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Systematic Review and Meta-Analysis: Fussing and Crying Durations and Prevalence of Colic in Infants

      Objective

      To determine the mean duration of fussing and crying and prevalence of colic using modified Wessel criteria in infants in the first 3 months of life.

      Study design

      A systematic literature search was performed using the databases Medline, PsycINFO, and Embase. The major outcome measure was mean total fuss/cry duration during 24 hours at ages 1-2 weeks (11 samples), 3-4 weeks (6 samples), 5-6 weeks (28 samples), 8-9 weeks (9 samples), and 10-12 weeks (12 samples).

      Results

      Of 5687 articles reviewed, 28 diary studies (33 samples) were suitable for inclusion in meta-analysis; these studies included 8690 infants. No statistical evidence for a universal crying peak at 6 weeks of age across studies was found. Rather, the mean fuss/cry duration across studies was stable at 117-133 minutes (SDs: 66-70) in the first 6 weeks and dropped to a mean of 68 minutes (SD: 46.2) by 10-12 weeks of age. Colic was much more frequent in the first 6 weeks (17%-25%) compared with 11% by 8-9 weeks of age and 0.6% by 10-12 weeks of age, according to modified Wessel criteria and lowest in Denmark and Japan.

      Conclusions

      The duration of fussing/crying drops significantly after 8-9 weeks of age, with colic as defined by modified Wessel criteria being rare in infants older than 9 weeks. Colic or excessive fuss/cry may be more accurately identified by defining fuss/cry above the 90th percentile in the chart provided based on the review.

      Keywords

      Colic is a common source of concern for parents, a frequent reason for seeking help and advice from healthcare professionals.
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      Paroxysmal fussing in infancy: sometimes called “colic”.
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      Although the modified Wessel criteria are widely used, normative studies in the general infant population are lacking.
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      thus, the prevalence may be different than that noted in the 1950s. Although modified Wessel criteria have been used in different countries, the impact of cultural variations such as caregiving styles
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      Infant crying and sleeping in London, Copenhagen and when parents adopt a “proximal” form of care.
      • Lucas A.
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      Crying, fussing, and colic behaviour in breast- and bottle-fed infants.
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      Mothers' reports of infant crying and soothing in a multicultural population.
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      Mothers' reports of infant crying and soothing in a multicultural population.
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      • Sawdon J.
      Infant crying patterns in Manali and London.
      on the duration of infant fussing and crying need to be taken into consideration. Furthermore, the cry/fuss duration may depend on the patterns of feeding (breast vs bottle).
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      Finally, several studies have documented a developmental pattern of fuss/cry duration in the first 3 months of life,
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      Infant fussing and crying patterns in the first year in an urban community in Denmark.
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      Crying in infancy.
      • Barr R.G.
      The early crying paradox: a modest proposal.
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      • et al.
      Effectiveness of educational materials designed to change knowledge and behaviors regarding crying and shaken-baby syndrome in mothers of newborns: a randomized, controlled trial.
      indicating a gradual increase that peaks at 5-6 weeks of age with a decrease to one-half the amount by 3-4 months of age.
      • Barr R.G.
      • Konner M.
      • Bakeman R.
      • Adamson L.
      Crying in !Kung San infants: a test of the cultural specificity hypothesis.
      • Hunziker U.A.
      • Barr R.G.
      Increased carrying reduces infant crying: a randomized controlled trial.
      • Brazelton T.B.
      Crying in infancy.
      • Barr R.G.
      The early crying paradox: a modest proposal.
      • Rebelsky F.
      • Black R.
      Crying in infancy.
      • Barr R.G.
      Crying in the first year of life: good news in the midst of distress.
      This “normal crying curve” has been interpreted as universal across cultures,
      • Barr R.G.
      • Konner M.
      • Bakeman R.
      • Adamson L.
      Crying in !Kung San infants: a test of the cultural specificity hypothesis.
      although some have not found evidence.
      • St. James-Roberts I.
      • Alvarez M.
      • Csipke E.
      • Abramsky T.
      • Goodwin J.
      • Sorgenfrei E.
      Infant crying and sleeping in London, Copenhagen and when parents adopt a “proximal” form of care.
      • Alvarez M.
      Caregiving and early infant crying in a Danish community.
      • St. James-Roberts I.
      • Plewis I.
      Individual differences, daily fluctuations, and developmental changes in amounts of infant waking, fussing, crying, feeding, and sleeping.
      We conducted a systematic review and meta-analysis of fuss/cry durations reported in diary studies from around the world. Twenty-four-hour behavior diaries are considered to be the international gold standard for measurement.
      • St. James-Roberts I.
      • Hurry J.
      • Bowyer J.
      Objective confirmation of crying durations in infants referred for excessive crying.
      • Salisbury A.
      • Minard K.
      • Hunsley M.
      • Thoman E.B.
      Audio recording of infant crying: comparison with maternal cry logs.
      • Barr R.G.
      • Kramer M.S.
      • Boisjoly C.
      • McVey-White L.
      • Pless I.B.
      Parental diary of infant cry and fuss behaviour.
      • St James-Roberts I.
      • Conroy S.
      • Wilsher K.
      Bases for maternal perceptions of infant crying and colic behaviour.
      We investigated the change in fuss/cry duration over the first 12 weeks of life to determine if there is a universal “crying curve” (5- to 6-week fuss/cry duration peak) and if mean fuss/cry duration varies across studies in different countries, according to feeding type or study quality. We also determined the prevalence of colic according to the modified Wessel criteria at different ages in the first 12 weeks.

