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The crying of newly born babies
The Journal of Pediatrics VOL. 2'7
A~GUST, 1945
No. 2
Original Communications THE
CRYING
OF
II. THE
C. ANDERSON
NEWLY
BORN
BABIES
INDIVIDUAL PHASE
ALDRICH, M.D.j ~" C~IEH
SUNG, M.D., D.P.H.,~ AND CATI:IARINE 14~NOP, M.D.S I~OCHESTER, MINN.
WITH
THE TECHNICAL
ASSISTANCE
OF GERALDINE
STEVENS,
R.N.,
AND MARGARET B U R C H E L L , B . S c . w
is our second report ~ summarizing one month's continuous observation T HIS os crying as it occurred in the nursery of newborn babies at one of the hospita]s at Rochester, Minn. The previous publication dealt w~th the crying o~ the babies as a community only, while this article concerns itself mainly with that of individual babies. The object of the study was to obtain accurate information as to the amount of crying which occurred and to investigate its causes. We, therefore, ~nterested ourselves in the duration in minutes, the intensity and the number and possible causes of crying episodes indulged ~n by the individual babies. We wanted to know how crying was d~stributed throughout each day and something about its variations during the first eight days of life. In studying the probable causes of crying we made notes of environmental influences such as food intake and nursing care and estimated the discomfort due to certain possible factors. We look on this work as a preliminary survey only and, because of the many indefinite assumptions which had to be made as to causes, we cannot claim mathematical accuracy in their tabulation. Th~s is merely an initial attempt to bring order out of that most chaotic of hospital wards, the nursery of newborn babies. ~ETHOD OF INVESTIGATION Our original data concerned all babies (seventy-two) cared for in the nursery during April, 1944. For our present study, however; we selected only those whose stay in the nursery was a full eight days. This left us with fifty babies on our list. All ~nfants in the ward were watched constantly by four observers, who took turns during the twenty-~our-hour periods. The recordings were made from midnight to midnight for each day. The average number of babies in the nursery at one time was twenty, We tried to take into con....... ~'Secti~n on Pediatrics, t A s s i s t a n t in l~ediat~'ics, Mayo Clinic. $~ellow in Pediatrics, ~Viayo Foundation. w Worker, R o c h e s t e r Child H e a l t h Project, F r o m the P~ochester Child H e a l t h Project.
89
90
THE JOURI~AL OF PEDIATRICS
sideration the nursery and floor routines so that our activities might interrupt the usual procedures as little as possible. We were solely observers, who recorded data relative to the cryi.ng of each inhabitant of the nursery. Actually, each crying period was indicated on the work sheet as a straight line, above which the crying time in minutes was indicated and beneath which was shown the possible reason for the spell (r standing for hunger; b, for vomitus; c, for soiled diapers; d, for wet diapers and j, for unknown reasons). The nursing care was similarly charted as a red line, above which was placed the number of minutes of care. This consisted of diaper changing, taking temperatures and offering water and also included the feeding time spent in the mother's or the nurse's arms. From these original data, calculations were made and figures and tables were drawn: (1) to illustrate the incidence of crying of individual babies in relation to nursing care; (2) to show the daily and total amount of crying of each baby and the distribution curve of their differences in this respect; (3) to demonstrate the average crying curve of the first eight days of life and (4) to estimate the causes of crying and its relation to feeding, gain of weight~ and other environmental factors. A
~
1st- d,a[j
2 n--~d ~
5 -r~ aat~
4 9 dct~
A-H.
A,ff-
AK
A-M-
F,I'$
BM,
P~
[ 5~aa~
PI~
A-~I,
I 6 ~ dct~
l~M9
AH
PH.
I 7~ da~
AM
Fq-f
8 th dCX~L
AM" 12. ~/,f8 12
t5
4 8194 A-M.
812,4 I~M-
8 ]&4
AH.
~-
81~4
812,4 ~:I'I-
8 ~4 I~M9
81,?.4 &l'1.
81s
lal'i 9
81&4 A.FI.
8~-,4 /aFi,
{~IZ4 AFI,
51Z-4
I~i'1 -
8]2,4
Al'I.
