Child:

Original Article
care, health and development
doi:10.1111/j.1365-2214.2010.01201.x

Predictors of crying, feeding and sleeping problems:

a prospective study cch_1201 493..502

G. Schmid,* A. Schreier,† R. Meyer‡ and D. Wolke†

*Department of Psychosomatic Medicine and Psychotherapy, Klinikum rechts der Isar, Technische Universitaet, Muenchen, Germany
†Department of Psychology and Health Sciences Research Institute, University of Warwick, Coventry, UK, and
‡BQS – Institute for Quality and Patient Safety, Düsseldorf, Germany

Accepted for publication 11 November 2010

Keywords
crying, feeding and
sleeping problems,
infancy, predictors,
prenatal
Correspondence:
Gabriele Schmid,
Department of
Psychosomatic Medicine
and Psychotherapy,
Klinikum rechts der Isar,
Technische Universitaet
Muenchen, Langerstr. 3,
81675 Muenchen,
Germany
E-mail: g.schmid@
tum.de
Abstract
Background Infant regulatory problems, that is, excessive crying, feeding and/or sleeping
difficulties, are precursors of adverse development. However, the aetiology of regulatory problems is
still unclear. The aim of this study was to investigate pre-, peri- and post-natal neurophysiological
and psychosocial predictors of single and multiple regulatory problems at 5 months of age.
Methods This prospective longitudinal study included all children born at neonatal risk in a
geographically defined area in southern Germany. The data of n = 5093 singleton infants (83.6%)
were analysed using crude and multivariate logistic regression analyses. As outcome measures we
used single and multiple regulatory problems, that is, crying, feeding and/or sleeping difficulties at
5 months of age, which were assessed via a standardized interview with the parents by study
paediatricians as part of a neurodevelopmental examination.
Results In total, 30.7% of the sample suffered from single or multiple regulatory problems at 5
months. Breastfeeding increased the odds of single sleeping problems 5.12-fold, but decreased the
odds of single feeding problems [odds ratio (OR) 0.51; 95% confidence interval (CI) 0.35–0.74]. Very
preterm birth was predictive of single feeding (OR 1.79; 95% CI 1.25–2.55) and multiple regulatory
problems (OR 2.03; 95% CI 1.19–3.46), and foetal abnormalities increased the odds of single feeding
and multiple regulatory problems from 1.53- to 1.64-fold. Family adversity and psychosocial stress
factors were associated with single crying and multiple regulatory problems.
Conclusions Pre-, peri- and post-natal neurophysiological and psychosocial factors are predictive
of single and multiple regulatory problems. The results may be useful in terms of early recognition
of at risk groups for regulatory problems.

sleeping problems indicate shared difficulties of the infant to

Introduction
Approximately 25% of infants suffer from excessive or pro-
longed crying (>3 months of age), feeding and/or sleeping dif-
ficulties during the first years of life (Wolke et al. 1995; Wolke
2003; Rao et al. 2004; von Kries et al. 2006; Wake et al. 2006).
These problems are associated with high parental burden and
are a frequent reason for contact with health services (St James-
Roberts 2008). It has been suggested that crying, feeding and
regulate or inhibit ongoing behaviour, expressed in difficulties
to self-soothe, fall asleep unaided, or to overcome neophobia to
try new foods. They are thus sometimes referred to as regulatory
problems of infancy (Zero to Three 2005). When these prob-
lems co-occur, they have been labelled multiple regulatory
problems (Papousek et al. 2008). There is evidence that infant
regulatory problems are precursors of subsequent cognitive,
motor, behaviour and attention-hyperactivity problems (Wolke