      Methods

      The current meta-analysis was conducted in line with PRISMA guidelines.
      • Moher D.
      • Liberati A.
      • Tetzlaff J.
      • Altman D.G.
      Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement.
      We searched the databases Medline (1964-December 2015), PsycINFO (1964-December 2015), and Embase (1964-December 2015) using the search headings “infant and crying” OR “crying and amount” OR “crying and duration” OR “fussing and infant.” In addition, infant cry researchers who had participated in the International Cry Research Workshops were approached concerning unpublished data. Finally, we conducted a separate bibliography search and included all new relevant research.
      Criteria for inclusion of articles in the analysis were as follows: (1) at least one 24-hour behavior diary to measure fuss/cry duration; (2) unselected sample (ie, no infants had been excluded according to fuss/cry duration [eg, only colic infants or all noncolic infants]); (3) observation study (ie, no intervention trial); (4) infant age between 1 and 13 weeks; and (5) the authors reported (or provided after request) mean fuss/cry duration as well as distribution indices (ie, SD). For the colic prevalence analysis, only the studies that reported at least three 24-hour behavior diaries were included to meet the modified Wessel criteria. Abstracts were screened according to the selection and inclusion criteria explained above by 2 authors, each screening one-half of the abstracts. Study selection and data extraction were performed independently by 2 authors.
      The quality of studies was evaluated according to 8 criteria: (1) subject selection (whole vs convenience population), (2) recruitment rate (≥50% vs <50%), (3) participation rate (≥75% vs <75%), (4) sample size (≥ 101 vs <101), (5) whether the following 4-sample characteristics were reported: socioeconomic status, parity, infant sex, and maternal age (3 of 4 reported vs <3 reported), (6) feeding type (reported vs not reported), (7) resolution time for the diary (5 vs 15 minutes), (8) number of days requested for diary (≥4 vs <4 days), and (9) whether modified Wessel criteria were employed. Each sample, at each measurement age, received a score of 0 or 1 for each of the criteria. A score of 0 was also given in cases where the information for the criterion was not reported. The individual scores were summed to give a total quality score that could range from 0 to 8 (Table I; available at www.jpeds.com).
      The major outcome measure was mean total fuss/cry duration during 24 hours. The studies were grouped according to age at assessment: 1-2 weeks (11 samples), 3-4 weeks (6 samples); 5-6 weeks (28 samples), 8-9 weeks (9 samples), and 10-12 weeks (12 samples). Furthermore, information regarding the sample size and feeding type (bottle-fed, breastfed, mixed) was extracted from the articles.
      To test fuss/cry peak duration, we calculated a weighted mean and the pooled weighted SD for each period. To test for mean differences, ANOVA was performed between individual weighted means. To evaluate the prevalence of colic, 3 samples which used the diaries for less than 3 days were removed from the 8- to 9-week analysis. The prevalence of colic for each study at each assessment point was computed according to the modified-Wessel criteria, and overall prevalence rates are reported as weighted mean and pooled weighted SD.
      Meta-analysis was conducted with the comprehensive meta-analysis software.
      • Borenstein M.
      • Hedges L.
      • Higgins J.
      • Rothstein H.
      Comprehensive meta-analysis (Version 2) [Computer Software].
      Effect sizes are reported as standardized mean difference with 95% CIs for each study. The mean difference (Cohen d) compares the individual study's mean with the overall weighted mean across studies at each assessment time. A d of .20 is a small, .50 medium, and .80 or more a large effect.
      • Cohen J.
      Statistical power analyses for the behavioral sciences.
      Effect sizes were analyzed using the random effects model, in which the error term is composed of variation originating from both within-study variability and between-study differences.
      • Cooper H.
      • Hedges L.
      The handbook of research synthesis.
      • Borenstein M.
      • Hedges L.V.
      • Higgins J.P.T.
      • Rothstein H.R.
      Inroduction to meta-analysis.
      The distribution of effect sizes was examined using tests of heterogeneity. Significant heterogeneity indicates that differences across effect sizes are likely due to sources other than sampling error, such as different study characteristics. Categorical moderator tests were applied to test for within groups Q (Qw) and between groups Q (Qb). A significant value for Qw indicates that the effect sizes within a category of the moderator variable are heterogeneous, whereas a significant value for Qb indicates that the effect sizes are significantly different across different categories of the moderator variable. Meta-regression analyses were performed to test quality of assessment as a continuous moderator.
      We examined the potential for publication bias by using 2 methods suggested for observational studies. First, biases according to study size were assessed with use of the Begg and Mazumdar
      • Begg C.B.
      • Mazumdar M.
      Operating characteristics of a rank correlation test for publication bias.
      rank correlation test (Kendall tau b). Second, the Duval and Tweedie
      • Duval S.
      • Tweedie R.
      A nonparametric trim and fill method of accounting for publication bias in meta-analysis.
      • Duval S.
      • Tweedie R.
      Trim and fill: a simple funnel-plot-based method of testing and adjusting for publication bias in meta-analysis.
      “trim and fill” method was applied.

