Background
Unsettled behaviours among infants (babies aged 0–12 months) are defined as behaviours that include excessive crying episodes, being inconsolable and unreceptive to soothing, difficulties falling asleep, brief durations of sleep, and frequent waking periods during the night [
1]. Amongst afebrile infants, a physical cause for unsettled behaviours (e.g. hunger, gastrointestinal reflux or allergies) can only be found in around 5 % of cases [
1‐
3]. Among infants who are otherwise well, unsettled behaviours remain difficult to explain, but are thought to be multifactorially determined. Factors such as infant temperament, and parents’ caregiving practices and sleeping arrangements have each been associated with infant sleep problems and total daily duration of crying [
1,
4].
Multiple terms have been used to describe unsettled infant behaviour including colic, excessive crying, fussing and infant irritability [
1,
5]. In the 1950’s, Wessel and colleagues introduced the “rule of three” to define colic as occurring among infants who cried for at least three hours per day on at least three days of at least three consecutive weeks [
6]. Whilst different definitions exist, and the term is understood differently by lay people and professionals, colic is generally used to describe healthy infants who inexplicably and inconsolably cry for prolonged periods [
7]. As there are variations in the use of the term ‘colic’, identifying and defining specific infant behaviours that parents seek help for may be more useful than such generalised terms. More recently, in the United State and Canada, the “period of PURPLE crying” concept has been used to describe the period between 2 week and 3–5 months of age where an infant may inconsolably cry for increasing periods each day, reaching a peak at around the second month of age [
8]. This concept has been used to educate parents about understanding and responding to infant crying and to raise awareness of the risks posed by prolonged crying for maltreatment of infants including shaken baby syndrome [
9].
Evidence from high-income countries indicates that unsettled infant behaviours are one of the most common reasons that parents seek assistance from health professionals [
10,
11]. Despite problem being common, the way in which unsettled infant behaviours are understood, investigated and managed by health professionals is inconsistent. Conflicting or inconsistent advice from health professionals about the causes, and effective responses to unsettled infant behaviour is confusing for new parents, who may already be experiencing feelings of stress and under-confidence. Mothers with infants who cry excessively report significantly higher parenting stress and lower feelings of efficacy than the mothers of infants without excessive crying [
12]. In high-income countries, clinical depression rates are approximately twice as prevalent amongst mothers with unsettled infants [
13,
14]. Whilst most evidence of this association originates from cross-sectional studies, meaning the direction of the association cannot be determined, two longitudinal studies have demonstrated that excessive inconsolable infant crying preceded postnatal depressive symptoms [
15,
16]. There is also evidence that mothers’ perceptions of their ability to soothe their infant may be more relevant to postpartum depressive symptoms than crying duration alone [
16].
Perinatal common mental disorders (PCMDs) are predominantly socially determined and are often correlated with unsettled infant behaviour [
17,
18]. In LALMI settings, PCMDs have been associated with socio-economic disadvantage, experiences of intimate partner violence, low partner empathy or support, and insufficient emotional and practical support [
17]. Whilst there is evidence that unsettled infant behaviour is associated with PCMDs in high-income settings [
13‐
16], the prevalence of unsettled infant behaviour and sleep disturbance in low and lower-middle income (LALMI) countries is rarely reported. In a large cross-sectional study, Sadeh et al. [
19] identified a higher prevalence of parent reported sleep problems in “predominantly-Asian” countries (52%) compared to “predominantly-Caucasian” countries (26%), but did not analyse differences between LALMI and high and upper-middle income Asian countries.
Little is known about how health professionals in LALMI settings such as Vietnam conceptualise unsettled infant behaviour, and what professional advice and support they offer to the families of unsettled infants. This study aimed to explore how unsettled behaviour was understood, clinically investigated and responded to by Vietnamese health professionals, and to describe what health education on infant sleep and settling was available.