© 2011 Blackwell Publishing Ltd 493

494 G. Schmid et al.
et al. 2002; Rao et al. 2004). We have found that feeding prob-
lems and multiple regulatory problems at 5 months of age had
a high stability until pre-school age. Additionally, regulatory
problems at 5 months were predictive of adverse social and
adaptive behaviour and of lower cognition at pre-school age
(Wolke et al. 2009; Schmid et al. 2010). However, the aetiology
of single and multiple regulatory problems is still unclear.
Pregnancy-related factors such as increased maternal stress,
anxiety or depression (Dahl et al. 1986; Papousek & von
Hofacker, 1998; Wurmser et al. 2006), pregnancy or neonatal
complications (Wurmser & Papousek 2008), maternal negative
experiences of delivery (Räihä et al. 2002), early neurodevelop-
mental problems (Wolke et al. 2009) and parenting (St James-
Roberts 1987; Papousek & von Hofacker 1995, 1998) have been
reported as precursors of these regulatory problems. Further-
more, multiple regulatory problems have been found to be asso-
ciated with the presence of a polymorphism of the dopamine
receptor gene (DRD4-7r), however, only in boys (Becker et al.
2007). There is some suggestion that infant sleeping problems
are more frequent in breastfeeding infants (Thunström 1999),
and a history of feeding problems in the father or mother
during their own infancy has been found to be related to infant
feeding problems in their offspring (Dahl et al. 1986).
However, many of the studies on precursors of regulatory
problems had some limitations such as small sample size,
referred samples or cross-sectional design. Thus, prospective
studies with large samples are needed. The aim of this study was
to investigate pre-, peri- and post-natal neurophysiological and
psychosocial predictors of single and multiple regulatory
problems at 5 months of age in a population-based sample of
children born at risk.
Methods
Study population
The sample consisted of all infants born at neonatal risk in a
geographically defined area in southern Bavaria (Germany)
during a 15-month period in 1985–1986 who were admitted to 1
of 16 children hospitals within 10 days after birth (n = 7505 out
of n = 70 600 life births, 10.6% of all life births). At that time all
newborns who were born preterm or experienced birth compli-
cations, caesarean section, poor Apgar scores (i.e. Apgar <9 at
1 min after birth and <10 at 5 min after birth) or neonatal
complications (e.g. neonatal jaundice) were admitted to a chil-
dren’s hospital neonatal unit. The treatments ranged from obser-
vation of the neonates to intensive neonatal care. Parents were
approached within 48 h of the infant’s hospital admission and
© 2011 Blackwell Publishing Ltd, Child: care, health and development, 37, 4, 493–502
asked to give written informed consent to participate. The
detailed study protocol of the Bavarian Longitudinal Study has
been reported elsewhere (Riegel et al. 1995). Ethical approval was
obtained from the University of Munich Children’s Hospital.
During their stay in hospital n = 305 infants died, and parents
of n = 6785 infants (94.2% of 7200 survivors) gave informed
consent. This report includes all children who participated at
the 5-month age corrected follow-up (n = 5756, 85.2% of 6757
eligible survivors who had given informed consent). For our
analyses, in addition, exclusion criteria were being younger than
4 months (corrected age) of age at the 5-month measurement
point (n = 37), and multiple births (n = 626) as the standardized
norms for infant’s weight, length and head circumference which
were used as predictors were for singletons (Voigt et al. 1996).
The final sample for analyses consisted of n = 5093 (83.6% of
6094) singleton infants with a mean age of 5.08 ⫾ 0.48 months.
Participating infants were more often born to parents of middle
or upper social class who were German and lived together com-
pared with dropouts. Additionally, participating infants had a
slightly shorter gestational age and were more often born very
preterm, and the mothers were older and primiparous com-
pared with dropouts (see Table 1).
Predictive measures
Both neurophysiological and psychosocial factors were consid-
ered as pre-, peri- and post-natal predictors of regulatory prob-
lems at 5 months (see Table 2). For infants not born at term the
5-month assessment date was corrected for prematurity.
Neurophysiological predictors
Prenatal data were obtained from the medical records in the
obstetric units, and peri- and post-natal data were collected via
standardized interviews with the mother/father and medical
examinations. Optimality scores similar to previously proposed
optimality scoring systems were constructed (see Table 2)
(Prechtl 1968; Riegel et al. 1995). Additionally, the following
information was assessed: gestational age (Dubowitz et al.
1970), mode of delivery, parity, infant’s body weight, length and
head circumference at birth (Voigt et al. 1996), foetal abnor-
malities and neonatal neurological problems (intensity of neo-
natal treatment index score) (Riegel et al. 1995) (Table 2).
Psychosocial predictors
Maternal age at birth (Sondergaard et al. 2003), socio-economic
status (SES), maternal smoking before and during pregnancy,
parent–infant relationship index, family adversity index,
 Crying, feeding and sleeping problems 495