      Results

      The online search yielded 5680 articles. An additional seven potential studies were identified through searches of bibliographies and from the Infant Cry Research Workshops (Figure 1; available at www.jpeds.com). After removing the duplicates, the overall systematic literature search included 4109 articles. We reviewed the titles and abstracts of all articles found (N = 4109), resulting in 227 abstracts for joint review. After excluding 138 articles based on their abstract, a total of 89 full-text articles were independently reviewed by 2 authors. Based on the inclusion criteria, 43 articles were further excluded. Among the remaining 46 articles, there were 18 studies with missing data, which required their authors to be contacted to obtain further information about the fuss/cry duration or moderator variables. However, some authors were not able to provide missing data (eg, means, SD etc)
      • Barr R.G.
      • Paterson J.A.
      • MacMartin L.M.
      • Lehtonen L.
      • Young S.N.
      Prolonged and unsoothable crying bouts in infants with and without colic.
      • St. James-Roberts I.
      • Hurry J.
      • Bowyer J.
      Objective confirmation of crying durations in infants referred for excessive crying.
      • Barr R.G.
      • Rotman A.
      • Yaremko J.
      • Leduc D.
      • Francoeur T.E.
      The crying of infants with colic: a controlled empirical description.
      • Hunziker U.A.
      • Barr R.G.
      Increased carrying reduces infant crying: a randomized controlled trial.
      • Keller H.
      • Chasiotis A.
      • Risau-Peters J.
      • Volker S.
      • Zach U.
      • Restemeier R.
      Psychobiological aspects of infant crying.
      • Milgrom J.
      • Westley D.T.
      • McCloud P.I.
      Do infants of depressed mothers cry more than other infants?.
      • St. James-Roberts I.
      • Conroy S.
      • Hurry J.
      Links between infant crying and sleep-waking at six weeks of age.
      • Hyodynmaa E.
      • Tammela O.
      Cradling in the prevention of excessive crying and colic symptoms in infants.
      • Kaley F.
      • Reid V.
      • Flynn E.
      Investigating the biographic, social and temperamental correlates of young infants' sleeping, crying and feeding routines.
      or could not be reached
      • Harrison Y.
      The relationship between daytime exposure to light and night-time sleep in 6-12-week-old infants.
      • van Sleuwen B.E.
      • L'Hoir M.P.
      • Engelberts A.C.
      • Busschers W.B.
      • Westers P.
      • Blom M.A.
      • et al.
      Comparison of behavior modification with and without swaddling as interventions for excessive crying.
      • Walker A.M.
      • Menahem S.
      Normal early infant behaviour patterns.
      • Walker A.M.
      • Menahem S.
      Intervention of supplementary carrying on normal baby crying patterns: a randomized study.
      • Saeidi R.
      • Abadi M.Z.L.
      • Saeidi A.
      • Robatsangi M.G.
      The effectiveness of mother infant interaction on infantile colic.
      ; and some studies did not meet the inclusion criteria (eg, selected population, no fuss/cry duration data etc.).
      • St James-Roberts I.
      • Conroy S.
      • Wilsher K.
      Links between maternal care and persistent infant crying in the early months.
      • Killerby E.
      A comparison of cry-behaviours of clinic-referred and non-referred infants 4-12 weeks old.
      • Baildam E.M.
      • Hillier V.F.
      • Ward B.S.
      • Bannister R.P.
      • Bamford F.N.
      • Moore W.M.O.
      Duration and pattern of crying in the first year of life.
      • Worobey J.
      • Pena J.
      • Ramos I.
      • Espinosa C.
      Infant difficulty and early weight gain: does fussing promote overfeeding?.
      These studies were, therefore, not included in the meta-analysis. Five study reports
      • St. James-Roberts I.
      • Alvarez M.
      • Csipke E.
      • Abramsky T.
      • Goodwin J.
      • Sorgenfrei E.
      Infant crying and sleeping in London, Copenhagen and when parents adopt a “proximal” form of care.
      • Lucas A.
      • St. James-Roberts I.
      Crying, fussing, and colic behaviour in breast- and bottle-fed infants.
      • Barr R.G.
      • Kramer M.S.
      • Pless I.B.
      • Boisjoly C.
      • Leduc D.
      Feeding and temperament as determinants of early infant crying/fussing behavior.
      • Darlington A.S.E.
      • Wright C.M.
      The influence of temperament on weight gain in early infancy.
      • Fujiwara T.
      • Barr R.G.
      • Brant R.
      • Barr M.
      Infant distress at five weeks of age and caregiver frustration.
      reported on more than one sample, resulting in a total of 28 articles with 33 samples being included in the meta-analysis (Table I). The majority of the studies used at least 3 days diary except 3 samples from 2 study reports.
      • Darlington A.S.E.
      • Wright C.M.
      The influence of temperament on weight gain in early infancy.
      • Wake M.
      • Morton-Allen E.
      • Poulakis Z.
      • Hiscock H.
      • Gallagher S.
      • Oberklaid F.
      Prevalence, stability, and outcomes of cry-fuss and sleep problems in the first 2 years of life: prospective community-based study.
      The studies included in the analysis with their quality rating scores and descriptions of each study are shown in Table I.
      The overall agreement in the selection of articles according to the predefined criteria was Cohen k = 0.89 at the full-text retrieval stage. The discrepancies in articles were discussed and mutually resolved by the coders.

       Fuss/Cry Duration across 1-12 Weeks of Age

       Mean Fuss/Cry Duration

      The weighted mean average for each period was computed (Figure 2, A). As shown, mean fuss/cry durations were 117-133 minutes (SDs: 66-70) in the first 6 weeks and then dropped to 68 minutes (SD: 46) by 10-12 weeks of age. Post-hoc comparisons showed that fuss/cry duration did not significantly differ from each other across the first 6 weeks. However, the fuss/cry duration at 10-12 weeks (mean: 68.03, SD: 46.2) was significantly lower than at 1-2 weeks of age (mean: 117.3, SD: 66.8; P < .001); 3-4 weeks of age (mean: 118.2, SD: 69.3; P < . 01); and 5-6 weeks of age (mean: 133.3, SD: 70.1; P < .001).
      Figure 2
      Figure 2A, Weighted mean fuss/cry duration (in minutes) across countries (1-2 vs 10-12 weeks of age [P < .001]; 3-4 vs10-12 weeks of age [P < .01]; 5-6 vs 10-12 weeks of age [P < .001]) and B, overall colic percentages (95% CI) for all studies combined in each period (1-2 vs 10-12 weeks of age [P < .01]; 3-4 vs 10-12 weeks of age [P < .001]; 5-6  vs 10-12 weeks of age [P < .001]; 8-9  vs10-12 weeks of age [P < .05]; and 5-6 vs 8-9 weeks of age [P < .05]).