&124 I~M
512,4 ArI-
~.IZ ~M-
Fig; i . - - C r y i n g c h a r t compared with nursing care (two babies)~ RESULTS
Graphic Representation of the Crying of Babies and Their Nursing Care for the First Eight Days.--Of the fifty charts made of crying activity as compared with nursing care during the first eight days of life, we have chosen two for demonstration, that of the quietest baby and that of the most vociferous. In addition, one chart is shown to illustrate the hourly crying per average baby in the nursery. Fig~ 1,A is that of the baby who cried the least during his hospital stay, a total of 386 minutes for the eight days, or 48.2 minutes per day. Fig. 1,B is that of the baby who cried the most, 1,947 minutes during the eight days, or 243 minutes per day, five times as much. Fig. 2 shows the average hourly Crying per infant during the eight days, a total of 936 minutes, or 117 minutes per day. The general distribution of crying with its periodic daily high points shows similarities, especially in the last four days in most charts. One can detect a n increase of crying as the feeding hours are approached with a relative lull in between. The amount of "relative lull" depends in a rough way on the amount of nursing care giver~ to the children. We notice that besides these
ALDRICI-I E T AL. :
C R Y I N G OF N E W L Y
91
BORN BABIES
fluctuations there is a tendency for two peaks to appear, higher than any others through the day and centering around 6 ~.~. and midnight. These can be seen in the individual charts and are most consistent in the average graph for the entire eight days. As already mentioned in the paper on the community phase, 1 the prolonged crying period at 6 P.~. is caused by lack of synehrony between nursery and floor routines. The babies have to be in the nursery by 2 P.M. because of visiting hours, a fact which advances the 2 P.~. feeding time to 1:15 or 1:30 P.M. Since the 6 P.~. feeding hour, unfortunately, had to be postponed because of the mothers' dinners, a feeding interval of five or six hours occurred, which resulted in the prolonged crying at 6 P.~. recorded in the graphs, a It is easily seen from Fig. 1,A and B, showing minimal and maximal crying, that one baby may cry much more than another for the same type of cause. Aside from the actual length of crying time and its distribution through the day, observations were made on the pattern of crying during the first twenty-four or forty-eight hours. It was observed that many infants expressed themselves by Very short sounds, like short high-pitched grunts, w h i c h appeared in groups of ten to thirty successively, without ever culminating in
A.~.
~-M-
A-M.
P.M.
Fig. 2 . - - C r y i n g c h a r t - - a v e r a g e
A-H-
P.H-
A-H-
P.H.
of f i f t y b a b i e s - - f i r s t e i g h t d a y s .
actual crying. Such sounds were noticed through the whole hospital stay but they were almost the only vocal expression of some babies for the first twentyfour to forty-eight hours. Just as large a group, however, commenced Iife with immediate, persistent, and intense crying. This pattern did not seem dependent on the total crying of the individual infant, as it occurred in the " q u i e t " as well as i~ the more persistently crying babies. Frequency Diagram.--Having established the marked variation in amount of crying time exhibited by different babies, from 386 to ],947 minutes, it seemed worth while to study a frequency curve showing the distribution of the fifty babies in relation to their total crying minutes. This shows the majority falling in the middle range (Fig. 3). The Average Crying per Baby per Day.--From a practical standpoint it may be of some interest to observe the curve resulting when we plotted the average minutes of crying per day for the eight consecutive days in the hospital (Fig. 4). Here we found a smooth curve, rising from birth to the fourth day at a rather steep angle. From the fourth to the sixth day it remained at a fairly even level, to decline more abruptly thereafter. However, a very difP.Mo
*Tl~is d i s c r e p a n c y w a s p r o m p t l y r e c t i f i e d b y h a v i n g t h e m o t h e r s ' t r a y s s e n t u p s t
5:30
92
THE
JOUgNAL
OF P E D I A T R I C S
ferent picture appeared when we attempted to superimpose the fifty curves of each baby on one chart. This showed a wild crisscross of seemingly unrelated lines, out of which it was impossible to read any tendency toward rhyme or reason. Much less were we able to reproduce it here. To demonstrate the difference, then, between an " a v e r a g e " curve and that of an "individual" baby we superimposed a typical curve of one infant in Fig. 4. Instead of the smoothness of the average, the curve of the individual baby climbs and falls in an irregular manner.
% 1 a 3 4 S 6 ~ 8 910111&lS141516171619PA3 N u m b e r , of' hundped_ m i n u t e s of c p ~ i n ~ p e r , 8 d a ~ s bNg. 3 . - - D i s t r i b u t i o n
of f i f t y b a b i e s
arranged according days,
to t o t a l
crying
minutes--first
eight
~00, 180
I
x
I
%
I
160 ca
I
I
~. 9
t40
120 100
J
/,/
8o 6O
'-%
4/
40
,// v
! .I
2O
I
/ /
1
I
I
2.
3
I
r
1
i
r
4 5 6 ~ 8 Dc~s --Total c p g i n 9 p e p d a ~ of a v e p a ~ e 5a5~ ~-~ Total cp~in~ pep da~ of an individucd bab~ ]eig. 4 . - - C r y i n g
p e r d a y in m i n u t e s .
-kverage baby
compared
with
individual.