Table 1. Sample description and comparison

Participants Dropouts
of participants and dropouts
% or % or
Characteristic n mean ⫾ SD n mean ⫾ SD OR (95% CI)*
Infant’s sex 5093 1001
Male 2779 54.6 540 53.9 1
Female 2314 45.4 461 46.1 0.98 (0.85–1.12)
Gestational age (weeks)† 5093 37.5 ⫾ 3.1 1001 37.8 ⫾ 2.8 0.97 (0.95–0.99)
Term 3407 66.9 717 71.6 1
Preterm 1404 27.6 253 25.3 1.17 (1.00–1.37)
Very preterm 282 5.5 31 3.1 1.91 (1.31–2.80)
Parity 5093 1001
Primiparous 2788 54.7 475 47.5 1
ⱖ1 previous births 2305 45.3 526 52.5 0.75 (0.65–0.86)
Mother’s age at birth (years) 5084 28.2 ⫾ 5.3 1000 27.7 ⫾ 5.5 1.02 (1.00–1.03)
Father’s age at birth (years) 4866 31.5 ⫾ 6.5 531 31.6 ⫾ 7.5 1.00 (0.99–1.01)
Socio-economic status 5047 658
Lower class 2218 43.9 348 52.9 1
Middle class 1879 37.2 191 29.0 1.54 (1.28–1.86)
Upper class 950 18.8 119 18.1 1.25 (1.00–1.56)
Family status: 4920 543
Living together 4664 94.8 482 88.8 1
Living apart 256 5.2 61 11.2 0.43 (0.32–0.58)
Place of residence: 5085 994
City 1516 29.8 324 32.6 1
Countryside 3569 70.2 670 67.4 1.14 (0.98–1.32)
Nationality 5073 990
German 4659 91.8 844 85.3 1
Non-German 414 8.2 146 14.7 0.51 (0.42–0.63)

*The ORs (95% CIs) in bold are significant at the P < 0.05 level.
†Term: ⱖ37 weeks of gestation; preterm: 32–36 weeks of gestation; very preterm: <32 weeks of gestation.
CIs, confidence intervals; ORs, odds ratios; SD, standard deviation.

psychosocial stress index (Riegel et al. 1995) and breastfeeding
were used as psychosocial predictors (Table 2).
Outcome measure: regulatory problems at 5 months
As part of a neurodevelopmental assessment, parents received a
standardized interview by study paediatricians to record crying,
feeding and sleeping problems at 5 months of age. The defini-
tions of crying, feeding and sleeping problems have been
derived from literature (Lindberg et al. 1991; St James-Roberts
& Halil 1991; Messer & Richards 1993) and are shown in
Table 3. The outcome variable ‘Regulatory problems at 5
months’ consisted of five mutually exclusive categories, namely
(i) no regulatory problems at 5 months; (ii) single crying; (iii)
single feeding; (iv) single sleeping; and (v) multiple regulatory
problems, that is, combined crying and feeding, crying and
sleeping, feeding and sleeping, or all three problems.
Statistical analyses
All analyses were conducted with spss (11.0). Binary logistic
regression analyses were conducted to assess differences
between participants and dropouts. Odds ratios (ORs) and
95% confidence intervals (CIs) are reported (see Table 1).
Binary logistic regression analyses were conducted to examine
the impact of pre-, peri- and post-natal predictors on regula-
tory problems at 5 months, that is, single crying, single
feeding, single sleeping or multiple regulatory problems; the
reference group was always ‘no regulatory problems at 5
months’. Firstly, the crude OR (95% CI) of each predictor vari-
able were evaluated concerning each outcome category of
regulatory problems at 5 months (see Appendix, Table A1). In
the crude analyses, the significance level was set P < 0.001
regarding the inflation of Type I error. If the optimality scores
were significant (P < 0.001) in the crude analyses, the single
items of the optimality scores were investigated in terms of
their predictive value concerning regulatory problems at 5
months. Second, for each outcome category of regulatory
problems at 5 months those variables that had been significant
(P < 0.001) in the crude analyses were considered in the mul-
tivariate logistic regression analyses (backward likelihood ratio
method). Table 4 shows the results of these subsequent mul-
tivariate analyses; significant (P < 0.05) ORs and 95% CIs are

© 2011 Blackwell Publishing Ltd, Child: care, health and development, 37, 4, 493–502
496 G. Schmid et al.

