “5 S’s.” 62 63 There is a broad body of evidence showing that soothing measures, such as pacifiers, strong white noise      and jiggly rocking     are effective in calming babies during crying bouts. These techniques form the core of the “5 S’s” approach62 63: 1st S - Swaddling      (safe swaddling carefully avoiding overheating, covering the head, using bulky or loose blankets, and allowing the hips to be flexed   ); 2nd S - Side or stomach (holding a baby on the back is the only safe position for sleep, but it is the worst position for calming a fussy baby); 3rd S - Shhh sound 77-81 (making a strong shush sound near the baby's ear or using a CD of womb sound/white noise); 4th S - Swinging the baby with tiny jiggly movements (supporting the neck and no more than 1” back and forth)82-85; 5th S - Sucking (Letting the baby suckle on the breast or pacifier75,76) When done correctly and in combination, these techniques offer significant potential of promptly reducing infant crying. In a study conducted by the Boulder Colorado Department of Public Health home visiting nurses taught the “5S’s“ to 42 at-risk families (teen parents, addicts, parents of premature babies, etc) with fussy babies. After a single, one-hour visit to teach parents this approach (plus giving parents The Happiest Baby DVD and CD of womb sounds and a large swaddling blanket) 41/ 42 (98%) families reported a dramatic improvement in their ability to calm the fussing, even in babies diagnosed with acid reflux and those whose mothers abused methadone and methamphetamine. Many parents also reported that their babies slept longer. Numerous studies 77 78 80 87-89 have shown that 2 parts of the “5 S’s” (swaddling and shushing) used all night can improve sleep even among breastfed babies.27 Crying from an overreaction to the gastro-colic reflex (described above) is easy corrected with the “5 S’s.” Rapid reduction in crying with the “5 S’s” makes it unlikely that the baby is in pain (pain does not disappear with simple calming measures). In some communities, clinics and support groups have been set up for parents of children with colic. Such groups include the colic clinic at Woman’s and Infant’s Hospital, Providence, RI; several fussy baby clinics organized by the Erikson Institute of Chicago, IL and hundreds of Happiest Baby classes across North America. 95  101-103 Over the past 5 years, thousands of professionals have trained to teach Happiest Baby classes across the US…and 6 other countries, including: hospitals (e.g. University of Michigan, Northwestern, St. Luke's Children's Hospital, Boise, ID) , military bases  , teen parenting programs, state and local child abuse prevention programs,   PPD support groups,  fatherhood classes and state departments of health and child welfare (PA, WY, MN, CO, MA, CT, etc) 95 The University of Arizona conducted two surveys on over 300 parents-to-be before and after taking a Happiest Baby class. They showed a dramatic boost in confidence. Pre-class ~40% reported being moderately to very worried about being able to calm their baby's crying/problems, Post-class that dropped to a mere 0.5-1%. If simple approaches are not working to reduce the crying, parents should consult their health care provider to ask: 1) are they doing the ”5 S’s” correctly? or 2) Is there a medial problem requiring treatment? The most common medical causes of colic are food related. In a breastfed baby, the doctor may suggest eliminating all stimulant foods (e.g. coffee, tea, cola, chocolate, decongestants, diet supplements, etc) from a mother’s diet for a few days to evaluate for improvements in the baby's condition. If food allergy is suspected, the doctor may suggest a hypoallergenic formula for a formula fed infant or, if the mother is breastfeeding, a period of elimination of allergenic foods (e.g. dairy, nuts, soy, citrus, etc) from her diet in order to observe changes in the baby's condition.49-51 If the crying is related to a cow’s milk allergy benefits are usually seen within 2-7days. Mothers can then choose to add back small amounts of the suspected offending food a little bit at a time as long as persistent crying does not reappear. If crying dies reappear the offending foods may need to be avoided for many months. Persistently fussy babies with poor weight gain, vomiting more than 5 times/day, or other significant feeding problems should be evaluated by a healthcare professional for other illnesses (e.g. urinary infection, intestinal obstruction, acid reflux).

PUT THIS IN WIKI UNDER GERD TOO) Baby colic (also known as infant colic, three month colic, and Infantile colic) is a condition in which an otherwise healthy baby cries or screams frequently and for extended periods without any discernible reason. The condition typically appears within the first two weeks of life and almost invariably disappears, often very suddenly, before the baby is three to four months old. It is equally common in bottle-fed and breastfed babies.  The crying often increases during a specific period of the day, frequently this happens in the early evening (the so-called “witching hour”). The medical definition of colic, is a health baby with periods of intense, unexplained fussing/crying lasting more than 3 hours a day, more than 3 days a week for more than 3 weeks. However, many doctors consider that definition, first described by Dr. Morris Wessel, to be overly narrow and would consider some babies with sudden, severe, unexplained crying lasting less than 3 hours/day as having “colic” as well (so-called “non-Wessel’s” colic). Persistent infant crying is much more than a nuisance. Crying and the parental exhaustion associated with it can trigger significant problems and even death, such as marital stress, breastfeeding failure  , shaken baby syndrome (also known as abusive head trauma)       , postpartum depression       , excess visits to the doctor/emergency room , unnecessary treatment for acid reflux          and maternal smoking. And crying and exhaustion may also contribute to SIDS   , infant obesity , maternal obesity   and even automobile accidents. The total financial burden (medical costs, lost productivity, legal/penal, adverse long term health effects, etc) of the 500,000 infants/year in the United States with colic the ultimate cost may exceed $1billion dollars/year.