       Potential Moderator Variables

       Country

      Random effects meta-analyses (Figure 3; available at www.jpeds.com) showed that the standardized fuss/cry duration means in Germany at 1-2 (mean: 69, SD: 60) weeks and 3-4 weeks of age (mean: 80.8, SD: 67.4) and in Japan at 5-6 weeks of age (mean: 107, SD: 36) were significantly lower than the overall weighted average mean (Figure 3). Similarly, the standardized fuss/cry duration means in Denmark were significantly lower than the overall weighted average mean across the first 12 weeks except 8-9 weeks of age. On the other hand, the standardized fuss/cry duration mean in Canada at 3-4 weeks of age (mean: 149.8, SD: 73.5) and in The Netherlands at 5-6 weeks of age (mean: 150.4, SD: 66.3) was significantly higher than the overall weighted fuss/cry duration mean (Table II). The Q test for heterogeneity was significant at each age (P < .001).
      Table IICountries with statistically significant deviations from mean fuss/cry duration and colic percentages compared with the overall mean across all countries (all studies)
      Fuss/cry duration
      Number of studiesOverall mean (SD) in minMean (SD) in minHigher or lower than overallZ scoreP
      1-2 wk
       Denmark1117.3(66.8)80(44)Lower−3.86<.001
       Germany1117.3(66.8)69(60)Lower−4.55<.001
      3-4 wk
       Canada1118.2(69.3)149.8(73.5)Higher3.50<.001
       Denmark1118.2(69.3)90(58)Lower−3.24<.001
       Germany1118.2(69.3)80.8(67.4)Lower−3.78<.001
      5-6 wk
       Denmark3133.3(70.1)85.6(64.7)Lower−11.27<.001
       Japan1133.3(70.1)107(36)Lower−2.04<.05
       The Netherlands1133.3(70.1)150.4(66.3)Higher2.05<.05
      10-12 wk
       Denmark168(46.2)48(44)Lower−3.01<.01
      Colic percentage
      Number of studiesOverall colic percentageColic percentageHigher or lower than overallZ scoreP
      1-2 wk
       United Kingdom717.4%28%Higher2.73<.01
      3-4 wk
       Canada118.4%34.1%Higher2.76<.01
       Denmark118.4%5.5%Lower−2.84<.001
       Germany118.4%6.7%Lower−2.36<.001
      5-6 wk
      Country overall was not a significant moderator.
       Denmark325.1%6.7%Lower−7.22<.001
       Japan125.1%2.1%Lower−2.16<.05
       United Kingdom725.1%18.1%Lower−2.56<.05
      8-9 wk
       Italy211.5%20.9%Higher1.98<.05
      Please note that this only illustrates the findings for countries that were significantly different from overall.
      * Country overall was not a significant moderator.

       Feeding Type

      Feeding type was found to be a significant moderator at ages 1-2 weeks (Qb = 22.91; P < .001), 5-6 weeks (Qb = 12.28; P < .01), and 10-12 weeks (Qb = 21.01; P < .001). Samples which included babies who were bottle-fed (z = −3.461; P < .01) or mixed-fed (breast and bottle) (z = −3.656; P < .01) had significantly lower fuss/cry durations than the overall weighted fuss/cry mean at 5-6 weeks of age. In contrast, samples which included babies who were breastfed had significantly higher fuss/cry durations at 3-4 weeks of age (z = 3.500; P < .01). Furthermore, samples that did not report on the type of feeding (at 1-2 and 10-12 weeks of age) reported significantly higher fuss/cry durations than the overall weighted fuss/cry.

       Quality Assessment

      Univariate meta-regression analyses indicated a positive significant moderating influence of study quality at 8-9 weeks of age (the slope: point estimate = 0.15; z = 4.09; SE = 0.04; P < .001; Qb = 16.79; df: 1; P < .001): As study quality increased, fuss/cry duration also increased.

       Prevalence of Colic

      We calculated the overall mean weighted colic prevalence of all studies at each assessment point (Figure 2, B). Mean colic prevalence at 10-12 weeks age (0.6%) was significantly lower than the mean colic prevalence at 1-2 weeks of age (17.4%, z = 2.95; P < .01), 3-4 weeks of age (18.4%, z = 3.40; P < .001), 5-6 weeks of age (25.1%, z = 3.64; P < .001), and 8-9 weeks of age (10.8%, z = 2.93, P < .01). Furthermore, it was found that colic prevalence at 5-6 weeks of age was significantly higher than colic prevalence at 8-9 weeks of age (z = 2.01; P < .05).

       Potential Moderator Variables

      Significant moderating effects were observed for country at 1-2 weeks of age (Qb = 16.24; P < .01), 3-4 weeks of age (Qb = 22.91; P < .001), and 8-9 weeks of age (Qb = 9.44; P < .05). The average standardized difference (d) in mean colic prevalence of the United Kingdom studies at 1-2 weeks of age (28%), Canada at 3-4 weeks of age (34.1%), and Italy at 8-9 weeks of age (20.9%) was significantly higher than the overall weighted colic prevalence. In contrast, Denmark (5.5%) and Germany (6.7%) had lower colic rates at 3-4 weeks of age (Table II).
      Although country was not a significant moderator at 5-6 weeks of age, fewer infants with colic were reported across all Danish studies (6.7%), the Japanese study (2.1%), and the United Kingdom studies (18.1%) compared with the overall prevalence.
      Feeding type was found to be a significant moderator at 5-6 weeks of age (Qb = 14.23; P < .01) and 10-12 weeks of age (Qb = 4.55; P < .05). At 5-6 weeks of age, studies thatreported infants who were bottle-fed (z = −3.87; P < .001) and mixed fed (z = −3.54; P < .001) had lower prevalence of colic. On the other hand, at 10-12 weeks of age, studies that did not report the feeding type (6 studies) had significantly higher colic prevalence (z = 2.62; P < .05) compared with overall weighted colic prevalence.
      The heterogeneity analysis was significant at the following ages: 1-2 weeks: Q = 29.42; P < .01; 3-4 weeks: Q = 24.87; P < .001; and 5-6 weeks: Q = 74.57; P < .001.

       Quality Assessment

      Univariate meta-regression analyses showed that study quality had a positive significant moderating influence at 8-9 weeks of age (the slope: point estimate = 0.53; z = 2.57; SE = 0.21; P < .05; Qb = 6.61; df: 1; P < .5). Increased quality of study was associated with increased prevalence of colic.

       Publication Bias

      The Begg and Mazumdar Rank Correlation Test (correlation between study size and effect size) suggest that there was little evidence for publication bias. We assessed the possibility of publication bias by using a funnel plot to assess for asymmetry. The Duval and Tweedie's trim and fill method indicates that 2 studies are missing left to the mean at 1-2 weeks of age (combined studies: 0.01; 95% CI: −0.23 to 0.26; using trim and fill, the imputed point estimate: −0.08; 95% CI: −0.32 to 0.16), 3 studies are missing left to the mean at 3-4 weeks of age (combined studies: −0.02; 95% CI: −0.38 to 0.34; using trim and fill, the imputed point estimate: 0.29; 95% CI: −0.67 to 0.09), and 3 studies are missing left to the mean at 10-12 weeks of age (combined studies: 0.14; 95% CI: −0.09 to 0.38; using trim and fill, the imputed point estimate: −0.01; 95% CI: −0.26 to 0.24).