Table 2. Overview of predictors, their descriptions, frequencies or means ⫾ SDs in the study population, their assessment points and mode
of predictor
Assessment Mode of
point Predictor and description (frequencies or means ⫾ SDs) predictor
Prepregnancy Optimality:* sum score, ranging from 0 (best state) to 8 (worst state); (1.10 ⫾ 0.79) NP
Prenatal Optimality:† sum score, ranging from 0 (best state) to 14 (worst state); (1.28 ⫾ 1.17) NP
Parity: primiparous (54.7%) versus ⱖ1 prior births (45.3%) NP
Foetal abnormality: evaluated in a physical examination including level of impairment and severity (according to ICD-9), NP
ranging from minor congenital malformations/abnormalities without dysmorphias and minor dysmorphic signs (e.g.
pigmented mole, atrial/ventricular septum defect, skew foot), to chromosomal abnormalities (e.g. trisomy); recoded into
0 (no foetal abnormality; 71.6%) versus 1 (foetal abnormality; 28.4%)
Infant’s sex: female (45.4%) versus male (54.6%) NP
Maternal smoking status: cigarettes per day before and during pregnancy; recoded into three categories: (1) never PS
smoked (67.4%); (2) stopped smoking before pregnancy (14.2%); and (3) persistent smoking (18.4%)
Socio-economic status: obtained via a standardized interview; three categories: (1) lower (43.9%); (2) middle (37.2%); and PS
(3) upper class (18.8%)
Perinatal Gestational age: determined from maternal dates of the last menstrual period and serial ultrasounds during pregnancy; if NP
these two methods differed by more than 2 weeks, Dubowitz examination result was used. The gestational age was
divided into three categories: term ⱖ37 weeks of gestation (66.9%); preterm 32–36 weeks of gestation (27.6%); very
preterm <32 weeks of gestation (5.5%)
Optimality:‡ sum score, ranging from 0 (best state) to 15 (worst state); (3.05 ⫾ 1.69) NP
Mode of delivery: vaginal birth (70.2%) versus caesarean section (29.8%) NP
Body weight, length and head circumference (HC): measured in grams and centimetres, respectively; dichotomized NP
according to sex and gestational age into ⱖ10th percentile (weight 71.4%, length 80.6% and HC 79.0%) versus <10th
percentile (28.6%, 19.4% and 21.0%)
Maternal age: in years, recoded into three categories: (1) ⱕ24 years (25.7%); (2) 25–34 years (13.0%); and (3) ⱖ35 years PS
(61.3%)
Post-natal Optimality:§ sum score, ranging from 0 (best state) to 21 (worst state); (4.48 ⫾ 2.86) NP
Neonatal neurological problems (intensity of neonatal treatment index score): daily assessments of (1) care level; (2) NP
respiratory support; (3) feeding dependency; (4) mobility; (5) muscle tone; and (6) neurological excitability; mean score
of daily ratings during the first 10 days of life or until a stable clinical state was reached sooner, ranging from 0 (best
state) to 18 (worst state); (5.48 ⫾ 3.89)
Parent–infant relationship index: obtained by a standardized interview with the parents and by study nurses’ PS
observations; eight items covering attachment-related parental concerns and feelings, and current or anticipated
relationship problems (e.g. mother shows little pleasure when interacting with the child); sum score ranging from 0
(no parent–infant relationship problems) to 8 (severe parent–infant relationship problems); (0.67 ⫾ 1.07)
Family adversity index: obtained via a standardized interview with the parents; eight items covering adverse PS
characteristics of the parents and the environment (e.g. parental psychopathology); sum score ranging from 0 (no
adverse factors) to 8 (high family adversity); (1.26 ⫾ 1.13)
Psychosocial stress index: obtained via a standardized interview with the most important attachment person of the infant PS
(mostly mother); 14 items concerning family-related problems and trouble (e.g. recent death of a family member,
partnership problems); sum score ranging from 0 (no psychosocial stress) to 14 (extreme psychosocial stress); (0.48 ⫾
1.00)
Breastfeeding: obtained via an interview with the mother at 5 months; three categories: 0 = has never breastfed (52.3%); PS
1 = has already stopped (33.7%); 2 = still partly or fully breastfeeding (13.9%)