Causes Over the decades, researchers have offered various hypotheses for colic including the exposure to cigarette smoke,   insufficient melatonin production (which does not begin until 12 weeks of age, about the time colic seems to disappear) , circadian rhythms  , and stress of the mother in the third trimester. It has also been said that babies cry because they sense their mother’s anxiety, but this is highly unlikely. Newborns lack the ability to tell whether a mother is anxious, depressed, frustrated, etc. After all new babies even need help to burp! In fact, it has been shown that a couple’s later children are as likely to be colicky as their first,2 even though parental anxiety is markedly reduced with successive children. It is plausible, however, that anxiety may have some relationship to crying through a more circuitous route. Anxious parents tend to lack confidence and may jump from one calming intervention to another without doing anything long enough for it to be effective. For thousands of years, the number one belief of worried parents, grandparents and doctors has been that colicky crying was provoked by abdominal pain from intestinal spasm or trapped gas. In fact, the word “colic” comes from the ancient Greek word for intestine (sharing the same root as the word “colon”). This gastrointestinal (GI) theory of colic probably originated because fussy babies often: grunt/pass gas/double-up/cry after eating; have noisy stomachs; improve with tummy pressure, warmth or massage; may improve with pain medication (e.g. paregoric, or tincture of opium)  or sips of herbal teas used for stomach upset (e.g. mint, fennel). However, most doctors no longer believe colic is related to gas, cramps, or overfeeding. Research has shown that 85-90% of colicky babies have no evidence of a true GI problem. The prevailing view is that colic is just the extreme range of normal crying. In other words, all healthy babies cry, but the 10-15% loudest, most persistent, “shriekiest” criers are labeled as having “colic.” 1 There are many reasons why most experts have abandoned the idea that colic is usually a result of stomach upset: 1) Fussiness peaks at ~6 weeks and reliably ends by 3-4 months, yet older infants still experience plenty of burps, flatus, BMs, etc. 2) Premature babies are no more likely to suffer from colic than full term babies despite the fact that their intestines are immature. And, although they eat, poop, burp and “toot” every day, they rarely get colic until they reach their due date. (In other words, a baby born three months early has the same 10-15% chance of developing colic as a full term baby, but his/her fussing won’t even begin until after three months! ) 3) Contrary to the belief that babies cry from air in the stomach, research X-rays of crying babies reveal that colicky babies have much more air trapped in their stomachs at the end of crying episodes - when already calm - than at the start of the crying!  (This is because babies gulp air while crying.) 4) “Burp” drops (simethicone) are no better at reducing crying than drops of ordinary placebo (distilled water). 5) Car rides and vacuum cleaners often calm fussing, yet certainly don’t lessen GI pain. (Car rides and vacuums don’t soothe our stomachaches). In 90% of cases colic is unrelated to the type of milk consumed by the baby,   however occasionally it is triggered by GI upset from food allergy and may require a hypoallergenic formula (e.g. Pregestimil).    The most problematic foods are cow’s milk based formula and, for breastfeeding babies, dairy products in the mother’s diet. Other, less common allergens are wheat, soy and nuts. Breastfed babies may also become irritable from stimulants in the mother’s diet (see section on treatment).     One of the main reasons parents and doctors choose a soy formula is for the relief of colic. However, it is not clear that switching to soy reduces colic. 47  Unlike older children and adults who may have GI discomfort from lactose intolerance, there is little evidence that this is a cause of persistent crying in infants. Some reports have associated colic to changes in a baby’s intestinal bacterial. They suggest treating the crying with daily doses of probiotics (such as Lactobacillus acidophilus or Lactobacillus reuteri). In one study, 83 colicky babies given probiotics had reduced crying. After one week, treated babies had 10% less crying (159 min/day vs. 177 min/day). By 4 weeks treated babies had 65% less crying the (51min/day vs. 145 min/day). However, a more recent study found no reduction in colic in over 1000 babies who were given probiotics from birth. In 2009, a University of Texas study observed that colicky babies had a higher incidence of mild intestinal inflammation and a specific intestinal bacteria, Klebsiella. But, a commentary in the same journal, noted that the inflammation and bacteria were most likely just an exaggerated variation of normal. Over the past 15 years, increasing numbers of fussy babies have been put on medication under the presumption that their crying was a sign of pain from acid reflux, so-called gastro-esophageal reflux disease (GERD). In fact from 2000-2003 the number of babies treated with anti-reflux medicines increased 400%! 