Do psychological factors play a role in the etiology of infantile colic? a follow-up study

Authors

Abstract

AimThis study aimed to assess the association between the level of prenatal attachment, hopelessness, and family stressors and coping strategies during pregnancy and the presence of infantile colic in their offspring.
MethodsThis research was conducted as a nested case-control follow-up study. In the first step, the study population consisted of 366 pregnant women who were admitted to a tertiary hospital obstetric outpatient clinic for routine obstetrical control between 24-28 weeks of gestation. Prenatal data were collected using a personal information questionnaire, the prenatal attachment questionnaire, the Beck hopelessness scale, and the family stressors coping strategies scale. In the second step, the scores of these scales were compared between the groups regarding having infantile colic in the offspring, which was conducted with a visit after the 6th week of delivery.
ResultsThe ratio of infantile colic was 30% for the study population. Concerning the scores of prenatal attachments, hopelessness, and family stress coping strategies total, and subscales, there was no significant association with the presence of infantile colic in a baby.
ConclusionThis study did not show any effect on the development of infantile colic with prenatal attachment, hopelessness, or family stress coping strategies during pregnancy. The results of the study primarily suggested that organic causes, rather than psychosocial causes, may have a risk for the development of infantile colic.

Keywords

Introduction

Infantile colic (IC) is a benign-likely, self-limited process, characterized by inconsolable crying. Colic affects approximately 20% of infants worldwide.¹ Pediatricians often use the “Rule of 3”: crying for at least three hours per day; crying occurs at least three days a week; the episodes last for at least three weeks.²
The incidence is equal between sexes, and there is no correlation with the type of feeding, gestational age, or socioeconomic status.³ Continuously having agitation or crying periods can make parents scared and seem the process more confusing. Excessive crying and fussing may harm the mother-infant relationship and has even been mentioned as a possible cause of violence towards the infant.^4,5,6 Associations with later gastrointestinal problems, atopy, autism spectrum disorder, migraine, and behavioral/cognitive problems have also been reported.^7,8,9 It has been included in childhood functional gastrointestinal disorders in the Rome III criteria.⁷
There can be many causes of IC, but although decades have been spent searching for somatic, developmental, and psychosocial reasons, none of them has been determined yet. Moreover, this process is associated with many psychosocial factors including anxiety, abuse, socioeconomic status, and frustration, and is strongly related to maternal anxiety and depression.^4,10,11,12
Data about the relationship between prenatal mental health problems and infantile colic are limited. Parental support and reassurance are key components of the management of colic.³ Novel information may serve as a moderating variable about preventive health care and of mother-infant dyads in need of psychological or psychiatric interventions.¹⁰ Therefore, the objective of this study is to examine the pregnant women’s psychosocial risk factors such as poor prenatal attachment, family stress coping skills, and hopelessness that have any value in predicting their infant’s colic.