*(1) Maternal age < 20 or >30 years; (2) condition after infertility; (3) condition after ⱖ two abortions; (4) prior preterm birth; (5) prior dead/disabled infant; (6)
prior difficult labour; (7) severe illness (kidney disease, diabetes, other illness); and (8) no or > two prior labours.
†(1) Eph gestosis; (2) anaemia (according to ICD-9); (3) urinary tract infection; (4) bleeding; (5) foetal retardation and/or pathologic CTG; (6) preterm labour; (7)
multiples; (8) nicotine addiction; (9) alcohol and/or drug addiction; (10) check-up started after week 12; (11) no regular check-up; (12) infectious disease; (13)
severe illness, hyperaemesis and/or accident; and (14) (oligo-)hydramnion.
‡(1) Amnion infectious syndrome; (2) over term; (3) pathologic CTG; (4) acidosis; (5) green amniotic fluid; (6) cord prolapse or other cord complication; (7)
transverse lie; (8) breech presentation; (9) prolonged labour; (10) adjustment anomaly; (11) dilation in early labour <3 or >12 h; (12) bearing-down pains <10 or
>60 min; (13) anaesthesia; (14) no spontaneous labour; and (15) placenta praevia.
§(1) Ventilation or intubation; (2) Apgar at 1 min after birth <9 and at 5 min after birth <10; (3) buffering and/or volume substitution; (4) cord artery pH ⱖ 7.3;
(5) outborn (i.e. infants were transported after birth from outside obstetric units for neonatal care); (6) body temperature ⱕ36°C; (7) artificial aspiration; (8)
apnoea/bradycardia; (9) ventilation disorder; (10) hypoglycaemia; (11) heart failure; (12) hyperbilirubinaemia; (13) other metabolic diseases; (14) severe anaemia
(according to ICD-9); (15) sepsis; (16) operation; (17) deficits in development (i.e. neurodevelopmental problems); (18) medication > one time/day; (19)
nasogastric feeding; (20) neonatal seizures; and (21) cerebral haemorrhage (on ultrasound examination neonatally).
CTG, cardiotocography; ICD-9, International Classification of Diseases, Version 9; NP, neurophysiological; PS, psychosocial; SDs, standard deviations.

© 2011 Blackwell Publishing Ltd, Child: care, health and development, 37, 4, 493–502
 Crying, feeding and sleeping problems 497

reported (the full results are available on request from the first
Results
author). The fit of the final models was evaluated using the
Omnibus test of coefficients [c2, degrees of freedom (d.f.) and
Prevalence of regulatory problems at 5 months of age
significance level P < 0.05] and the Hosmer–Lemeshow statis-
tic (c2, d.f., good fit if P > 0.05) (Table 4) (Tabachnik & Fidell One-fourth of the sample suffered from single regulatory
2007). problems at 5 months of age, namely 4.7% of single crying
problems, 10.9% of single feeding problems and 9.7% of
single sleeping problems. Multiple regulatory problems were
Table 3. Definition of regulatory problems at 5 months of age found in 5.4%, namely 1.2% had combined crying and feeding
Regulatory problems, 1.5% crying and sleeping problems, 1.9% feeding
problems Definition and sleeping problems and finally, 0.8% had all three problems
Crying 1. Cry duration: ⱖ2 h per day. AND/OR at 5 months of age.
problems: 2. Cry amount: above average. AND/OR
3. Infant is usually difficult to soothe. AND/OR
4. Infant is constantly irritable. Associations between predictors and regulatory problems
Feeding 1. Infant does not eat and drink well. AND/OR
problems: 2. Formerly and currently problems with vomiting. AND/OR at 5 months
3. Disordered oral-motor functioning, that is, problems with
sucking / swallowing, disordered mouth/tongue
The results of the crude analyses are shown in the Appendix
movement. (Table A1). For each outcome category, that is, single crying,
Sleeping 1. Infant wakes up ⱖ two times per night. AND/OR single feeding, single sleeping and multiple regulatory problems
problems: 2. Infant wakes up for ⱖ15 min at night.
at 5 months, only those variables that had been significant in the

Table 4. Pre-, peri- and post-natal neurophysiological and psychosocial predictors of regulatory problems at 5 months – multivariate logistic regression
models – significant adjusted ORs and 95% CIs are reported
Multiple regulatory
Single crying Single feeding Single sleeping problems
(n = 239)* (n = 554)* (n = 494)* (n = 275)*

OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI)

Prenatal predictors:
Neurophysiological Foetal abnormality Foetal abnormality
1.53 (1.26–1.86) 1.64 (1.26–2.14)
Perinatal predictors:
Neurophysiological Very preterm† Very preterm†
1.79 (1.25–2.55) 2.03 (1.19–3.46)
Post-natal predictors:
Neurophysiological Deficits in development‡
1.29 (1.05–1.58)
Neonatal seizures
1.63 (1.13–2.35)
Psychosocial FAI (0–8)§ Still breastfeeding¶ Still breastfeeding¶ FAI (0–8)§
1.25 (1.11–1.40) 0.51 (0.35–0.74) 5.12 (4.05–6.49) 1.13 (1.01–1.26)
PSI (0–14)§ PSI (0–14)§
1.23 (1.10–1.38) 1.30 (1.17–1.44)
Model fit**
(1) 37.5, 2 (<0.001) 70.2, 6 (<0.001) 199.5, 2 (<0.001) 68.5, 6 (<0.001)
(2) 1.4, 5 (0.93) 1.6, 6 (0.95) 0.0, 1 (1.00) 15.7, 8 (0.05)