Discussion
This study is the first to explore how Vietnamese health professionals conceptualise and manage unsettled infant behaviour, and what health information on sleep and settling is available to Vietnamese parents. The findings revealed that unsettled infant behaviours are a serious, recognised and complex problem in Vietnam and potentially therefore in other LAMI countries. Health professionals in this study stated that infant settling advice was given by informal sources such monks at Buddhist pagodas. This was seen as a ‘last resort’ when other sources of advice such as family members and health professionals failed to meet the needs of parents with unsettled infants. It is known that the caregivers of unsettled infants in Vietnam consult sources such as family members, buddhist monks and other types of traditional healers before presenting at formal health services [
24]. In the absence of health professional training in infant sleep and settling, little effective, evidence-based advice was available for the parents of infants, leaving them to rely on informal approaches without a literature supporting their effectiveness. These findings are significant as there are known negative consequences for the caregivers of unsettled infants (such as decreased confidence and increased stress), as well as for the caregiver-infant relationship [
12,
13].
Strengths of this study included the use of qualitative methodology to elicit the perspectives of health professionals in light of their sociocultural and professional context. Participants were interviewed in their own language, which allowed them to express concepts and insights in a more comfortable way, resulting in a richer and more nuanced dataset. Participants from both urban and rural areas were included in order to provide a representative sample of health professionals who work with children throughout the province.
In terms of limitations, the inclusion of a broader range of health professionals, such as those working in different tertiary settings, might have resulted in a wider range of perspectives. Due to the Principal researcher not speaking Vietnamese, interpreters were required for most interviews, which can lead to errors of translation. Despite this, use of contemporaneous interpretation and independent verification of all interview transcripts ensured rigour of translation [
21]. The results of qualitative studies are not generalizable to other settings, where there may be differences in health service provision, health professional training, and the education provided to new parents. Therefore, the findings of our study are relevant only in the Vietnamese context.
No health professionals had received formal training on unsettled infant behaviour as part of their professional qualification, and hence based their advice to parents on personal experience. This finding is not unexpected as Mindell et al. [
25] found that internationally, content about sleep in paediatric residency programs is minimal, and in Vietnam, paediatric programs contain no information on normal sleep, psychology or behavioural insomnia in childhood. When conceptualising possible causes for physically unexplained unsettled infant behaviour, no Vietnamese health professionals used the concept of “colic” or the “period of PURPLE crying”. Rather, insufficient breast milk was perceived to cause excessive crying. This is consistent with published evidence that reports ‘hunger’ is the most commonly assumed reason for unsettled infant behaviour in both high-income and low-and-middle income settings [
26‐
28]. Participants also stated that they advised parents that crying in early infancy was ‘normal’ and would cease after three months and ten days. Interestingly, this advice does correspond with evidence that healthy infant crying reaches a peak at around two to three months of age and then declines, which is also taught as part of the period of “PURPLE” crying concept in the USA and Canada [
8,
29]. In this study, no participants referred to standardised advice for settling infants of different ages that was provided by health services.
The explanations for causes of unsettled infant behaviour that were given by health professionals were based around the mother not understanding and responding to infant cues. Responding sensitively to infant cues is internationally recognised as an important part of providing nurturing care for infants to promote optimal health outcomes [
1,
30]. Previous qualitative research has revealed that Vietnamese mothers and grandmothers received settling advice solely from other family members, and this advice focused on interpreting unsettled infant behaviour as “loneliness” or hunger [
28]. There is currently no published research regarding Vietnamese caregiver’s expectations of infant behaviour (e.g duration of crying) or sleep patterns at different ages, nor ethnographic research about how cultural practices such as postnatal confinement influence caregiver settling techniques. Such research is recommended as it would provide insight into what advice and interventions are likely to be effective and socially acceptable in this context.
In high-income countries such as Australia, advice regarding the causes and appropriate responses to unsettled infant behaviour appears to exist on a spectrum between two main positions: the “intuitive parent” position and the “infant behaviour management” position. The “intuitive parent” position is based on the premise that parents should follow their “intuition” about their babies’ needs as opposed to a strict set of guidelines about when to feed, settle or respond to a baby’s cry [
31,
32]. Advocates of this position suggest interpreting and responding to infant cries with active comforting techniques (such as rocking and walking) and frequent overnight waking, co-sleeping and feeding to sleep. Alternatively, the infant behaviour management position recognises that unsettled infant behaviour can cause significant problems for some families, and once organic illness is ruled out, a cause may not be identifiable [
1]. This position assumes that if parents are seeking help regarding unsettled infant behaviour, it is likely the baby is crying for longer and more intensely than the average baby, and that this is contributing to poor family functioning [
33]. Infant behaviour management approaches assert that parents can acquire knowledge and skills about their baby’s developmental capacities, which can be translated into settling strategies to assist their babies to self-soothe and return to sleep independently when they wake up [
1]. There is agreement on some aspects of unsettled infant behaviour between the two positions, including: trying to enhance pleasurable interactions between infants and parents; promoting sensitivity and responsiveness to infant cues; acknowledgement that healthy babies under six months will need their parents for feeding and help to settle during the night; that infant crying is care-eliciting behaviour, and that a baby should never be shaken [
1,
34,
35].