Crying in Relation to Feeding and Weight Gain.--In order to study the relation of crying to feeding and weight gain we charted these three factors for each of the fifty babies. Examination of these charts did not lead to any simple conclusions. They seemed to be rather evenly divided into two groups, those which seemed to show g relationship and those which did not exhibit any correlation between food intake and crying. Out of the set of fifty, two typical charts are reproduced, each demonstrating a type (Fig. 5). In Fig. 5,A a definite increase in food intake is accompanied by an obvious fall in the amount of crying. A slight decrease in food supply on the seventh day shows a simultaneous rise in crying, followed by a correlated divergence of the curves on the eighth day. However, although food intake and crying seem related there does not seem to be any similar correlation between weight
ALDRICH
ET
AL. :
CRYING
OF
NEWLY
BORN
93
BABIES
gain and crying in this chart9 The crying increases and falls independently of the weight gain. In Fig. 5,B the decreased and increased food intake curve is parallel with that of the fall and rise in crying activity and therefore does not suggest any rational correlation. Also, here again, there is no reciprocal relationship between weight gain and crying. B
A
'..Foo& .,~qei@ht
"intake
\Weight Foo&
~chanOe
,', /
%
N
I
I
I
Fig. 5.--Superimposed
%
4
I
I
2, 3 4 5 b~s
1
intake "<...4
9
1
I
I
6 ~{ 8
1 ~ 3 4 5 6 '7 6
Dass
curves of crying minutes, weight fluctuation, and food intake (two babies ). 130 1~0 110
&O
9 18 < 17
3 90 "~ 8 0 ~
o 15
S I
'~ 35
_~a0
"c~ ~o I .~ 4 0 ~
ao
6 0 10
:t
[~
Gooct f e e c t c r s Poop f~r
Fig. 6,--Reduction in crying (center) noted w h e n good feeders arc c o m p a r e d with poor feeders as s h o w n b y weight a n d food intake data.
Since this attack on the problem faile'd to show a consistent relation between food intake and crying, we tried another method. The ten babies with the best and the ten with the poorest feeding histories were compared. Scatter diagrams were made of crying and food intake in both of these groups but no correlation was demonstrable in either group. Therefore, another atterhpt was undertaken to show that the amount of food taken would reduce the crying time. In the two groups defined in the
94
THE JOURNAL OF PEDIATRICS
previous paragraph data were estimated per baby per day as to (1) the amount of food taken in ounces, (2) the weight fluctuation in grams, and (3) the amount of crying in minutes. This resulted in our ability to demonstrate (Fig. 6) a reduction of 17.8 minutes (15 per cent) of crying per day in the babies with good feeding histories. This seems of some significance, but, as our number of babies compared was small (ten in each group), the result cannot be considered of statistical importance. Fifteen per cent reduction in a large number would have been definitely significant but in only twenty babies it is merely an indication. Causes of Crying.--As mentioned before, the recorded causes of crying were only an estimate dependent on the judgment of the observer and, t h e r e fore, cannot be considered absolutely accurate. Nevertheless, the information obtained should be of some clinical value as an approach to the problem of neonatal crying in hospital nurseries. The causes observed were hunger, vomiting, soiled or wet diapers, and unknown reasons. Our method of investigation was as objective as possible. A prolonged, intense crying spell in a kicking infant at feeding time, sucking on his fingers or fist, was noted down as hunger. A crying child, lying in his vomitus or in soiled or wet diapers, was charted according to the apparent reason. The rest of the crying was charted as due to unknown reasons. The number of minutes of crying ascribed to each cause was calculated and the results shown in Table I were obtained. TABLE I. i~/~INUTES OF CRYING FOE ]~ACII CAUSE AUSES 0E aEYING BABIES
(~o.)
DAYS
(No.)
