EDITORIAL

The fourth trimester

As it stands, motherhood is a sort of wilderness through which

each woman hacks her way, part martyr, part pioneer; a turn of

events from which some women derive feelings of heroism, while

others experience a sense of exile from the world they knew.

Rachel Cusk (born 1967), Canadian novelist

Recently, two advanced trainee paediatricians of my acquain-

tance have become first-time mothers in their early 30s and have

felt almost overwhelmed by having a demanding newborn baby.

These highly capable young women are used to nocturnal sleep

deprivation, although when you are on call you can look forward

to some rest when your shift ends. But they both described how

the lack of sleep drained them of energy and confidence. They

felt to blame for their baby’s crying, even though, at an intellec-

tual level they had read and were well aware that many babies

cry a lot during their first few weeks of life. They knew of the

fourth trimester, a term coined by US paediatrician Harvey Karp

referring to the 3 months that babies cry inconsolably every eve-

ning.1 The concept of the fourth trimester is that human babies

are born less mature than other animals and may need nurturing

as if they were in utero (Fig. 1). The mothers tried swaddling and

shushing to soothe their babies as suggested in the world accord-

ing to Karp. And still the babies cried, and the young mothers felt

to blame and struggled to cope.

Both young women had husbands who were sympathetic and

supportive but who had busy, demanding jobs with responsibili-

ties they could not shirk. One had a grandmother who was no

longer in paid employment and was willing and able to drop

everything and look after the baby during the day while the

baby’s mother caught up on much-needed sleep. The other’s par-

ents were overseas, so her feelings of helplessness and

hopelessness were compounded by her sense of isolation. Both

grandmothers reassured their daughters that they were not to

blame, but the mother who could catch up on sleep was better

able to accept the reassurance.

One mother took the intellectual response you might expect

from a highly educated woman and read everything she could

about crying babies. The result was that she discovered PURPLE

crying, which was new to me but apparently is the period when

a baby cries more than any other time.2 This is a colourful way of

formulating what the literature already describes, that babies cry

a lot in the first 9 weeks after birth; then for the vast majority,

the crying gradually settles.3 This can be reassuring to know, but

your baby is still crying. One mother said it helped when she

came to realise that the fourth trimester is a period of rapid

adjustment not only for the mother but also for the baby.

Another response is the medical one: if a baby cries, there

must be a medical explanation. This drives parents to seek medi-

cal help. Doctors never like to admit they do not have a quick

medical fix to a problem, and pharmaceutical companies are

always happy to provide the fix in the form of a marketable med-

ication, even if the evidence shows it is usually ineffective and

possibly harmful.4 So before long the persistently crying baby has

a diagnosis of infantile colic, soon followed by another diagnosis

of infantile reflux, and has been started on a proton-pump inhibi-

tor.4 Reflux is a genuine entity but is over-diagnosed and over-

treated.4

Paediatricians are of course keen to breastfeed and are easy

prey to advise about the importance of exclusive breastfeeding.

Many people will tell them that even a drop of cows milk for-

mula increases their infant’s risk of allergy. As a result, they do

not complement their infant’s breastfeeds with formula top-ups,

even when the infant is hungry and not putting on weight. There

is no evidence to support this strongly held belief that early expo-

sure to cows milk promotes allergy. A randomised controlled trial

comparing early introduction of allergenic foods at 3 months

with delayed introduction at 6 months found no difference for

cows milk, although the overall incidence of food allergy was

lower in the early introduction group.5 Furthermore, there is

strong evidence showing early introduction of peanuts reduces

the incidence of peanut allergy in children from atopic families,6

and similarly early egg introduction reduces the risk of egg

allergy.7 The result of the well-intentioned advice on breastfeed-

ing from experts is that anxious mothers do not top up their hun-

gry babies, and the result can be that the exhausted mother’s

milk supply is compromised, resulting in failure to thrive from

failure to feed.

Young first-time parents often think they will mould their

infant to be a wonderful moral human being who will reflect

their parents’ values. After a while, they come to the realisa-

tion that the infant is born with her or his own personality,

and it is the parents who are being moulded by this extraordi-

nary little human being. Each baby is born with his or her

Fig. 1 Two mothers with crying babies and one in a walking frame,comparing the human infant’s helplessness with the self-sufficiency ofnewborn animals. (Engraving by P. Galle, c1563.)

doi:10.1111/jpc.14257

1174 Journal of Paediatrics and Child Health 54 (2018) 1174–1175© 2018 Paediatrics and Child Health Division (The Royal Australasian College of Physicians)

own characteristics, which are apparent from the moment of

birth. One is alert and inquisitive. That one will always be on

the qui vive, but sleep will be a problem for weeks, months or

years. One is calm and relaxed. Another just wants to feed all

the time and is always going to be needy but rewarding. And

so it goes. Influential British paediatrician Ronald Illingworth

published his book The Normal Child in 1953 and wrote a new

edition after the birth of each of his three children as his con-

cept of normality broadened. Berry Brazelton, who died at the

grand old age of 99, was a keen observer of newborn behav-

iour and, in his 1969 book Infants and Mothers, described three

different kinds of babies: quiet, active and middle of the road.8

Brazelton called these differences ‘constitutional’ and suggested

parents should learn to adjust to these differences. Brazelton

promoted the idea that newborn infant behaviour affects par-

enting and helped shatter the myth of the baby as a clean

slate.8

Parenthood is a privilege and can be as challenging and as

rewarding as anything we do in our lives. Surely, Charles

Dickens must have been remembering becoming a new parent

when he wrote: ‘It was the best of times, it was the worst of

times’.

Acknowledgements

Thank you to Carmel Isaacs, Ameneh Khatami and Catherine

White for helpful suggestions.

Professor David Isaacs,Editor-in-Chief

Children’s Hospital at WestmeadSydney, New South Wales

Australia

References

1 Karp H. The Fourth Trimester and Crying. c2004. Available from:https://www.drdefranca.com/the-fourth-trimester-and-colic.html[accessed 8 April 2018].

2 National Center on Shaken Baby Syndrome. The Period of PURPLE Crying.Farmington, UT: The Center; 2018. Available from: http://purplecrying.info/[accessed 8 April 2018].

3 Wolke D, Bilgin A, Samara M. Systematic review and meta-analysis:Fussing and crying durations and prevalence of colic in infants.J. Pediatr. 2017; 185: 55–61.

4 Isaacs D. Disease marketing. J. Paediatr. Child Health 2017; 53: 1141–2.5 Perkin MR, Logan K, Tseng A et al. Randomized trial of introduction of

allergenic foods in breast-fed infants. N. Engl. J. Med. 2016; 374:1733–43.

6 Du Toit G, Roberts G, Sayre PH et al. Randomised controlled trial ofpeanut consumption in infants at risk of peanut allergy. N. Engl.J. Med. 2015; 372: 803–13.

7 Natsume O, Kabashima S, Nakazato J et al. Two-step egg introductionfor prevention of egg allergy in high-risk infants with eczema (PETIT): Arandomised, double-blind, placebo-controlled trial. Lancet 2016; 389:276–86.

8 Oates K. “Always say something positive about the child” T. Berry Bra-zelton 1918–2018. J. Paediatr. Child Health 2018; 54: 828–9.

Journal of Paediatrics and Child Health 54 (2018) 1174–1175© 2018 Paediatrics and Child Health Division (The Royal Australasian College of Physicians)

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D Isaacs The fourth trimester