      Discussion

      This review and meta-analysis found no statistical evidence for a “universal” increase of fuss/cry duration over the first 6 weeks of life culminating in a “crying peak” at 5-6 weeks of age as proposed previously,
      • Barr R.G.
      The early crying paradox: a modest proposal.
      • Barr R.G.
      • Rivara F.P.
      • Barr M.
      • Cummings P.
      • Taylor J.
      • Lengua L.J.
      • et al.
      Effectiveness of educational materials designed to change knowledge and behaviors regarding crying and shaken-baby syndrome in mothers of newborns: a randomized, controlled trial.
      although visual inspection shows a slight increase.
      • Barr R.G.
      • Trent R.B.
      • Cross J.
      Age-related incidence curve of hospitalized Shaken Baby Syndrome cases: convergent evidence for crying as a trigger to shaking.
      Overall, fuss/cry durations were high across the first 6 weeks of life, then reduced significantly over the following 6 weeks. All studies found a “universal” reduction in fuss/cry duration between 6 and 12 weeks of age.
      The significant differences in mean fuss/cry durations between studies were moderated by country of origin. The most consistent finding was the lower fuss/cry durations reported in Denmark at several age points.
      • Alvarez M.
      Caregiving and early infant crying in a Danish community.
      On the other hand, with the exception of Denmark, no consistent pattern for significantly higher fuss/cry duration between other countries was found. At different assessment ages, studies from The Netherlands
      • de Weerth C.
      • Buitelaar J.K.
      Childbirth complications affect young infants' behavior.
      and Canada
      • Kramer M.S.
      • Barr R.G.
      • Dagenais S.
      • Yang H.
      • Jones P.
      • Ciofani L.
      • et al.
      Pacifier use, early weaning, and cry/fuss behavior: a randomized control trial.
      • Miller A.R.
      • Barr R.G.
      • Eaton W.O.
      Crying and motor behavior of six-week-old infants and postpartum maternal mood.
      had significantly higher fuss/cry durations compared with the overall mean weighted fuss/cry duration.
      The findings regarding the country differences appear robust according to publication bias results. However, we can only speculate on the reasons why there are country differences, in particular between Denmark and the rest of Europe and North America. These could range from economic conditions, such as less social inequality, to caretaking patterns such as responsiveness, carrying behavior and management in Denmark that have been shown to differ from the United Kingdom.
      • St. James-Roberts I.
      • Alvarez M.
      • Csipke E.
      • Abramsky T.
      • Goodwin J.
      • Sorgenfrei E.
      Infant crying and sleeping in London, Copenhagen and when parents adopt a “proximal” form of care.
      However, there may also be population genetic differences, and the infants both inherit their parents' genes and are reared by them (gene-environment correlation).
      • Rutter M.
      Genes and behavior: nature-nurture interplay explained.
      Nevertheless, further analysis of caretaking patterns may prove to provide clues for effective preventative strategies.
      Feeding type was a further moderator of fuss/cry duration. Bottle or mixed feeding was associated with reduced duration of fussing and crying or colic from 3-4 weeks of age onward. Switch in feeding type is one frequently adopted method by parents dealing with a crying baby
      • Forsyth B.W.
      • McCarthy P.L.
      • Leventhal J.M.
      Problems of early infancy, formula changes, and mothers' beliefs about their infants.
      and has been found to reduce crying regardless of what formula change is instituted, suggesting a placebo effect.
      • Berseth C.L.
      • Johnston W.H.
      • Stolz S.I.
      • Harris C.L.
      • Mitmesser S.H.
      Clinical response to 2 commonly used switch formulas occurs within 1 day.
      Feeding type has also been previously reported to be associated with more night waking in infants.
      • Schmid G.
      • Schreier A.
      • Meyer R.
      • Wolke D.
      Predictors of crying, feeding, and sleeping problems: a prospective study.
      • Thunström M.
      Severe sleep problems among infants in a normal population in Sweden: prevalence, severity, and correlates.
      Night waking is often signaled by fussing or crying and, thus, may have increased the total fuss/cry duration in diary reports in those breast feeding. Alternatively, cultural differences might have influenced the accuracy of diary keeping. Furthermore, mothers' perception of the frequency of their infants' crying might be enhanced by cultural variations in support for shouldering the burden in caring for their infant.
      The prevalence of colic according to Wessel modified criteria ranged from 17% to 25% in the first 6 weeks, then decreased to 11% by 8-9 weeks of age and finally, to only 0.6% by 10-12 weeks of age. Notably, the lowest colic prevalence rate was found for Danish infants (6%) and Japanese (2%) infants during the first 6 weeks. In contrast, the highest mean prevalence rate was found for the United Kingdom studies at 1-2 weeks of age (ranged from 17% to 47%). If colic is considered the extreme of a normal distribution of fuss/cry duration, then it is not surprising that fewer infants with colic were found in Denmark where the mean fuss/cry duration was lower than in other countries. However, if alternatively, colic is considered to be qualitatively different from normal fussing and crying
      • Barr R.G.
      • Paterson J.A.
      • MacMartin L.M.
      • Lehtonen L.
      • Young S.N.
      Prolonged and unsoothable crying bouts in infants with and without colic.
      then a similar prevalence should have been found across countries. Our findings are consistent with the first interpretation that colic reflects the extreme of normal fuss/cry distribution. Further, but less consistent, moderation of colic prevalence was found by feeding type. There was a weak trend for infants who were bottle or mixed-fed to have lower prevalence of colic at 5-6 weeks of age.
      There are strengths and limitations that require comment. The study only included those with diary measures: all but 3
      • Darlington A.S.E.
      • Wright C.M.
      The influence of temperament on weight gain in early infancy.
      • Bensel J.
      Was sagt mir mein Baby, wenn es schreit?.
      used 5-minute resolution, and most samples had 3 or more days of diaries. On the other hand, there were unequal numbers of studies from different countries. Although we identified empirical studies in Australia, Iran, and Korea, despite contacting the authors, the required distribution measures were not available. Thus, this is a review of studies in North America and parts of Europe with only 1 study from Japan. No studies from threshold or developing countries were available, but these would be needed to provide adequate feedback to parents on other continents. Feeding type information was also not available for some studies. We consider it unlikely that relevant studies with diary data were missed, but it cannot be excluded. Moreover, there might be a loss of studies in the title and abstract screening procedure, which was conducted by 1 author. Furthermore, multiple statistical comparisons were not Bonferroni adjusted and need to be interpreted cautiously. Finally, the lack of a significant peak at 5-6 weeks of age should be interpreted cautiously because our study might be underpowered to detect a small peak amounting to 15 minutes.
      There are several implications for research on colic and clinical practice. Firstly, colic is best defined as the extreme of the distribution of fuss/cry duration. Secondly, the cut-off points need to take into account the rapid developmental changes occurring in fuss/cry durations during the first 3 months. The modified Wessel criteria may have served researchers or clinicians well for more than sixty years but may be inaccurate when applied at any time across the first 3 months. As shown here, fuss/cry duration is highest in the first 6 weeks and reduces rapidly during the next 6 weeks. Thus cut-off points need to be determined for the first 6 weeks of age, at 8-9 weeks of age, and 10-12 weeks of age. Figure 4 provides a percentile chart for “average” and “excessive” fussing and crying on basis of this meta-analysis across countries, allowing clinicians an approximation of whether the infant is excessively fussing or crying according to age or within the normal range. This feedback to parents is a first step of education on fussing or crying and whether their infant's fuss/cry is within the normal range. Those above the 90th percentile may be identified as excessive criers or infants with colic. As the mean fuss/cry duration was found to vary between countries, future normative country specific studies may be required on representative samples. The rapid developmental change in fuss/cry duration has implications for treatment and interpretation of treatment studies. Colic is the extreme of normal fuss/cry behavior, self-limiting, and, thus, the vast majority will spontaneously remit.
      • Barr R.G.
      • Rivara F.P.
      • Barr M.
      • Cummings P.
      • Taylor J.
      • Lengua L.J.
      • et al.
      Effectiveness of educational materials designed to change knowledge and behaviors regarding crying and shaken-baby syndrome in mothers of newborns: a randomized, controlled trial.
      Adequate management of fussing and crying in the first 3 months rather than treatment may be required.
      • Wolke D.
      • Gray P.
      • Meyer R.
      Excessive infant crying: a controlled study of mothers helping mothers.
      However, if excessive fuss/cry persists beyond the first 3 months, there is increasing evidence that this may indicate regulatory problems with adverse consequences for future development and may require treatment.
      • Hemmi M.H.
      • Wolke D.
      • Schneider S.
      Associations between problems with crying, sleeping and/or feeding in infancy and long-term behavioural outcomes in childhood: a meta-analysis.
      Figure 4
      Figure 4Percentile chart of above average fuss/cry at the ages 1-2, 3-4, 5-6, 8-9, and 10-12 weeks in infants.
      We would like to thank Marissa Alvarez, PhD, for her contributions to the study.