Materials and Methods

Patients And MethodsThe study has a nested case-control design and includes all cases admitted to the outpatient perinatology department of a referral hospital. The pregnant women who were consecutively applied to Tepecik Training and Research Hospital Gynecology and Obstetrics Outpatient Clinic between September 2018 and July 2019, between 24 and 28 weeks of gestation and willing to participate in the questionnaire were included in the study. Therefore, face-to-face interviews were made with the patients who applied to the pregnant follow-up outpatient clinic; pregnant women who were at high risk, illiterate Turkish, pregnant women with psychiatric illness, and those who refused to participate in the study were excluded. Also, infants with severe physical malformations, chronic diseases, and infants still in the hospital were excluded from the study.
The difference between the two averages in the independent groups was used to compare the prenatal attachment scale score, which is the main dependent variable of the study, for the pregnant women who were prepared or not. Since the t-test, which is the significance test, will be analyzed, for the 95% confidence interval, the sample size of the study was determined as n = 199 pregnant women for the effect power d = 0.2 (small level), α = 0.05 and 80% power. The study was planned to be conducted with 259 pregnant women, considering the possible 30% of case losses. We invited all patients who met the criteria for the study, 422 pregnant women consecutively applied, and 381 of them accepted to participate in the study. However, the study was completed with 366 pregnant women due to the marital status, postnatal availability of access to the participants, and consent to give information during the phone call.
Ethics And Consent
Ethical approval for the study was obtained from the local ethics committee (Approval date: 08/08/2018, Approval number: 2018/10-4). Pregnant women submitted verbal and written consent before participating in the study. All study procedures were conducted in accordance with the Declaration of Helsinki and local laws and regulations.
Data Collection Instruments
Socio-demographic Data Form
This form was prepared to collect information about the socio-demographic characteristics of adolescents and their parents such as the participant’s age, sex, as well as educational status, marital status, and occupation. First, a checklist that was developed by the researchers that contained questions about age, smoking, educational status, parity, high-risk pregnancy, and phone number, and was filled in by the physician for all cases. The volunteer pregnant women filled the Prenatal Attachment Inventory (PAI), Beck Hopelessness Scale, and Family Stressors Coping Strategies Scale (FSCSS).
Prenatal Attachment Inventory (PAI)
The PAI test form was designed to identify the woman’s level of attachment to her fetus. The PAI measures the prenatal relationship as a single factor independent of the woman’s feelings about pregnancy or motherhood.¹³ The PAI was developed by Muller, and consists of 21 Likert-type items arranged in a 4-point response set ranging from “almost always” to “almost never.” A minimum score of 21 and a maximum of 84 can be obtained from the scale. PAI does not have a cut-off point, and the level of attachment increases as the score of PAI increases. The Cronbach Alpha Reliability Coefficient of PAI, adapted to Turkish by Yilmaz and Beji, is α = 0.84.¹⁴
Beck Hopelessness Scale
Beck and colleagues in 1974 developed the Hopelessness Scale specifically to measure hopelessness, a construct that had been regarded as impossible to empirically evaluate. Beck’s cognitive model attested that individuals who are depressed have a subjective perception of being ineffectual, have appropriate self-criticism for their individual difficulties, and hold a non-productive view of their future. The scale’s items are phrased in such a way that the respondents either assent to a futuristically positively worded statement or reject a futuristically negatively worded statement to get a score of one point per question.¹⁵
Family Stressors Coping Strategies Scale (FSCSS)The FSCSS is an instrument aiming to reveal the coping strategies that married individuals use against the stress factors in the family that was developed by Clark et al.¹⁶ It was adapted to Turkish by Ekşi et al. It incorporates 15 following factors: sharing the workload, rearranging schedules, planning, interpersonal communication, family-work segmentation, work-family segmentation, working to improve skills, cognitive restructuring, changing behaviors, social support search, relaxation exercises, physical exercises, spending time with family, care between spouses, organization of budget (available at: https://toad.halileksi.net/olcek/aile-stresorleri-ile-basa-cikma-yontemleri-olcegi).
Telephone VisitsAbout five months after the volunteers were included in the study, a visit was made via phone, and those who agreed to participate were asked whether the babies have crying attacks according to Wessel criteria and the birth weight of the infant.² The volunteers were dichotomized into two groups with this telephone call and a comparative analysis was performed between the cases with infantile colic and without.
Ethical Approval
Ethics Committee approval for the study was obtained.

Results

In our study, the infantile colic rate accounted for 30%. Socio-demographic data and the scale scores of 366 pregnant women are shown in Table 1. We observed an increased risk of infantile colic for low-birth-weight infants in our investigation.
The relationship between prenatal attachment, hopelessness, and family stressors coping strategies and infantile colic is shown in Table 2. No relationship was found between these parameters and infantile colic.