5----v-- ~
(0.5%)
2,024.2 323.9 40.5
26.7 4.3 0.5
4~74~.8 76.0 9.5
B
HUNGER
VO~HTUS
16,193.5
50 1
(35.5%)
214.5
c SOILED DIAPERS 3,799.0
A
1
(8.3%)
D -WET DIAPERS 9,359.5
J U17]~NOWI~ REASONS 16,005.5
(20.6%)
(35.1%)
1,169.9 187.2 23.8
2,000.6 320.1 40.0
Hunger and " u n k n o w n causes," according to our estimate, then, were the most important reasons for the crying of our babies. " U n k n o w n causes" may seem to have a surprisingly high incidence but, if one remembers that infants at birth are individualists and that present nursery routines are not adapted to efficient individual care, it is understandable that we could be at a loss to explain many of these expressions of unhappiness. Because we suspected that urgent fundamental needs would probably be expressed by more prolonged, continuous crying than that provoked by matters of less vital importance, we calculated the number of periods as well as the number of minutes of crying for each single cause (Table II). Our results confirmed this possibility, for the number of crying spells due to hunger dropped below that for "unknown reasons"; that is, the hunger cries were of longer duration than those due to unknown reasons. COMMENT
In our consideration of the neonatal crying problem we have assumed that the cry of a newly born baby is a reflex protective mechanism used as a signal of need to whoever may attend him. As such, it becomes a useful attribute, one which, if ignored, may lead to harmful omissions in the baby's care. It is quite evident that many different stimuli, both from within and from without,
ALDRICH ET AL. :
CRYING OF NEWLY BORN BABIES
95
may suffice to trip the central automatic switch which turns on the cry. Hunger, chilling, bright lights, irritation of the skin from wet or soiled diapers, peristaltic movements, vomiting, bowel or bladder evacuation, l o u d noises, or loss of equilibrium may be listed among the generally accepted causes. Perhaps, to be complete, we should add such more or less negative factors as need for fondling and lack of rhythmic motion. In studying the use of the cry by the individual babies we found marked differences. Some put up a -vigorous, earsplitting objection for apparently trivial reasons;others seemed more phlegmatic and were perhaps less efficient. We are not prepared to say whether this is a matter of inherent disposition, of varying thresholds to stimuli, or of some other attribute of the baby but, at any rate, the fact of individual differences stands out clearly. But no matter how much or how littIe the particular baby cries, one constant relationship is evident in our charts, the reciprocal effect of nursing care. The more care, the less crying. To our great surprise it turned out to be a difficult matter to relate food intake and weight gain to the amount of crying. Even after persistent effort, the correlations that we were able to make between these factors were suggestive but not statistically significant. This result, however, was probably due more to the fact that in our preliminary thinking we underestimated the importance of other less obvious causes than that we overestimated that of hunger. If we had been able to chart crying due to hunger separately and then to compare the amount of hunger crying before and after the establishment of lactation, a very different picture might have appeared. TABLE I I .
BABIES
Di iS
I~U~BER OF CLOYING SPELLS FOR EACH CAUSE
A
B
u
50 50
I
2,760.0 345.0
1
55.2
1
6.9
45.00 5.60 0.90 0.11
(3AUSES O~ (3~YING (J D "WET SOILED DIAFEI~S DIAPERS 737.0 1,630.00 92.0 203.80 15.732.50 1.9 4.07
J UNKNOWN" REASONS 3,295.0 411.7 65.9 8.2
The most clear-cut result of our study of the causes of neonatal crying in the individual baby is a demonstration of the importance of unknown reasons. In total minutes of crying this group of reasons closely approaches the amount for hunger and in the number of crying spells it exceeds it. When we take into account the unique situation of the newborn infant and the probable list of these unknown causes, we should not be surprised at this result. During intrauterine life the fetus becomes adjusted to a quiet, dark, warm, aquatic environment characterized by considerable rhythmic movement and absolute freedom from any responsibility in providing himself with food or oxygen. Immediately after birth his sensations are assailed by considerable noise, bright lights, cool, dry atmosphere and relatively little rhythmic movement and he is obliged to begin active participation in matters of oxygen and food intake, digestion, and elimination. It would be strange if, in the face of all of these major changes, he did not use his protective cry freely to register his adverse reactions to many sorts of unaccustomed stimuli. Because there are so many stimuli, the one factor of hunger, while still important, may well become less dominant in the crying picture at this time. We, therefore, feel that in order to modify this situation in which we find n e w babies protesting violently for an appreciable part of their neonatal life--
96
THE JOURN'AL OF PEDIATRICS
and an overwhelming proportion of their waking hours--it will be necessary to pay more attention to these unknown causes in addition to perfecting our methods of routine care. This will probably mean more nurses on the job. It will also mean individualization of the management of each baby and the provision of closer contact with nurse or mother during the neonatal period. SUI~x~IARu
A controlled study on crying of fifty individual babies was made in a hospital during April, 1944. Four observers took turns in recording the amount os crying in minutes and the estimated causes of the crying. The amount of crying for the baby with the least crying activity was 386 minutes during eight days, or 48.2 minutes per day. The baby who cried the most totaled 1,947 minutes during eight days, or 243 minutes per day. The average crying per infant amounted to 936 minutes during eight days, or 117 minutes per day~ A definite correlation between crying and nursing care was noted: the more care, the less crying. The distribution of the total crying time of the fifty babies was bell-shaped. A graph of the crying of the average baby per day for eight days resulted in a smooth curve, while that of any individual infant climbed and fell in an irregular manner. Three different methods were used to evaluate the relation of crying to weight gain and feeding. The results were vague, except for that of the last method, which showed 17.8 minutes less crying daily in favor of the good feeders. An attempt was made to estimate the causes of crying. Obvious causes, such as hunger, vomiting, soiled and wet diapers, and unknown reason% were tabulated in minutes and number of spells. The most clear-cut result of our study of the causes of neonatal crying is t h e demonstration of the importance of unknown reasons. In total minutes of crying this group of reasons, closely approaches the amount for hunger and in the number of crying spells it exceeds it. REFERENCE
1. Aldrich, C. A., Sung, Chieh, Xnop, Catharine, Stevens~ Geraldine and BurchelI, Margaret: The Crying of :Newly Born Babies: I: The Community Phase, g. PEDIAT. ~26: 313~ 1945.