The ORs (95% CIs) in bold are significant at the P < 0.05 level.
*Compared with all infants without regulatory problems at 5 months (n = 3474).
†Very preterm <32 weeks of gestation; reference category = born at term (ⱖ37 weeks of gestation).
‡Deficits in development, that is, neurodevelopmental problems.
§In continuous predictors: the range is reported.
¶Still partly or fully breastfeeding; reference category = has never breastfed.
**Model fit: (1) Omnibus test of model coefficients (good fit if P < 0.05), and (2) Hosmer–Lemeshow test (good fit if P > 0.05).
CIs, confidence intervals; FAI, family adversity index; ORs, odds ratios; PSI, psychosocial stress index.

© 2011 Blackwell Publishing Ltd, Child: care, health and development, 37, 4, 493–502
498 G. Schmid et al.
crude analyses were considered in the multivariate logistic
regression analyses (backward likelihood ratio method)
(Table 4).
Each increase in one family adversity or psychosocial stress
factor increased the odds of single crying problems 1.25- or
1.23-fold, respectively (Table 4).
Foetal abnormalities, very preterm birth and a poor post-
natal optimality score, namely deficits in development (i.e.
neurodevelopmental problems) or neonatal seizures, were
predictive of single feeding problems, whereas partly or fully
breastfeeding at 5 months decreased the odds of single feeding
problems (Table 4).
The only predictor of single sleeping problems was still partly
or fully breastfeeding at 5 months: Breastfed infants were 5.12-
fold more likely to wake up frequently at night than those who
had never been breastfed (Table 4).
Finally, multiple regulatory problems at 5 months were best
predicted by very preterm birth; in addition, foetal abnormali-
ties were predictive of multiple regulatory problems at 5
months. Furthermore, each increase in one family adversity or
psychosocial stress factor increased the odds of multiple regu-
latory problems 1.13- or 1.30-fold, respectively (Table 4).
Discussion
In this prospective study with infants born at risk pre-, peri- and
post-natal neurophysiological and psychosocial factors
increased the odds of single and multiple regulatory problems,
that is, excessive crying, feeding and/or sleeping difficulties at 5
months of age. The prevalence rates of single and multiple
regulatory problems were similar to those found in other
studies (e.g. Rao et al. 2004; von Kries et al. 2006).
In our study, breastfeeding at 5 months was a protective
factor in regards to single feeding problems. Breastfeeding is
most adapted for oral-motor abilities of the suckling and may
thus reduce feeding problems (Wolke et al. 2006). Further-
more, it has been reported that mothers who breastfeed
display greater sensitivity in dyadic interactions with their
infants at 3 months than those who are bottle-feeding (Britton
et al. 2006). This might enhance the development of infant’s
self-regulatory competencies (Papousek & von Hofacker
1995). In contrast, breastfeeding at 5 months predicted single
sleeping problems: infants who were still partly or fully breast-
fed were 5.12-fold more likely to suffer from single sleeping
problems at 5 months of age compared with infants who had
never been breastfed. This result is in line with previous
research (e.g. Thunström 1999). Breastfeeding infants wake
more frequently for feeds at night than bottle-feeding infants
© 2011 Blackwell Publishing Ltd, Child: care, health and development, 37, 4, 493–502
in the first 6 months of life but this has not been shown to
have any adverse effects on long-term sleeping during the pre-
school years (Wolke et al. 1998). Breastfeeding has a range of
associated positive effects on health (Owen et al. 2005; Bartick
& Reinhold 2010) and cognitive and behavioural development
(Golding et al. 1997; Anderson et al. 1999; Mortensen et al.
2002; Wolke et al. 2009). Furthermore, sleeping disorders
should not be diagnosed before 6 months of age (von
Hofacker et al. 2007), because during this period the infant’s
sleep is reorganized to a more mature pattern, and waking up
at night is also necessary to fulfil the infant’s need for frequent
nutrition, in particular, if breastfed (Thunström 1999). Fur-
thermore, sleeping problems are strongly related to parenting
practices (Thunström 1999) and are amenable to early inter-
vention and treatment (Ramchandani et al. 2000).
Family adversity, for example, severe partnership problems
or psychopathology in the family, and psychosocial stress
factors, such as financial problems or work overload, were pre-
cursors of single crying and multiple regulatory problems at 5
months of age. Women who experienced stress and emotional
problems during pregnancy have been found to be at risk of
having an excessively crying infant at 3 and 6 months of age
(Wurmser et al. 2006; van der Wal et al. 2007). Prenatal mater-
nal stress may have an impact on foetal brain development,
and thus, on infant self-regulation (Posner et al. 2007). In our
study, psychosocial stress and family adversity were assessed
neonatally and at 5 months of age. However, they are usually
already present during pregnancy (Heron et al. 2004; Evans
et al. 2005) and may have adversely influenced the foetal devel-
opment. Furthermore, postpartum maternal stress may com-
promise the parent–infant relationship, which is important for
the development of infant’s self-regulatory competencies
(Papousek & von Hofacker 1995).
Both single feeding and multiple regulatory problems at 5
months were predicted by foetal abnormalities ranging from
minor congenital malformations to chromosomal abnormali-
ties which have been associated with developmental, behav-
ioural and cognitive delays and deficits (Hauser-Cram et al.
1999; Field et al. 2003; Short et al. 2003). Thus, these may also
be related to neurological and early behavioural differences.
Alternatively, most infants had only minor abnormalities
(Riegel et al. 1995), and it might be possible that parental
reported regulatory problems of these infants might be influ-
enced by the perception of continued vulnerability (Perrin
et al. 1989).
Moreover, single feeding and multiple regulatory problems
were predicted by very preterm birth, which has been shown to
be associated with neurological and developmental disabilities
 Crying, feeding and sleeping problems 499