21 And the use of a popular liquid PPI formulated specifically for young children increased 16 fold from 1999-2004. In truth, most babies have mild reflux …we simply call it spiting up. It rarely requires treatment and almost invariably disappears within 4-6 months. Over the past 5 years, repeated studies have shown that GERD rarely causes infant crying. Even if the crying occurs during feeding and is accompanied by writhing and back arching it is rarely related to acid reflux unless the baby also has: 1) poor weight gain, 2) vomiting at least 5 times/day or 3) other significant feeding problems.16 17 1819 20 21 A multicenter study, organized by researchers at Pittsburgh Children’s Hospital, concluded that GERD medicine (proton pump inhibitors, or PPI’s) is no better than placebo at reducing infant crying. Surprisingly, 50% of fussy babies improved on the PPI…but so did 50% of fussy babies who received a mere placebo!22 A more logical explanation for why fussy babies worsen during feeding is that they are overreacting to a totally normal intestinal process called the gastro-colic (GC) reflex. When the stomach fills with food it sends a message to the colon to start tightening (to squeeze out the poop and make room for the coming new food). The GC reflex is an automatic response present in all babies and adults. In adults, it occurs peaks about an hour after eating, but in babies it happens within minutes of the start of a meal (often triggering a BM while the baby is still eating). Most infants have little or no awareness when the reflex is working, however some overly sensitive children do feel it and arch and cry as waves of mild squeezing move the partially digested food through the intestines. These cries are often sharp and severe and misdiagnosed as pain from acid reflux, gas cramps or overfeeding. But, it is easy to prove they are not the cries of pain because they usually quickly abate when parents correctly perform the “5 S’s.” (Babies who cry from the GC reflex are often the same sensitive infants who scream when startled by a sudden loud laugh or telephone ring.) The ability of many hyperirritable babies to be calmed by simple soothing maneuvers has given birth to an engaging new theory of colic, the “missing 4th trimester.” This theory, the basis of the work of California pediatrician, Dr. Harvey Karp    is now recommended by many leading pediatricians and parenting books. The “missing 4th trimester” is based on the observation that our newborns are very immature at birth. Baby horses, by comparison, can walk and even run on the very first day of life. However, since human fetuses have such large brains, they must be born before they are mature enough to stand or run…or even smile. Babies held inside longer to fully mature would have such large heads that they would never be able to squeeze through the birth canal and they (and their mothers) would likely die in childbirth. (The head of a newborn chimpanzee is ~90% of their mother’s pelvic outlet. On the other hand, a human baby’s head overfills the pelvic outlet and has to “mold” - squish into a cone head or banana shape – to fit out!) Contrary to outdated theories that babies cry from gas pains or from being over-stimulated, Dr. Karp’s theory suggests that infant crying is actually related to our under-stimulation of babies. In other words, babies cry because of their “eviction” from the womb with its rich symphony of rhythmic, entrancing sensations to the still, quiet world we create for them in our homes. In the womb, fetuses experience several potent and hypnotic stimuli (e.g. stroking against the soft uterus walls; frequent tiny, jiggly movements; constant warmth; and continual sound - louder than a vacuum cleaner - created by the whooshing of blood through the placental arteries). No wonder babies often fall asleep at crowded parties and noisy basketball games. Dr. Karp postulates that all babies are born with a “calming reflex” that is a relative “off-switch” for crying and “on-switch” for sleep. This unique response is activated when parents perform 5 techniques (the “5 S’s”), which closely mimic the rhythmic sensations in the uterus. Duplicating the baby’s womb experience and turning on the “calming reflex” is probably how traditional calming methods work (for example, car rides, vacuum cleaners, bouncy dancing, warm baths, carrying babies in slings, etc). Think of the “calming reflex” as analogous to the knee reflex. Knee reflexes are extremely predictable and can be activated hundreds of times in a row when triggered correctly. However, hit the knee 1 inch too high - or low - or hit it too softly and the reflex will never be triggered. Similarly, parents can turn on the “calming reflex” over and over again, but only when the “S’s” are done in a very specific way (see below - section on treatment). Babies who continue crying despite the “5 S’s” being done correctly may be hungry, flooded from a breast milk oversupply, uncomfortable or ill. Parents who are unable to soothe their baby’s crying should call their healthcare provider to make sure the baby is not sick. Fortunately, only 5% of cases of colic are caused by illness (the most common cause being intestinal allergy, described above). Parents should consider illness or pain as the cause of their baby’s fussing if the crying is accompanied by at least one of the following ten “red flag” symptoms: 62 1) Persistent moaning or weak crying 2) High-pitched, shrill cry (sharp and more dramatic than usual) 3) Vomiting (vomit that is green or yellow and/or more than 5/day) 4) Change in stool (constipation or diarrhea, especially with blood or mucous) 5) Fussing during eating (twisting, arching, or crying that begins during or just after a feed) 6) Abnormal temperature (a rectal temperature less than 97.0°F or over 100.2°F) 7) Irritability (crying all day with few calm periods in between) 8) Lethargy (excess sleepiness, lack of smiles or interested gaze, weak sucking lasting over 6 hours) 9) Bulging soft spot on the head (even when the baby is sitting up) 10) Poor weight gain (gaining less than ½ ounce a day)