      Appendix

      Figure 1
      Figure 1Search strategy for the systematic review.
      Figure 3
      Figure 3Random effect meta-analysis comparing crying amounts across countries at 1-2 weeks of age, 3-4 weeks of age, 5-6 weeks of age, 8-9 weeks of age, and 10-12 weeks of age. A, Random effect meta-analysis comparing crying amounts across countries at 1-2 weeks of age. B, Random effect meta-analysis comparing crying amounts across countries at 3-4 weeks of age. C, Random effect meta-analysis comparing crying amounts across countries at 5-6 weeks of age. D, Random effect meta-analysis comparing crying amounts across countries at 8-9 weeks of age. E, Random effect meta-analysis comparing crying amounts across countries at 10-12 weeks of age.
      Figure 3
      Figure 3Random effect meta-analysis comparing crying amounts across countries at 1-2 weeks of age, 3-4 weeks of age, 5-6 weeks of age, 8-9 weeks of age, and 10-12 weeks of age. A, Random effect meta-analysis comparing crying amounts across countries at 1-2 weeks of age. B, Random effect meta-analysis comparing crying amounts across countries at 3-4 weeks of age. C, Random effect meta-analysis comparing crying amounts across countries at 5-6 weeks of age. D, Random effect meta-analysis comparing crying amounts across countries at 8-9 weeks of age. E, Random effect meta-analysis comparing crying amounts across countries at 10-12 weeks of age.
      Table ISummary table of all samples included in the meta-analysis with quality ratings
      Sample codesstudyWkSample sizeMean (SD) of cry/fuss duration in minRecruitment rateParticipation rate at each ageCharacteristic of sampleSubject selection (whole vs defined population)Feeding typeDiary durationResolution time for the diary (5 vs 15 min)Modified- Wessel definitionQuality rating scores
      AuthorsYear
      1UK1
      Excluded from the colic prevalence analysis.
      Darlington and Wright
      • Darlington A.S.E.
      • Wright C.M.
      The influence of temperament on weight gain in early infancy.
      2006824105(47.7)Not reported20%YesWholeBreastfed2 d15 minNo3
      2UK2
      Excluded from the colic prevalence analysis.
      Darlington and Wright
      • Darlington A.S.E.
      • Wright C.M.
      The influence of temperament on weight gain in early infancy.
      200685158(45.8)Not reported42%YesWholeBottlefed2 d15 minNo3
      3UK3St. James-Roberts and Plewis
      • St. James-Roberts I.
      • Plewis I.
      Individual differences, daily fluctuations, and developmental changes in amounts of infant waking, fussing, crying, feeding, and sleeping.
      19962

      6

      12
      128

      94

      69
      133(77)

      128(70)

      97(44)
      74%64%

      47%

      35%
      NoWholeNot reported3 d5 minNo4

      3

      3
      4UK4St. James-Roberts et al
      • St. James-Roberts I.
      • Sleep J.
      • Morris S.
      • Owen C.
      • Gillham P.
      Use of a behavioural programme in the first 3 months to prevent infant crying and sleeping problems.
      20011

      3

      6

      12
      191

      181

      173

      152
      107(77)

      122(72)

      102(66)

      60(42)
      35%94%

      89%

      85%

      75%
      YesWholeMixed3 d5 minNo5

      6

      6

      6
      5UK5St. James-Roberts et al
      • St. James-Roberts I.
      • Alvarez M.
      • Csipke E.
      • Abramsky T.
      • Goodwin J.
      • Sorgenfrei E.
      Infant crying and sleeping in London, Copenhagen and when parents adopt a “proximal” form of care.
      20061