A~GUST, 1945
No. 2
Original Communications THE
CRYING
OF
II. THE
C. ANDERSON
NEWLY
BORN
BABIES
INDIVIDUAL PHASE
ALDRICH, M.D.j ~" C~IEH
SUNG, M.D., D.P.H.,~ AND CATI:IARINE 14~NOP, M.D.S I~OCHESTER, MINN.
WITH
THE TECHNICAL
ASSISTANCE
OF GERALDINE
STEVENS,
R.N.,
AND MARGARET B U R C H E L L , B . S c . w
is our second report ~ summarizing one month's continuous observation T HIS os crying as it occurred in the nursery of newborn babies at one of the hospita]s at Rochester, Minn. The previous publication dealt w~th the crying o~ the babies as a community only, while this article concerns itself mainly with that of individual babies. The object of the study was to obtain accurate information as to the amount of crying which occurred and to investigate its causes. We, therefore, ~nterested ourselves in the duration in minutes, the intensity and the number and possible causes of crying episodes indulged ~n by the individual babies. We wanted to know how crying was d~stributed throughout each day and something about its variations during the first eight days of life. In studying the probable causes of crying we made notes of environmental influences such as food intake and nursing care and estimated the discomfort due to certain possible factors. We look on this work as a preliminary survey only and, because of the many indefinite assumptions which had to be made as to causes, we cannot claim mathematical accuracy in their tabulation. Th~s is merely an initial attempt to bring order out of that most chaotic of hospital wards, the nursery of newborn babies. ~ETHOD OF INVESTIGATION Our original data concerned all babies (seventy-two) cared for in the nursery during April, 1944. For our present study, however; we selected only those whose stay in the nursery was a full eight days. This left us with fifty babies on our list. All ~nfants in the ward were watched constantly by four observers, who took turns during the twenty-~our-hour periods. The recordings were made from midnight to midnight for each day. The average number of babies in the nursery at one time was twenty, We tried to take into con....... ~'Secti~n on Pediatrics, t A s s i s t a n t in l~ediat~'ics, Mayo Clinic. $~ellow in Pediatrics, ~Viayo Foundation. w Worker, R o c h e s t e r Child H e a l t h Project, F r o m the P~ochester Child H e a l t h Project.
89
90
THE JOURI~AL OF PEDIATRICS
sideration the nursery and floor routines so that our activities might interrupt the usual procedures as little as possible. We were solely observers, who recorded data relative to the cryi.ng of each inhabitant of the nursery. Actually, each crying period was indicated on the work sheet as a straight line, above which the crying time in minutes was indicated and beneath which was shown the possible reason for the spell (r standing for hunger; b, for vomitus; c, for soiled diapers; d, for wet diapers and j, for unknown reasons). The nursing care was similarly charted as a red line, above which was placed the number of minutes of care. This consisted of diaper changing, taking temperatures and offering water and also included the feeding time spent in the mother's or the nurse's arms. From these original data, calculations were made and figures and tables were drawn: (1) to illustrate the incidence of crying of individual babies in relation to nursing care; (2) to show the daily and total amount of crying of each baby and the distribution curve of their differences in this respect; (3) to demonstrate the average crying curve of the first eight days of life and (4) to estimate the causes of crying and its relation to feeding, gain of weight~ and other environmental factors. A
~
1st- d,a[j
2 n--~d ~
5 -r~ aat~
4 9 dct~
A-H.
A,ff-
AK
A-M-
F,I'$
BM,
P~
[ 5~aa~
PI~
A-~I,
I 6 ~ dct~
l~M9
AH
PH.
I 7~ da~
AM
Fq-f
8 th dCX~L
AM" 12. ~/,f8 12
t5
4 8194 A-M.
812,4 I~M-
8 ]&4
AH.
~-
81~4
812,4 ~:I'I-
8 ~4 I~M9
81,?.4 &l'1.
81s
lal'i 9
81&4 A.FI.
8~-,4 /aFi,
{~IZ4 AFI,
51Z-4
I~i'1 -
8]2,4
Al'I.