Babies with persistent crying or any “red flag” symptoms should be checked by a healthcare professional to rule out illness. The top ten medical problems to consider in irritable babies with “red flag” symptoms are: 62 1) Infections (e.g. ear infection, urine infection, meningitis, appendicitis) 2) Intestinal pain (e.g. food allergy, acid reflux, constipation, intestinal blockage) 3) Trouble breathing (e.g from a cold, excessive dust, congenital nasal blockage, oversized tongue) 4) Increased brain pressure (e.g., hematoma, hydrocephalus) 5) Skin pain (e.g. a loose diaper pin, irritated rash, a hair wrapped around a toe) 6) Mouth pain  (e.g. yeast infection) 7) Kidney pain (e.g. blockage of the urinary system) 8) Eye pain (e.g. scratched cornea, glaucoma) 9) Overdose (e.g. excessive Vitamin D, excessive sodium) 10) Others (e.g. migraine headache, heart failure, hyperthyroidism)

Effect on the family Infant crying (and the parental fatigue that typically accompanies it) often have a serious impact on parents and babies. Crying and exhaustion can inflict enormous emotional strain causing parents to feel inadequate and overwhelmed. (Hours of tape-recorded infant shrieks are even used in Navy Seal training to test the sailor’s ability to withstand torture!) A baby’s cries may make parents feel that their baby doesn’t like them and trigger anxiety, stress, resentment and low self-esteem. Persistent infant crying has been associated with severe marital discord 5, postpartum depression (affecting 10-15% of new mothers 12-15 and many new dads  ), Shaken Baby Syndrome (the leading cause of child abuse fatalities), 8-11 SIDS (from agitated babies flipping onto their stomachs, frustrated parents placing fussy babies on the stomach to sleep, exhausted parents falling asleep in unsafe places - like couches or beds with bulky covers) 24,25, early termination of breastfeeding6 7, frequent visits to doctors (1 in 6 children are brought to the doctor/emergency rooms for evaluation of persistent crying),16 maternal smoking23 and over a quadrupling of excessive laboratory tests and prescription of medication for acid reflux. 21 Parents at especially high risk of experiencing a serious reaction to their infant’s crying, include: teens, drug addicts, military families, foster parents, parents of premies and parents of multiples. Families living in dense housing projects, such as apartment blocks, may also suffer strained relationships with neighbors and landlords if their babies cry loudly for extended periods of time each day.

TREATMENT In past decades, doctors recommended treating colicky babies with sedative medications (e.g. Phenobarbital, Valium, ethanol), analgesics (e.g. opium) or anti-spasm drugs (e.g. scopolamine, Donnatal, dicyclomine), but all of these have been stopped because of potential serious side-effect, including death. Currently, the first approach most commonly recommended in healthy babies (without any “red flag” symptoms) is to use non-medicinal, noninvasive treatments like emotional support   or the rhythmic calming of the “5 S’s.” 62 63 There is a broad body of evidence showing that soothing measures, such as pacifiers, strong white noise      and jiggly rocking     are effective in calming babies during crying bouts. These techniques form the core of the “5 S’s” approach62 63: 1st S - Swaddling      (safe swaddling carefully avoiding overheating, covering the head, using bulky or loose blankets, and allowing the hips to be flexed   ); 2nd S - Side or stomach (holding a baby on the back is the only safe position for sleep, but it is the worst position for calming a fussy baby); 3rd S - Shhh sound 77-81 (making a strong shush sound near the baby's ear or using a CD of womb sound/white noise); 4th S - Swinging the baby with tiny jiggly movements (supporting the neck and no more than 1” back and forth)82-85; 5th S - Sucking (Letting the baby suckle on the breast or pacifier75,76) When done correctly and in combination, these techniques offer significant potential of promptly reducing infant crying. In a study conducted by the Boulder Colorado Department of Public Health home visiting nurses taught the “5S’s“ to 42 at-risk families (teen parents, addicts, parents of premature babies, etc) with fussy babies. After a single, one-hour visit to teach parents this approach (plus giving parents The Happiest Baby DVD and CD of womb sounds and a large swaddling blanket) 41/ 42 (98%) families reported a dramatic improvement in their ability to calm the fussing, even in babies diagnosed with acid reflux and those whose mothers abused methadone and methamphetamine. Many parents also reported that their babies slept longer. Numerous studies 77 78 80 87-89 have shown that 2 parts of the “5 S’s” (swaddling and shushing) used all night can improve sleep even among breastfed babies.27 Crying from an overreaction to the gastro-colic reflex (described above) is easy corrected with the “5 S’s.” Rapid reduction in crying with the “5 S’s” makes it unlikely that the baby is in pain (pain does not disappear with simple calming measures). In some communities, clinics and support groups have been set up for parents of children with colic. Such groups include the colic clinic at Woman’s and Infant’s Hospital, Providence, RI; several fussy baby clinics organized by the Erikson Institute of Chicago, IL and hundreds of Happiest Baby classes across North America. 