      5
      111

      81
      120(63)

      126(58)
      81%64%

      47%
      YesWholeBreastfed4 d5 minYes8

      7
      6UK6St. James-Roberts and Menon-Johansson
      • St. James-Roberts I.
      • Menon-Johansson P.
      Predicting infant crying from fetal movement data: an exploratory study.
      19991

      6

      12
      14

      20

      20
      170(133.9)

      129(65.1)

      82(45.4)
      Not reported56%

      80%

      80%
      NoWholeNot reported3 d5 minNo2

      3

      3
      7UK7Lucas and St. James-Roberts
      • Lucas A.
      • St. James-Roberts I.
      Crying, fussing, and colic behaviour in breast- and bottle-fed infants.
      19982

      6
      43

      36
      128(79)

      149(66)
      Not reported96%

      80%
      YesWholeBreastfed3 d5 minYes5

      5
      8UK8Lucas and St. James-Roberts
      • Lucas A.
      • St. James-Roberts I.
      Crying, fussing, and colic behaviour in breast- and bottle-fed infants.
      19982

      6
      49

      41
      144(98)

      110(51)
      Not reported94%

      79%
      YesWholeBottlefed3 d5 minYes5

      5
      9UK9St. James-Roberts et al
      • St. James-Roberts I.
      • Goodwin J.
      • Peter B.
      • Adams D.
      • Hunt S.
      Individual differences in responsivity to a neurobehavioural examination predict crying patterns of 1-week-old infants at home.
      2003193126.8(75.3)Not reported68%YesSelectedMixed3 dNot reportedYes4
      10UK10St. James-Roberts and Peachey
      • St James-Roberts I.
      • Peachey E.
      Distinguishing infant prolonged crying from sleep-waking problems.
      20115-6

      12
      352

      316
      104.7(63.2)

      63(42.1)
      Not reportedNot reportedYesWholeMixed3 d5 minNo3
      11Canada1Barr et al
      • Barr R.G.
      • Kramer M.S.
      • Boisjoly C.
      • McVey-White L.
      • Pless I.B.
      Parental diary of infant cry and fuss behaviour.
      1988610125(48.1)Not reportedNot reportedYesDefinedMixed7 d5 minNo4
      12Canada2Barr et al
      • Barr R.G.
      • Kramer M.S.
      • Pless I.B.
      • Boisjoly C.
      • Leduc D.
      Feeding and temperament as determinants of early infant crying/fussing behavior.
      1989628393(61.1)84%69%NoWholeBreastfed8 d5 minNo6
      13Canada3Barr et al
      • Barr R.G.
      • Kramer M.S.
      • Pless I.B.
      • Boisjoly C.
      • Leduc D.
      Feeding and temperament as determinants of early infant crying/fussing behavior.
      198969188.7(65.7)84%22%NoWholeBottlefed8 d5 minNo5
      14Canada4Kramer et al
      • Kramer M.S.
      • Barr R.G.
      • Dagenais S.
      • Yang H.
      • Jones P.
      • Ciofani L.
      • et al.
      Pacifier use, early weaning, and cry/fuss behavior: a randomized control trial.
      20014

      6

      9
      183

      156

      148
      149.8(73.5)

      131.6(72.5)

      107.6(64.6)
      Not reported71%

      61%

      57%
      YesDefinedBreastfed3 d5 minNo3

      3

      3
      15Canada5Miller et al
      • Miller A.R.
      • Barr R.G.
      • Eaton W.O.
      Crying and motor behavior of six-week-old infants and postpartum maternal mood.
      1993588136.8(66)Not reported78%NoDefinedBreastfed7 d5 minYes6
      16Canada 6Fujiwara et al
      • Fujiwara T.
      • Barr R.G.
      • Brant R.
      • Barr M.
      Infant distress at five weeks of age and caregiver frustration.
      201151065163.4(75)78.6%58.3%YesWholeNot reported4 d5 minNo6
      17USA1Blum et al
      • Blum N.J.
      • Taubman B.
      • Tretina L.
      • Heyward R.Y.
      Maternal ratings of infant intensity and distractibility: relationship with crying duration in the second month of life.
      20025

      6

      8
      60

      59

      58
      140.9(75.1)

      127.1(69.9)

      97.9(46.9)
      Not reported53%

      52%

      51%
      YesDefinedNot reported4 d5 minNo3

      3

      3
      18USA2Stifter and Spinrad
      • Stifter C.A.
      • Spinrad T.L.
      The effect of excessive crying on the development of emotion regulation.
      20026116116.2(58.2)Not reported74%YesWholeNot reported4 d5 minNo6
      19USA3Stifter et al
      • Stifter C.A.
      • Bono M.
      • Spinrad T.
      Parent characteristics and conceptualizations associated with the emergence of infant colic.
      20036128120.6(64.1)Not reported89%YesWholeNot reported4 d5 minYes7
      20USA4Fujiwara et al
      • Fujiwara T.
      • Barr R.G.
      • Brant R.
      • Barr M.
      Infant distress at five weeks of age and caregiver frustration.
      201151857152(71.8)54.2%68.4%YesWholeNot reported4 d5 minNo6
      21USA5McRury and Zolotor
      • McRury J.M.
      • Zolotor A.J.
      A randomized, controlled trial of a behavioral intervention to reduce crying among infants.
      20104

      6

      8

      12
      16

      16

      17

      14
      126(72)

      114(66)

      90(72)

      72(48)
      1408 fliers distributed, 51 responses to fliers69%YesWholeNot reported3 d5 minNo2
      22Italy1Bonichini et al
      • Bonichini S.
      • Axia G.
      • St James-Roberts I.
      • DeCian S.
      Infant crying and maternal holding in the first 2 months of age: An Italian diary study.
      20082

      5

      8
      70

      70

      70
      147.6(90.2)

      150.6(100.1)