&124 I~M
512,4 ArI-
~.IZ ~M-
Fig; i . - - C r y i n g c h a r t compared with nursing care (two babies)~ RESULTS
Graphic Representation of the Crying of Babies and Their Nursing Care for the First Eight Days.--Of the fifty charts made of crying activity as compared with nursing care during the first eight days of life, we have chosen two for demonstration, that of the quietest baby and that of the most vociferous. In addition, one chart is shown to illustrate the hourly crying per average baby in the nursery. Fig~ 1,A is that of the baby who cried the least during his hospital stay, a total of 386 minutes for the eight days, or 48.2 minutes per day. Fig. 1,B is that of the baby who cried the most, 1,947 minutes during the eight days, or 243 minutes per day, five times as much. Fig. 2 shows the average hourly Crying per infant during the eight days, a total of 936 minutes, or 117 minutes per day. The general distribution of crying with its periodic daily high points shows similarities, especially in the last four days in most charts. One can detect a n increase of crying as the feeding hours are approached with a relative lull in between. The amount of "relative lull" depends in a rough way on the amount of nursing care giver~ to the children. We notice that besides these
ALDRICI-I E T AL. :
C R Y I N G OF N E W L Y
91
BORN BABIES
fluctuations there is a tendency for two peaks to appear, higher than any others through the day and centering around 6 ~.~. and midnight. These can be seen in the individual charts and are most consistent in the average graph for the entire eight days. As already mentioned in the paper on the community phase, 1 the prolonged crying period at 6 P.~. is caused by lack of synehrony between nursery and floor routines. The babies have to be in the nursery by 2 P.M. because of visiting hours, a fact which advances the 2 P.~. feeding time to 1:15 or 1:30 P.M. Since the 6 P.~. feeding hour, unfortunately, had to be postponed because of the mothers' dinners, a feeding interval of five or six hours occurred, which resulted in the prolonged crying at 6 P.~. recorded in the graphs, a It is easily seen from Fig. 1,A and B, showing minimal and maximal crying, that one baby may cry much more than another for the same type of cause. Aside from the actual length of crying time and its distribution through the day, observations were made on the pattern of crying during the first twenty-four or forty-eight hours. It was observed that many infants expressed themselves by Very short sounds, like short high-pitched grunts, w h i c h appeared in groups of ten to thirty successively, without ever culminating in
A.~.
~-M-
A-M.
P.M.
Fig. 2 . - - C r y i n g c h a r t - - a v e r a g e
A-H-
P.H-
A-H-
P.H.
of f i f t y b a b i e s - - f i r s t e i g h t d a y s .
actual crying. Such sounds were noticed through the whole hospital stay but they were almost the only vocal expression of some babies for the first twentyfour to forty-eight hours. Just as large a group, however, commenced Iife with immediate, persistent, and intense crying. This pattern did not seem dependent on the total crying of the individual infant, as it occurred in the " q u i e t " as well as i~ the more persistently crying babies. Frequency Diagram.--Having established the marked variation in amount of crying time exhibited by different babies, from 386 to ],947 minutes, it seemed worth while to study a frequency curve showing the distribution of the fifty babies in relation to their total crying minutes. This shows the majority falling in the middle range (Fig. 3). The Average Crying per Baby per Day.--From a practical standpoint it may be of some interest to observe the curve resulting when we plotted the average minutes of crying per day for the eight consecutive days in the hospital (Fig. 4). Here we found a smooth curve, rising from birth to the fourth day at a rather steep angle. From the fourth to the sixth day it remained at a fairly even level, to decline more abruptly thereafter. However, a very difP.Mo
*Tl~is d i s c r e p a n c y w a s p r o m p t l y r e c t i f i e d b y h a v i n g t h e m o t h e r s ' t r a y s s e n t u p s t
5:30
92
THE
JOUgNAL
OF P E D I A T R I C S
ferent picture appeared when we attempted to superimpose the fifty curves of each baby on one chart. This showed a wild crisscross of seemingly unrelated lines, out of which it was impossible to read any tendency toward rhyme or reason. Much less were we able to reproduce it here. To demonstrate the difference, then, between an " a v e r a g e " curve and that of an "individual" baby we superimposed a typical curve of one infant in Fig. 4. Instead of the smoothness of the average, the curve of the individual baby climbs and falls in an irregular manner.
% 1 a 3 4 S 6 ~ 8 910111&lS141516171619PA3 N u m b e r , of' hundped_ m i n u t e s of c p ~ i n ~ p e r , 8 d a ~ s bNg. 3 . - - D i s t r i b u t i o n
of f i f t y b a b i e s
arranged according days,
to t o t a l
crying
minutes--first
eight
~00, 180
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4 5 6 ~ 8 Dc~s --Total c p g i n 9 p e p d a ~ of a v e p a ~ e 5a5~ ~-~ Total cp~in~ pep da~ of an individucd bab~ ]eig. 4 . - - C r y i n g
p e r d a y in m i n u t e s .
-kverage baby
compared
with
individual.