95  101-103 Over the past 5 years, thousands of professionals have trained to teach Happiest Baby classes across the US…and 6 other countries, including: hospitals (e.g. University of Michigan, Northwestern, St. Luke's Children's Hospital, Boise, ID) , military bases  , teen parenting programs, state and local child abuse prevention programs,   PPD support groups,  fatherhood classes and state departments of health and child welfare (PA, WY, MN, CO, MA, CT, etc) 95 The University of Arizona conducted two surveys on over 300 parents-to-be before and after taking a Happiest Baby class. They showed a dramatic boost in confidence. Pre-class ~40% reported being moderately to very worried about being able to calm their baby's crying/problems, Post-class that dropped to a mere 0.5-1%. If simple approaches are not working to reduce the crying, parents should consult their health care provider to ask: 1) are they doing the ”5 S’s” correctly? or 2) Is there a medial problem requiring treatment? The most common medical causes of colic are food related. In a breastfed baby, the doctor may suggest eliminating all stimulant foods (e.g. coffee, tea, cola, chocolate, decongestants, diet supplements, etc) from a mother’s diet for a few days to evaluate for improvements in the baby's condition. If food allergy is suspected, the doctor may suggest a hypoallergenic formula for a formula fed infant or, if the mother is breastfeeding, a period of elimination of allergenic foods (e.g. dairy, nuts, soy, citrus, etc) from her diet in order to observe changes in the baby's condition.49-51 If the crying is related to a cow’s milk allergy benefits are usually seen within 2-7days. Mothers can then choose to add back small amounts of the suspected offending food a little bit at a time as long as persistent crying does not reappear. If crying dies reappear the offending foods may need to be avoided for many months. Persistently fussy babies with poor weight gain, vomiting more than 5 times/day, or other significant feeding problems should be evaluated by a healthcare professional for other illnesses (e.g. urinary infection, intestinal obstruction, acid reflux).

PUT THIS IN WIKI UNDER GERD TOO) Baby colic (also known as infant colic, three month colic, and Infantile colic) is a condition in which an otherwise healthy baby cries or screams frequently and for extended periods without any discernible reason. The condition typically appears within the first two weeks of life and almost invariably disappears, often very suddenly, before the baby is three to four months old. It is equally common in bottle-fed and breastfed babies.  The crying often increases during a specific period of the day, frequently this happens in the early evening (the so-called “witching hour”). The medical definition of colic, is a health baby with periods of intense, unexplained fussing/crying lasting more than 3 hours a day, more than 3 days a week for more than 3 weeks. However, many doctors consider that definition, first described by Dr. Morris Wessel, to be overly narrow and would consider some babies with sudden, severe, unexplained crying lasting less than 3 hours/day as having “colic” as well (so-called “non-Wessel’s” colic). Persistent infant crying is much more than a nuisance. Crying and the parental exhaustion associated with it can trigger significant problems and even death, such as marital stress, breastfeeding failure  , shaken baby syndrome (also known as abusive head trauma)       , postpartum depression       , excess visits to the doctor/emergency room , unnecessary treatment for acid reflux          and maternal smoking. And crying and exhaustion may also contribute to SIDS   , infant obesity , maternal obesity   and even automobile accidents. The total financial burden (medical costs, lost productivity, legal/penal, adverse long term health effects, etc) of the 500,000 infants/year in the United States with colic the ultimate cost may exceed $1billion dollars/year.

Causes Over the decades, researchers have offered various hypotheses for colic including the exposure to cigarette smoke,   insufficient melatonin production (which does not begin until 12 weeks of age, about the time colic seems to disappear) , circadian rhythms  , and stress of the mother in the third trimester. It has also been said that babies cry because they sense their mother’s anxiety, but this is highly unlikely. Newborns lack the ability to tell whether a mother is anxious, depressed, frustrated, etc. After all new babies even need help to burp! In fact, it has been shown that a couple’s later children are as likely to be colicky as their first,2 even though parental anxiety is markedly reduced with successive children. It is plausible, however, that anxiety may have some relationship to crying through a more circuitous route. Anxious parents tend to lack confidence and may jump from one calming intervention to another without doing anything long enough for it to be effective. For thousands of years, the number one belief of worried parents, grandparents and doctors has been that colicky crying was provoked by abdominal pain from intestinal spasm or trapped gas. In fact, the word “colic” comes from the ancient Greek word for intestine (sharing the same root as the word “colon”). This gastrointestinal (GI) theory of colic probably originated because fussy babies often: grunt/pass gas/double-up/cry after eating; have noisy stomachs; improve with tummy pressure, warmth or massage; may improve with pain medication (e.g. paregoric, or tincture of opium)  or sips of herbal teas used for stomach upset (e.g. mint, fennel). However, most doctors no longer believe colic is related to gas, cramps, or overfeeding. Research has shown that 85-90% of colicky babies have no evidence of a true GI problem. The prevailing view is that colic is just the extreme range of normal crying. In other words, all healthy babies cry, but the 10-15% loudest, most persistent, “shriekiest” criers are labeled as having “colic.” 