Discussion

The results do not indicate that poor prenatal attachment, family stressors coping strategies, and hopelessness during pregnancy increase the risk of IC. The only relationship was between the low birth weight and the development of IC. While an emerging body of literature is suggestive of possible associations between prenatal problems and infant development, there has been no study conducted that has explored the relationship of these determinants with the development of IC.
Here, we found the ratio of IC as 30%. Based on the evidence available, the experts considered that the likely worldwide prevalence according to Rome III criteria is approximately 20% for infantile colic.⁹ The reason for our higher ratio can be the medical problems of the pregnant women who were referred to our tertiary center, which was the data source for the present study.
In this study, there was no relation between IC and maternal-child characteristics, like maternal age, parity, educational level, maternal smoking during pregnancy, and the sex of the infant. The only significant difference was between birth weight and IC. Studies show that especially low birth weight increases the risk of IC.¹¹ A previous study reported that full-term infants with a birth weight below 2500 g had a higher risk for infantile colic. Low birth weight and intrauterine growth restriction have a multifactorial etiology that is not well understood. Possible mechanisms include understatement of crying in light of the more severe medical problems commonly faced by preterm and small-for-gestational age infants, or over-reporting because of increased attention and a lower threshold for parental issues. The other possible mechanism may be that small for gestational age and preterm infants are more often exposed to prenatal, perinatal, and neonatal environmental factors that affect growth and development, intestinal flora, sleep and wake cycle, and process of pain and other stimuli.¹⁷ Large and detailed prospective studies of growth-restricted infants are necessary to elucidate the mechanisms behind this association.
The psychological outcomes of the present study were that there was no difference in prenatal relationship and hopelessness as independent factors of the woman’s feelings about pregnancy or motherhood for having an infant with IC. The mother-infant relationship begins with the emotional attachment of the mother to the fetus in the prenatal period and acceptance of the fetus as a separate individual. The formation of a maternal identity begins and continues with this process.² Babies who show insecure attachment are less likely to experience their mothers as comforting. It is undeniable that in the absence of observable behaviors of the child, prenatal attachment is distinct from the attachment behaviors articulated by Bowlby. However, in light of the intergenerational transmission of cognitive models of relationships, it seems that what can be observed in the mother-child dyad after birth may have a prenatal correlate that can be measured.^18,19 Regardless of the environment, hopelessness has a negative impact on the psychological well-being and physical health of individuals.²⁰ However, this study did not find any relation between the prenatal hopelessness and IC.
Another target of our study was to evaluate the relationship between the family stressors coping strategies and the development of IC. Regarding the results, there was no relation between IC and poor family stressors coping strategies. Prolonged emotional stress has been associated with several medical and psychosomatic problems in mothers.²¹ Winnicott, an English pediatrician and psychoanalyst, said, “There is no baby without a mother.” An infant and his or her mother form a unit. This means that we cannot discuss an infant’s condition without discussing the mother’s condition.²² This study made an effort to explore different determinants that may affect the development of IC by exploring prenatal attachment, pregnancy hopelessness, and family stressors coping strategies. As a result, in the light of these findings, the authors suggested that there may be more organic causes in the pathogenesis of IC rather than the prenatal psychological causes.
The results of our study should be interpreted with some limitations. First, we obtained the data with self-report instruments without a psychiatric interview, which can provide an accurate diagnosis. However, the validated instruments that were used have strong consistency and are widely used in scientific research. Also, the prospective design of the study allowed us to detect the direct cause-effect relationship to rule out these detailed important psychological determinants of mother-infant dyads in the etiology of infantile colic.

Conclusion

This study did not find any association between IC and regarding the prenatal attachment, pregnancy hopelessness, and family stressors coping strategies. The only relation was between low birth weight and IC. In view of these results, future studies should focus on the possible organic determinants, which may be associated with the development of IC rather than the psychological reasons that we performed in a detailed method with a prospective design. More research with a collection of reliable data, a large sample size, and different populations in prospective design is needed to obtain a more accurate estimate on the etiology of infantile colic.

Declarations

References

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About This Article

Received:

October 14, 2022

Accepted:

November 14, 2022

Published Online:

November 24, 2022

Printed:

March 1, 2023