Burmese Community's Beliefs on Inconsolable Crying.

Dear Editor, Inconsolable crying or infantile colic is defined by the “rule of three”: crying for more than 3 hour per day, for more than 3 days per week, occurring later in the day (after 3 PM), and for longer than 3 weeks by a child who is well-fed and otherwise healthy.[1] Prolonged inconsolable crying bouts commonly occur in the first 3 months of life but can last up to 1 year or more.[2] Crying is unrelated to environmental events and the child cannot be soothed even by feeding. In addition to excessive crying, symptoms and descriptors of infantile colic include piercing and high-pitched screaming, flushed face, clenched fists, legs drawn up against the abdomen, furrowing of eyebrows, distended abdomen, arched back, passing of gas, postfeeding crying, and difficulty in defecating.[3] It has been considered to be a pain syndrome. Colic has no association with any particular racial, ethnic, or socioeconomic group, or gender.[4] The prevalence is seen in over 30% of infants throughout the world and the incidence is estimated to be 1.5-43% of the infant population.[5,6] The exact cause of colic can vary and sometimes the cause is unknown. Organic causes account for less than 5% of infants presenting with excessive crying.[1] Gastrointestinal, psychosocial, and neurodevelopmental disorders have been suggested as the cause of colic.[1] Inconsolable crying can also be a result of child abuse.[7] Colic is a diagnosis of exclusion that is made after performing a careful history and a physical examination to rule out the less common organic causes. Most of the time, the physical exam is normal in inconsolable crying. The physician's role is to ensure that there is no organic cause for the crying and to provide support to the family. Till date, there is no consensus concerning the management and treatment of colic in the Western medical community. Feeding changes are usually not advised. Medications available in the United States have not proved effective in the treatment of colic, and most behavior interventions have not been proved to be more effective than placebo.[1] Excessive crying can result in escalating parental stress and anxiety levels. As part of the treatment, the physician must acknowledge the difficulties the parents are facing and also ask about the well-being of the parents. Burmese (Myanmar) society is very traditional and superstitious. It has long been thought that spirits (nats) and witches can bring about disease in people. When a baby cries inconsolably, Burmese parents think that the spirits are dissatisfied with them because of something that they did or that the spirits are hungry and want the parents to offer them food. This belief is reinforced by the fact that inconsolable crying usually occurs suddenly at night. Parents may consult the local mediums (nat kadaws) to find out on how to please the spirits so that they would leave the baby alone. The traditional practice is that the parents leave food under a tree at the back of the house, which is done at night. In America, the Burmese immigrant community has carried over the traditions and practices from its native country. When an immigrant child exhibits colic, parents leave food at the back door of the house if there are no trees in the backyard. The Burmese community in America comprises refugees and asylees from the Thailand-Burma border, most of whom have low levels of education. Many still adhere to traditional medicine and forms of healing. Parents in Myanmar and immigrant parents in America claim that the practice of leaving food at night is an effective remedy for inconsolable crying. This may be a coincidence because the condition is self-limited and resolves as the infant grows older. This practice causes no harm to the child. Inconsolable crying may overlap with night terrors. Burmese parents think that crying spontaneously at night is a bad omen. They believe that their child might be possessed by a witch or an evil spirit. Night terrors are rarer than inconsolable crying and they can occur at almost any age. This condition is also very scary and distressing to the parents. Night terrors are recurrent episodes that can last up to 30 minutes and the children may experience intense crying, fear, and confusion. The child sits up in bed and screams, sweats and breathes very fast, thrashes around, and appears awake with dilated pupils but is unresponsive to stimuli. The child returns to regular sleep after the episodes. The child has no memory of the event when he/she wakes up the next day. Night terrors are often paired with sleepwalking. Usually, no treatment is necessary for routine night terrors. Similar to infantile colic, children outgrow night terrors. Burmese parents deal with night terrors in the same way as they do with colic, by making food offerings at night. Food offerings are made only one time or they may be made on consecutive nights until the mediums (nat kadaws) inform the parents that the spirits are appeased or satisfied. The majority of Burmese are Theravada Buddhists but animistic beliefs still endure to this day. With regard to inconsolable crying, families may turn to untested resources for help and the physician must make sure that these treatments do not cause harm to the child. Above all, parents need reassurance that their baby is healthy and that colic is self-limited with no long-term adverse effects. Finally, the physician must educate the families on infantile colic.