1 There are many reasons why most experts have abandoned the idea that colic is usually a result of stomach upset: 1) Fussiness peaks at ~6 weeks and reliably ends by 3-4 months, yet older infants still experience plenty of burps, flatus, BMs, etc. 2) Premature babies are no more likely to suffer from colic than full term babies despite the fact that their intestines are immature. And, although they eat, poop, burp and “toot” every day, they rarely get colic until they reach their due date. (In other words, a baby born three months early has the same 10-15% chance of developing colic as a full term baby, but his/her fussing won’t even begin until after three months! ) 3) Contrary to the belief that babies cry from air in the stomach, research X-rays of crying babies reveal that colicky babies have much more air trapped in their stomachs at the end of crying episodes - when already calm - than at the start of the crying!  (This is because babies gulp air while crying.) 4) “Burp” drops (simethicone) are no better at reducing crying than drops of ordinary placebo (distilled water). 5) Car rides and vacuum cleaners often calm fussing, yet certainly don’t lessen GI pain. (Car rides and vacuums don’t soothe our stomachaches). In 90% of cases colic is unrelated to the type of milk consumed by the baby,   however occasionally it is triggered by GI upset from food allergy and may require a hypoallergenic formula (e.g. Pregestimil).    The most problematic foods are cow’s milk based formula and, for breastfeeding babies, dairy products in the mother’s diet. Other, less common allergens are wheat, soy and nuts. Breastfed babies may also become irritable from stimulants in the mother’s diet (see section on treatment).     One of the main reasons parents and doctors choose a soy formula is for the relief of colic. However, it is not clear that switching to soy reduces colic. 47  Unlike older children and adults who may have GI discomfort from lactose intolerance, there is little evidence that this is a cause of persistent crying in infants. Some reports have associated colic to changes in a baby’s intestinal bacterial. They suggest treating the crying with daily doses of probiotics (such as Lactobacillus acidophilus or Lactobacillus reuteri). In one study, 83 colicky babies given probiotics had reduced crying. After one week, treated babies had 10% less crying (159 min/day vs. 177 min/day). By 4 weeks treated babies had 65% less crying the (51min/day vs. 145 min/day). However, a more recent study found no reduction in colic in over 1000 babies who were given probiotics from birth. In 2009, a University of Texas study observed that colicky babies had a higher incidence of mild intestinal inflammation and a specific intestinal bacteria, Klebsiella. But, a commentary in the same journal, noted that the inflammation and bacteria were most likely just an exaggerated variation of normal. Over the past 15 years, increasing numbers of fussy babies have been put on medication under the presumption that their crying was a sign of pain from acid reflux, so-called gastro-esophageal reflux disease (GERD). In fact from 2000-2003 the number of babies treated with anti-reflux medicines increased 400%! 21 And the use of a popular liquid PPI formulated specifically for young children increased 16 fold from 1999-2004. In truth, most babies have mild reflux …we simply call it spiting up. It rarely requires treatment and almost invariably disappears within 4-6 months. Over the past 5 years, repeated studies have shown that GERD rarely causes infant crying. Even if the crying occurs during feeding and is accompanied by writhing and back arching it is rarely related to acid reflux unless the baby also has: 1) poor weight gain, 2) vomiting at least 5 times/day or 3) other significant feeding problems.16 17 1819 20 21 A multicenter study, organized by researchers at Pittsburgh Children’s Hospital, concluded that GERD medicine (proton pump inhibitors, or PPI’s) is no better than placebo at reducing infant crying. Surprisingly, 50% of fussy babies improved on the PPI…but so did 50% of fussy babies who received a mere placebo!22 A more logical explanation for why fussy babies worsen during feeding is that they are overreacting to a totally normal intestinal process called the gastro-colic (GC) reflex. When the stomach fills with food it sends a message to the colon to start tightening (to squeeze out the poop and make room for the coming new food). The GC reflex is an automatic response present in all babies and adults. In adults, it occurs peaks about an hour after eating, but in babies it happens within minutes of the start of a meal (often triggering a BM while the baby is still eating). Most infants have little or no awareness when the reflex is working, however some overly sensitive children do feel it and arch and cry as waves of mild squeezing move the partially digested food through the intestines. These cries are often sharp and severe and misdiagnosed as pain from acid reflux, gas cramps or overfeeding. But, it is easy to prove they are not the cries of pain because they usually quickly abate when parents correctly perform the “5 S’s.” (Babies who cry from the GC reflex are often the same sensitive infants who scream when startled by a sudden loud laugh or telephone ring.) The ability of many hyperirritable babies to be calmed by simple soothing maneuvers has given birth to an engaging new theory of colic, the “missing 4th trimester.” This theory, the basis of the work of California pediatrician, Dr. Harvey Karp    is now recommended by many leading pediatricians and parenting books. The “missing 4th trimester” is based on the observation that our newborns are very immature at birth. Baby horses, by comparison, can walk and even run on the very first day of life. However, since human fetuses have such large brains, they must be born before they are mature enough to stand or run…or even smile. Babies held inside longer to fully mature would have such large heads that they would never be able to squeeze through the birth canal and they (and