during infancy and childhood (Marlow et al. 2005; Limper-
opoulos et al. 2009), and, thus, compromise self-regulatory
abilities (Rao et al. 2004). Furthermore, a poor post-natal
optimality score, that is, deficits in development and neonatal
seizures, predicted single feeding problems. Deficits in develop-
ment, that is, neurological problems, are related to reduced
motor skills (Laucht et al. 1992) and may increase the odds of
feeding problems because feeding requires oral-motor abilities
(Papousek et al. 2008).
Overall, there are a number of strengths to this study. First,
the dropout rate was low: about 85% of the eligible survivors
participated at the 5-month assessment point. Nevertheless,
those of lower SES but who were less often born very preterm
were more likely to have dropped out. Second, this study
included both psychosocial and neurophysiological predictors,
which had been meticulously measured. However, all infants
were admitted to a children’s hospital after birth and were thus
at increased risk for potential developmental problems. The
results might not be generalizable to all infants requiring
normal post-natal care. Furthermore, regulatory problems were
mainly assessed by maternal responses to a structured interview.
The completion of structured diaries (Wolke et al. 1994) would
have been preferable but not realistic in a general population
because of the often observed high subject loss in diary studies
(St James-Roberts et al. 2001).
In conclusion, we have shown that pre-, peri- and post-natal
factors, both psychosocial and neurophysiological ones,
increase the odds of single and multiple regulatory problems
at 5 months of age. Additionally, single and multiple regula-
tory problems share some aetiological factors, namely foetal
abnormalities, very preterm birth, family adversity and/or psy-
chosocial stress factors, and breastfeeding. Particularly single
feeding and multiple regulatory problems seem to be most
strongly related to neurophysiological factors such as foetal
abnormalities and very preterm birth (Samara et al. 2010),
while sleeping problems show strong associations with breast-
feeding practices, and single crying problems seem to be
related to psychosocial factors. As regulatory problems are
associated with high parental burden and subsequent behav-
iour, motor, cognitive and hyperactivity problems, and cause
substantial expenses in health-care delivery (Wolke et al. 2002,
2009; Rao et al. 2004; St James-Roberts 2008), our results are
relevant in terms of prevention, that is, recognizing families
with pre- and post-natal maternal and family stress, and fami-
lies or mothers at risk should be given support, for example,
preventive counselling during pregnancy and post-natally.
Infants born very preterm and with neurological problems
in the newborn period may require particular support to
establish adaptive feeding to prevent longer-term feeding or
multiple regulatory problems.
Key messages
• Regulatory problems were predicted by neurophysiologi-
cal and psychosocial factors but their relative contribution
differed between types of regulatory problem.
• Family adversity and psychosocial problems were precur-
sors of crying and multiple regulatory problems.
• Feeding and multiple regulatory problems at 5 months
were well predicted by neurophysiological factors such as
foetal abnormalities and very premature birth.
• Families or mothers at risk should be supported pre- and
post-natally, for example, by preventive counselling.
• Our results are relevant in terms of prevention as infant
regulatory problems are associated with high parental
burden and adverse development of the child.
Conflict of interest
The authors do not have any conflict of interest to disclose.
Acknowledgements
The Bavarian Longitudinal Study was supported by grants
PKE24, JUG14 (01EP9504 and 01ER0801) from the German
Ministry of Education and Science. This specific work is part of
the National Centre of Competence in Research (NCCR) Swiss
Etiological Study of Adjustment and Mental Health (sesam).
The Swiss National Science Foundation (project no. 51A240-
104890), the University of Basel, the F. Hoffmann-La Roche
Corp. and the Freie Akademische Gesellschaft provide core
support for the NCCR sesam.
References
Anderson, J. W., Johnstone, B. M. & Remley, D. T. (1999)
Breast-feeding and cognitive development: a meta-analysis. The
American Journal of Clinical Nutrition, 70, 525–535.
Bartick, M. & Reinhold, A. (2010) The burden of suboptimal
breastfeeding in the United States: a pediatric cost analysis.
Pediatrics, 125, e1048–e1056.
Becker, K., El-Faddagh, M., Schmidt, M. H. & Laucht, M. (2007)
Dopaminerge polymorphismen und frühkindliche
regulationsprobleme [Dopaminergic polymorphisms and
regulatory problems in infancy]. Zeitschrift für Kinder- und