Crying in Relation to Feeding and Weight Gain.--In order to study the relation of crying to feeding and weight gain we charted these three factors for each of the fifty babies. Examination of these charts did not lead to any simple conclusions. They seemed to be rather evenly divided into two groups, those which seemed to show g relationship and those which did not exhibit any correlation between food intake and crying. Out of the set of fifty, two typical charts are reproduced, each demonstrating a type (Fig. 5). In Fig. 5,A a definite increase in food intake is accompanied by an obvious fall in the amount of crying. A slight decrease in food supply on the seventh day shows a simultaneous rise in crying, followed by a correlated divergence of the curves on the eighth day. However, although food intake and crying seem related there does not seem to be any similar correlation between weight
ALDRICH
ET
AL. :
CRYING
OF
NEWLY
BORN
93
BABIES
gain and crying in this chart9 The crying increases and falls independently of the weight gain. In Fig. 5,B the decreased and increased food intake curve is parallel with that of the fall and rise in crying activity and therefore does not suggest any rational correlation. Also, here again, there is no reciprocal relationship between weight gain and crying. B
A
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"intake
\Weight Foo&
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Fig. 5.--Superimposed
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Fig. 6,--Reduction in crying (center) noted w h e n good feeders arc c o m p a r e d with poor feeders as s h o w n b y weight a n d food intake data.
Since this attack on the problem faile'd to show a consistent relation between food intake and crying, we tried another method. The ten babies with the best and the ten with the poorest feeding histories were compared. Scatter diagrams were made of crying and food intake in both of these groups but no correlation was demonstrable in either group. Therefore, another atterhpt was undertaken to show that the amount of food taken would reduce the crying time. In the two groups defined in the
94
THE JOURNAL OF PEDIATRICS
previous paragraph data were estimated per baby per day as to (1) the amount of food taken in ounces, (2) the weight fluctuation in grams, and (3) the amount of crying in minutes. This resulted in our ability to demonstrate (Fig. 6) a reduction of 17.8 minutes (15 per cent) of crying per day in the babies with good feeding histories. This seems of some significance, but, as our number of babies compared was small (ten in each group), the result cannot be considered of statistical importance. Fifteen per cent reduction in a large number would have been definitely significant but in only twenty babies it is merely an indication. Causes of Crying.--As mentioned before, the recorded causes of crying were only an estimate dependent on the judgment of the observer and, t h e r e fore, cannot be considered absolutely accurate. Nevertheless, the information obtained should be of some clinical value as an approach to the problem of neonatal crying in hospital nurseries. The causes observed were hunger, vomiting, soiled or wet diapers, and unknown reasons. Our method of investigation was as objective as possible. A prolonged, intense crying spell in a kicking infant at feeding time, sucking on his fingers or fist, was noted down as hunger. A crying child, lying in his vomitus or in soiled or wet diapers, was charted according to the apparent reason. The rest of the crying was charted as due to unknown reasons. The number of minutes of crying ascribed to each cause was calculated and the results shown in Table I were obtained. TABLE I. i~/~INUTES OF CRYING FOE ]~ACII CAUSE AUSES 0E aEYING BABIES
(~o.)
DAYS
(No.)
5----v-- ~
(0.5%)
2,024.2 323.9 40.5
26.7 4.3 0.5
4~74~.8 76.0 9.5
B
HUNGER
VO~HTUS
16,193.5
50 1
(35.5%)
214.5
c SOILED DIAPERS 3,799.0
A
1
(8.3%)
D -WET DIAPERS 9,359.5
J U17]~NOWI~ REASONS 16,005.5
(20.6%)
(35.1%)
1,169.9 187.2 23.8
2,000.6 320.1 40.0
Hunger and " u n k n o w n causes," according to our estimate, then, were the most important reasons for the crying of our babies. " U n k n o w n causes" may seem to have a surprisingly high incidence but, if one remembers that infants at birth are individualists and that present nursery routines are not adapted to efficient individual care, it is understandable that we could be at a loss to explain many of these expressions of unhappiness. Because we suspected that urgent fundamental needs would probably be expressed by more prolonged, continuous crying than that provoked by matters of less vital importance, we calculated the number of periods as well as the number of minutes of crying for each single cause (Table II). Our results confirmed this possibility, for the number of crying spells due to hunger dropped below that for "unknown reasons"; that is, the hunger cries were of longer duration than those due to unknown reasons. COMMENT
In our consideration of the neonatal crying problem we have assumed that the cry of a newly born baby is a reflex protective mechanism used as a signal of need to whoever may attend him. As such, it becomes a useful attribute, one which, if ignored, may lead to harmful omissions in the baby's care. It is quite evident that many different stimuli, both from within and from without,
ALDRICH ET AL. :
CRYING OF NEWLY BORN BABIES
95
may suffice to trip the central automatic switch which turns on the cry. Hunger, chilling, bright lights, irritation of the skin from wet or soiled diapers, peristaltic movements, vomiting, bowel or bladder evacuation, l o u d noises, or loss of equilibrium may be listed among the generally accepted causes. Perhaps, to be complete, we should add such more or less negative factors as need for fondling and lack of rhythmic motion. In studying the use of the cry by the individual babies we found marked differences. Some put up a -vigorous, earsplitting objection for apparently trivial reasons;others seemed more phlegmatic and were perhaps less efficient. We are not prepared to say whether this is a matter of inherent disposition, of varying thresholds to stimuli, or of some other attribute of the baby but, at any rate, the fact of individual differences stands out clearly. But no matter how much or how littIe the particular baby cries, one constant relationship is evident in our charts, the reciprocal effect of nursing care. The more care, the less crying. To our great surprise it turned out to be a difficult matter to relate food intake and weight gain to the amount of crying. Even after persistent effort, the correlations that we were able to make between these factors were suggestive but not statistically significant. This result, however, was probably due more to the fact that in our preliminary thinking we underestimated the importance of other less obvious causes than that we overestimated that of hunger. If we had been able to chart crying due to hunger separately and then to compare the amount of hunger crying before and after the establishment of lactation, a very different picture might have appeared. TABLE I I .