their mothers) would likely die in childbirth. (The head of a newborn chimpanzee is ~90% of their mother’s pelvic outlet. On the other hand, a human baby’s head overfills the pelvic outlet and has to “mold” - squish into a cone head or banana shape – to fit out!) Contrary to outdated theories that babies cry from gas pains or from being over-stimulated, Dr. Karp’s theory suggests that infant crying is actually related to our under-stimulation of babies. In other words, babies cry because of their “eviction” from the womb with its rich symphony of rhythmic, entrancing sensations to the still, quiet world we create for them in our homes. In the womb, fetuses experience several potent and hypnotic stimuli (e.g. stroking against the soft uterus walls; frequent tiny, jiggly movements; constant warmth; and continual sound - louder than a vacuum cleaner - created by the whooshing of blood through the placental arteries). No wonder babies often fall asleep at crowded parties and noisy basketball games. Dr. Karp postulates that all babies are born with a “calming reflex” that is a relative “off-switch” for crying and “on-switch” for sleep. This unique response is activated when parents perform 5 techniques (the “5 S’s”), which closely mimic the rhythmic sensations in the uterus. Duplicating the baby’s womb experience and turning on the “calming reflex” is probably how traditional calming methods work (for example, car rides, vacuum cleaners, bouncy dancing, warm baths, carrying babies in slings, etc). Think of the “calming reflex” as analogous to the knee reflex. Knee reflexes are extremely predictable and can be activated hundreds of times in a row when triggered correctly. However, hit the knee 1 inch too high - or low - or hit it too softly and the reflex will never be triggered. Similarly, parents can turn on the “calming reflex” over and over again, but only when the “S’s” are done in a very specific way (see below - section on treatment). Babies who continue crying despite the “5 S’s” being done correctly may be hungry, flooded from a breast milk oversupply, uncomfortable or ill. Parents who are unable to soothe their baby’s crying should call their healthcare provider to make sure the baby is not sick. Fortunately, only 5% of cases of colic are caused by illness (the most common cause being intestinal allergy, described above). Parents should consider illness or pain as the cause of their baby’s fussing if the crying is accompanied by at least one of the following ten “red flag” symptoms: 62 1) Persistent moaning or weak crying 2) High-pitched, shrill cry (sharp and more dramatic than usual) 3) Vomiting (vomit that is green or yellow and/or more than 5/day) 4) Change in stool (constipation or diarrhea, especially with blood or mucous) 5) Fussing during eating (twisting, arching, or crying that begins during or just after a feed) 6) Abnormal temperature (a rectal temperature less than 97.0°F or over 100.2°F) 7) Irritability (crying all day with few calm periods in between) 8) Lethargy (excess sleepiness, lack of smiles or interested gaze, weak sucking lasting over 6 hours) 9) Bulging soft spot on the head (even when the baby is sitting up) 10) Poor weight gain (gaining less than ½ ounce a day)

Babies with persistent crying or any “red flag” symptoms should be checked by a healthcare professional to rule out illness. The top ten medical problems to consider in irritable babies with “red flag” symptoms are: 62 1) Infections (e.g. ear infection, urine infection, meningitis, appendicitis) 2) Intestinal pain (e.g. food allergy, acid reflux, constipation, intestinal blockage) 3) Trouble breathing (e.g from a cold, excessive dust, congenital nasal blockage, oversized tongue) 4) Increased brain pressure (e.g., hematoma, hydrocephalus) 5) Skin pain (e.g. a loose diaper pin, irritated rash, a hair wrapped around a toe) 6) Mouth pain  (e.g. yeast infection) 7) Kidney pain (e.g. blockage of the urinary system) 8) Eye pain (e.g. scratched cornea, glaucoma) 9) Overdose (e.g. excessive Vitamin D, excessive sodium) 10) Others (e.g. migraine headache, heart failure, hyperthyroidism)

Effect on the family Infant crying (and the parental fatigue that typically accompanies it) often have a serious impact on parents and babies. Crying and exhaustion can inflict enormous emotional strain causing parents to feel inadequate and overwhelmed. (Hours of tape-recorded infant shrieks are even used in Navy Seal training to test the sailor’s ability to withstand torture!) A baby’s cries may make parents feel that their baby doesn’t like them and trigger anxiety, stress, resentment and low self-esteem. Persistent infant crying has been associated with severe marital discord 5, postpartum depression (affecting 10-15% of new mothers 12-15 and many new dads  ), Shaken Baby Syndrome (the leading cause of child abuse fatalities), 8-11 SIDS (from agitated babies flipping onto their stomachs, frustrated parents placing fussy babies on the stomach to sleep, exhausted parents falling asleep in unsafe places - like couches or beds with bulky covers) 24,25, early termination of breastfeeding6 7, frequent visits to doctors (1 in 6 children are brought to the doctor/emergency rooms for evaluation of persistent crying),16 maternal smoking23 and over a quadrupling of excessive laboratory tests and prescription of medication for acid reflux. 21 Parents at especially high risk of experiencing a serious reaction to their infant’s crying, include: teens, drug addicts, military families, foster parents, parents of premies and parents of multiples. Families living in dense housing projects, such as apartment blocks, may also suffer strained relationships with neighbors and landlords if their babies cry loudly for extended periods of time each day.