The advice health professionals in Vietnam gave regarding how to respond to unsettled behaviour tended to align more with the ‘intuitive parenting’ position. This included participants suggesting interventions with high levels of caregiver involvement such as constantly holding and patting babies and feeding them on demand. However, it should be noted that not all participants differentiated whether they gave advice according to the age of the infant. In the commune health centre context, infants are only routinely seen up to three months of age, although infants of any age can be brought in for consultations. None of the participants recommended advice on infant settling strategies linked to a scientific evidence base, or that referenced the infant behaviour management position or “sleep training” style programs or advice for older infants [
1]. It therefore appears that this approach was not familiar amongst Vietnamese health professionals.
Participants described how health education and primary health care programs for pregnant women and new parents were heavily focused on breastfeeding and did not include information on infant sleep and settling. There is a historical and political context as to why this is the case, as infant and child malnutrition was very common in Vietnam, especially during and immediately after the war from 1955 to 1975. However, over the last decade, rapid economic development, and public health programs to addressed micronutrient deficiencies have reduced malnutrition in the majority Kinh population [
36]. Despite a substantial decrease in malnutrition rates at a population level, many Vietnamese children under five years of age (particularly ethnic minorities and the socioeconomically disadvantaged) still experience malnutrition (40% underweight, 36% stunting and 10% wasting) [
36‐
38]. Vietnam also has low rates of exclusive breastfeeding (feeding only breast milk until six months of age) at around 20%, and Thu et al. [
39] suggest the benefits of exclusive breastfeeding are not well understood by Vietnamese women [
39,
40]. Therefore the health education provided by primary health professionals was generally focussed on infant and child nutrition. Whilst this focus is undoubtedly important, it has been noted that internationally, the provision of health education on infant sleep and settling has been given less priority in health education [
1].
Postnatal common mental disorders among women are prevalent in low and lower-middle income countries, and up to one-third of women in Vietnam experience a postnatal PCMD [
17,
41,
42]. One cross-sectional study identified an association between prolonged infant crying and higher Edinburgh Postnatal Depression Scores in Ho Chi Minh City [
41]. There is also a documented correlation between malnutrition amongst the children of mothers with PCMDs in Vietnam and other LALMI settings [
41‐
44]. Qualitative research reveals that the mothers of infants up to six months old in Vietnam experienced feelings of anxiety, helplessness, being overwhelmed, and a loss of control when their infant cried excessively [
24]. As PCMDs occur commonly in Vietnam, but are currently an under-recognised health concern, improving the understanding and management of infants with sleep issues and excessive crying could have positive impacts on PCMDs in Vietnam. Whilst there is general consensus that infants under six months of age will need assistance to settle and wake for feeds overnight, there is some evidence that programs that assist older infants to self-settle can decrease the frequency of night wakings, which may assist family functioning if caregivers are also getting more sleep. Therefore training health professionals to provide information on normal infant sleep patterns at different ages, and culturally appropriate settling strategies for infants over 6 months could be helpful additions to interventions aimed at assisting children to survive and thrive.
It is recommended that infant sleep and settling advice be included as part of multi-component interventions that encompass the child, primary caregivers and the relationship between caregivers and children. Such multi-component interventions align with the World Health Organisation “nurturing care” framework as part of the focus on early childhood development of the 2030 Sustainable Development Goals [
30]. As part of this framework, interventions that include support for caregivers to provide ‘nurturing care’ (a stable environment that includes protection from threats, opportunities for early learning and affectionate interactions and relationships) is required in addition to promoting optimal health and nutrition [
45]. In Vietnam, nurturing care education and interventions should consider the cultural context regarding current family sleeping arrangements, postnatal confinement practices, the inclusion of multi-generational caregivers, and caregiver expectations of “normal” infant behaviour and sleep patterns.