BABIES
Di iS
I~U~BER OF CLOYING SPELLS FOR EACH CAUSE
A
B
u
50 50
I
2,760.0 345.0
1
55.2
1
6.9
45.00 5.60 0.90 0.11
(3AUSES O~ (3~YING (J D "WET SOILED DIAFEI~S DIAPERS 737.0 1,630.00 92.0 203.80 15.732.50 1.9 4.07
J UNKNOWN" REASONS 3,295.0 411.7 65.9 8.2
The most clear-cut result of our study of the causes of neonatal crying in the individual baby is a demonstration of the importance of unknown reasons. In total minutes of crying this group of reasons closely approaches the amount for hunger and in the number of crying spells it exceeds it. When we take into account the unique situation of the newborn infant and the probable list of these unknown causes, we should not be surprised at this result. During intrauterine life the fetus becomes adjusted to a quiet, dark, warm, aquatic environment characterized by considerable rhythmic movement and absolute freedom from any responsibility in providing himself with food or oxygen. Immediately after birth his sensations are assailed by considerable noise, bright lights, cool, dry atmosphere and relatively little rhythmic movement and he is obliged to begin active participation in matters of oxygen and food intake, digestion, and elimination. It would be strange if, in the face of all of these major changes, he did not use his protective cry freely to register his adverse reactions to many sorts of unaccustomed stimuli. Because there are so many stimuli, the one factor of hunger, while still important, may well become less dominant in the crying picture at this time. We, therefore, feel that in order to modify this situation in which we find n e w babies protesting violently for an appreciable part of their neonatal life--
96
THE JOURN'AL OF PEDIATRICS
and an overwhelming proportion of their waking hours--it will be necessary to pay more attention to these unknown causes in addition to perfecting our methods of routine care. This will probably mean more nurses on the job. It will also mean individualization of the management of each baby and the provision of closer contact with nurse or mother during the neonatal period. SUI~x~IARu
A controlled study on crying of fifty individual babies was made in a hospital during April, 1944. Four observers took turns in recording the amount os crying in minutes and the estimated causes of the crying. The amount of crying for the baby with the least crying activity was 386 minutes during eight days, or 48.2 minutes per day. The baby who cried the most totaled 1,947 minutes during eight days, or 243 minutes per day. The average crying per infant amounted to 936 minutes during eight days, or 117 minutes per day~ A definite correlation between crying and nursing care was noted: the more care, the less crying. The distribution of the total crying time of the fifty babies was bell-shaped. A graph of the crying of the average baby per day for eight days resulted in a smooth curve, while that of any individual infant climbed and fell in an irregular manner. Three different methods were used to evaluate the relation of crying to weight gain and feeding. The results were vague, except for that of the last method, which showed 17.8 minutes less crying daily in favor of the good feeders. An attempt was made to estimate the causes of crying. Obvious causes, such as hunger, vomiting, soiled and wet diapers, and unknown reason% were tabulated in minutes and number of spells. The most clear-cut result of our study of the causes of neonatal crying is t h e demonstration of the importance of unknown reasons. In total minutes of crying this group of reasons, closely approaches the amount for hunger and in the number of crying spells it exceeds it. REFERENCE
1. Aldrich, C. A., Sung, Chieh, Xnop, Catharine, Stevens~ Geraldine and BurchelI, Margaret: The Crying of :Newly Born Babies: I: The Community Phase, g. PEDIAT. ~26: 313~ 1945.