TREATMENT In past decades, doctors recommended treating colicky babies with sedative medications (e.g. Phenobarbital, Valium, ethanol), analgesics (e.g. opium) or anti-spasm drugs (e.g. scopolamine, Donnatal, dicyclomine), but all of these have been stopped because of potential serious side-effect, including death. Currently, the first approach most commonly recommended in healthy babies (without any “red flag” symptoms) is to use non-medicinal, noninvasive treatments like emotional support   or the rhythmic calming of the “5 S’s.” 62 63 There is a broad body of evidence showing that soothing measures, such as pacifiers, strong white noise      and jiggly rocking     are effective in calming babies during crying bouts. These techniques form the core of the “5 S’s” approach62 63: 1st S - Swaddling      (safe swaddling carefully avoiding overheating, covering the head, using bulky or loose blankets, and allowing the hips to be flexed   ); 2nd S - Side or stomach (holding a baby on the back is the only safe position for sleep, but it is the worst position for calming a fussy baby); 3rd S - Shhh sound 77-81 (making a strong shush sound near the baby's ear or using a CD of womb sound/white noise); 4th S - Swinging the baby with tiny jiggly movements (supporting the neck and no more than 1” back and forth)82-85; 5th S - Sucking (Letting the baby suckle on the breast or pacifier75,76) When done correctly and in combination, these techniques offer significant potential of promptly reducing infant crying. In a study conducted by the Boulder Colorado Department of Public Health home visiting nurses taught the “5S’s“ to 42 at-risk families (teen parents, addicts, parents of premature babies, etc) with fussy babies. After a single, one-hour visit to teach parents this approach (plus giving parents The Happiest Baby DVD and CD of womb sounds and a large swaddling blanket) 41/ 42 (98%) families reported a dramatic improvement in their ability to calm the fussing, even in babies diagnosed with acid reflux and those whose mothers abused methadone and methamphetamine. Many parents also reported that their babies slept longer. Numerous studies 77 78 80 87-89 have shown that 2 parts of the “5 S’s” (swaddling and shushing) used all night can improve sleep even among breastfed babies.27 Crying from an overreaction to the gastro-colic reflex (described above) is easy corrected with the “5 S’s.” Rapid reduction in crying with the “5 S’s” makes it unlikely that the baby is in pain (pain does not disappear with simple calming measures). In some communities, clinics and support groups have been set up for parents of children with colic. Such groups include the colic clinic at Woman’s and Infant’s Hospital, Providence, RI; several fussy baby clinics organized by the Erikson Institute of Chicago, IL and hundreds of Happiest Baby classes across North America. 95  101-103 Over the past 5 years, thousands of professionals have trained to teach Happiest Baby classes across the US…and 6 other countries, including: hospitals (e.g. University of Michigan, Northwestern, St. Luke's Children's Hospital, Boise, ID) , military bases  , teen parenting programs, state and local child abuse prevention programs,   PPD support groups,  fatherhood classes and state departments of health and child welfare (PA, WY, MN, CO, MA, CT, etc) 95 The University of Arizona conducted two surveys on over 300 parents-to-be before and after taking a Happiest Baby class. They showed a dramatic boost in confidence. Pre-class ~40% reported being moderately to very worried about being able to calm their baby's crying/problems, Post-class that dropped to a mere 0.5-1%. If simple approaches are not working to reduce the crying, parents should consult their health care provider to ask: 1) are they doing the ”5 S’s” correctly? or 2) Is there a medial problem requiring treatment? The most common medical causes of colic are food related. In a breastfed baby, the doctor may suggest eliminating all stimulant foods (e.g. coffee, tea, cola, chocolate, decongestants, diet supplements, etc) from a mother’s diet for a few days to evaluate for improvements in the baby's condition. If food allergy is suspected, the doctor may suggest a hypoallergenic formula for a formula fed infant or, if the mother is breastfeeding, a period of elimination of allergenic foods (e.g. dairy, nuts, soy, citrus, etc) from her diet in order to observe changes in the baby's condition.49-51 If the crying is related to a cow’s milk allergy benefits are usually seen within 2-7days. Mothers can then choose to add back small amounts of the suspected offending food a little bit at a time as long as persistent crying does not reappear. If crying dies reappear the offending foods may need to be avoided for many months. Persistently fussy babies with poor weight gain, vomiting more than 5 times/day, or other significant feeding problems should be evaluated by a healthcare professional for other illnesses (e.g. urinary infection, intestinal obstruction, acid reflux).