      118.5(78.5)
      Not reported77%

      77%

      77%
      YesWholeNot reported3 d5 minYes5

      5

      5
      23Italy2
      Cross-sectional study. Please note that the following samples were reported in the same study:(1) UK1 and UK2;(2) UK5 and Denmark1;(3) UK7 and UK8;(4) Canada2 and Canada3; and(5) Canada6 and USA4.
      Mazzotti et al
      • Mazzotti S.
      • Bonichini S.
      • Axia G.
      Patterns of infant cry from 0 to 3 months in an Italian sample. [Italian].
      20032

      4

      6

      8

      10
      12

      12

      12

      12

      12
      106.8(46)

      145.4(77.1)

      119.9(53.9)

      105.7(88.8)

      86.7(34.5)
      Not reported79%No(2/4)WholeNot reported3 d5 minYes4
      24The Netherlands1de Weerth and Buitelaar
      • de Weerth C.
      • Buitelaar J.K.
      Childbirth complications affect young infants' behavior.
      20076103150.4(66.3)Not reported89%YesWholeMixed4 d5 minNo7
      25Germany1Keller et al
      • Keller H.
      • Lohaus A.
      • Volker S.
      • Cappenberg M.
      • Chasiotis A.
      Relationship between infant crying, birth complications, and maternal variables.
      1998126284.6(54)70%82%YesWholeNot reported3 d5 minNo5
      26Germany2Lohaus et al
      • Lohaus A.
      • Keller H.
      • Voelker S.
      Relationships between eye contact, maternal sensivity, and infant crying.
      2001122078.8(59.9)Not reported100%YesDefinedNot reported3 d5 minNo3
      27Germany3Bensel
      • Bensel J.
      Was sagt mir mein Baby, wenn es schreit?.
      20032

      3

      6

      9

      12
      96

      97

      99

      101

      91
      69(60)

      80.8(67.4)

      85(78)

      66.3(69)

      51(51)
      Not reported72%

      72%

      74%

      75%

      68%
      YesDefinedMixed2-3 times per wk15 minNo2

      2

      2

      2

      2
      28Germany4Wurmser et al
      • Wurmser H.
      • Rieger M.
      • Domogalla C.
      • Kahnt A.
      • Buchwald J.
      • Kowatsch M.
      • et al.
      Association between life stress during pregnancy and infant crying in the first six months postpartum: a prospective longitudinal study.
      20066

      12
      64

      63
      145.6(84.4)

      107.9(58.2)
      Not reported68

      67
      YesWholeNot reported5 d5 minNo4
      29Australia1
      Excluded from the colic prevalence analysis.
      Wake et al
      • Wake M.
      • Morton-Allen E.
      • Poulakis Z.
      • Hiscock H.
      • Gallagher S.
      • Oberklaid F.
      Prevalence, stability, and outcomes of cry-fuss and sleep problems in the first 2 years of life: prospective community-based study.
      20068446113.5(64.1)Not reported92%YesWholeMixed1 d5 minNo6
      30Denmark1St. James-Roberts et al
      • St. James-Roberts I.
      • Alvarez M.
      • Csipke E.
      • Abramsky T.
      • Goodwin J.
      • Sorgenfrei E.
      Infant crying and sleeping in London, Copenhagen and when parents adopt a “proximal” form of care.
      20061

      5
      70

      64
      80(44)

      81(60)
      88%80%

      79%
      YesWholeBreastfed4 d5 minYes8

      8
      31Denmark2Sondergaard
      • Sondergaard C.
      Infant crying and fussing pattern in a follow-up study of 432 infants.
      2000643288(67)Not reportedNot reportedYesDefinedMixed4 d5 minYes6
      32Denmark3Alvarez
      • Alvarez M.
      Caregiving and early infant crying in a Danish community.
      20043

      6

      12
      118

      111

      110
      90(58)

      79(67)

      48(44)
      55%79%

      74%

      73%
      YesDefinedMixed3 d5 minYes7

      6

      6
      33Japan1Shinohara and Kodama
      • Shinohara H.
      • Kodama H.
      Relationship between duration of crying/fussy behavior and actigraphic sleep measures in early infancy.
      20124-6

      8-10
      31107(36)

      80(36)
      50%Not reportedYesWholeMixed3 d5 minNo4
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      • St. James-Roberts I.
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      Predicting infant crying from fetal movement data: an exploratory study.
      ,
      • St. James-Roberts I.
      • Goodwin J.
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      Individual differences in responsivity to a neurobehavioural examination predict crying patterns of 1-week-old infants at home.
      ,
      • St James-Roberts I.
      • Peachey E.
      Distinguishing infant prolonged crying from sleep-waking problems.
      ,
      • Blum N.J.
      • Taubman B.
      • Tretina L.
      • Heyward R.Y.
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      ,
      • Stifter C.A.
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      ,
      • Stifter C.A.
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      ,
      • McRury J.M.
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      A randomized, controlled trial of a behavioral intervention to reduce crying among infants.
      ,
      • Bonichini S.
      • Axia G.
      • St James-Roberts I.
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      Infant crying and maternal holding in the first 2 months of age: An Italian diary study.
      ,
      • Mazzotti S.
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      Patterns of infant cry from 0 to 3 months in an Italian sample. [Italian].
      ,
      • Keller H.
      • Lohaus A.
      • Volker S.
      • Cappenberg M.
      • Chasiotis A.
      Relationship between infant crying, birth complications, and maternal variables.
      ,
      • Lohaus A.
      • Keller H.
      • Voelker S.
      Relationships between eye contact, maternal sensivity, and infant crying.
      ,
      • Wurmser H.
      • Rieger M.
      • Domogalla C.
      • Kahnt A.
      • Buchwald J.
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      • et al.
      Association between life stress during pregnancy and infant crying in the first six months postpartum: a prospective longitudinal study.
      ,
      • Sondergaard C.
      Infant crying and fussing pattern in a follow-up study of 432 infants.
      ,
      • Shinohara H.
      • Kodama H.
      Relationship between duration of crying/fussy behavior and actigraphic sleep measures in early infancy.
      available as Appendix(available at www.jpeds.com).
      * Excluded from the colic prevalence analysis.
      Cross-sectional study. Please note that the following samples were reported in the same study:(1) UK1 and UK2;(2) UK5 and Denmark1;(3) UK7 and UK8;(4) Canada2 and Canada3; and(5) Canada6 and USA4.

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