© 2011 Blackwell Publishing Ltd, Child: care, health and development, 37, 4, 493–502
500 G. Schmid et al.
Jugendpsychiatrie und Psychotherapie [Journal of Child and
Adolescent Psychiatry and Psychotherapy], 35, 145–151.
Britton, J. R., Britton, H. L. & Gronwaldt, V. (2006) Breastfeeding,
sensitivity, and attachment. Pediatrics, 118, 1436–1443.
Dahl, M., Eklund, G. & Sundelin, C. (1986) Early feeding problems in
an affluent society. II. Determinants. Acta Paediatrica Scandinavica,
75, 380–387.
Dubowitz, L. M., Dubowitz, V. & Goldberg, D. (1970) Clinical
assessment of gestational age in the newborn infant. Journal of
Pediatrics, 77, 1–10.
Evans, J., Heron, J., Lewis, G., Araya, R., Wolke, D. & Study, T. A.
(2005) Negative self-schemas and the onset of depression in
women: longitudinal study. British Journal of Psychiatry, 186,
302–307.
Field, D., Garland, M. & Williams, K. (2003) Correlates of specific
childhood feeding problems. Journal of Paediatrics and Child
Health, 39, 299–304.
Golding, J., Rogers, I. S. & Emmett, P. M. (1997) Association between
breast feeding, child development and behaviour. Early Human
Development, 49 (Suppl.), S175–S184.
Hauser-Cram, P., Erickson Warfield, M., Shonkoff, J. P., Wyngaarden
Krauss, M., Upshur, C. C. & Sayer, A. (1999) Family influences on
adaptive development in young children with down syndrome.
Child Development, 70, 979–989.
Heron, J., O’Connor, T. G., Evans, J., Golding, J., Glover, V. & Study,
T. A. (2004) The course of anxiety and depression through
pregnancy and the postpartum in a community sample. Journal of
Affective Disorders, 80, 65–73.
von Hofacker, N., Lehmkuhl, U., Resch, F., Papousek, M., Barth, R. &
Jacubeit, T. (2007) Leitlinien zur Diagnostik und Therapie Von
psychischen Störungen im Säuglings-, Kindes- und Jugendalter
[Guidelines for Clinical Diagnostics and Therapy of Mental Disorders
During Infancy, Childhood, and Adolescence]. Deutscher Ärzte
Verlag, Cologne, Germany.
von Kries, R., Kalies, H. & Papousek, M. (2006) Excessive crying
beyond 3 months may herald features of multiple regulatory
problems. Archives of Pediatrics and Adolescent Medicine, 160,
508–511.
Laucht, M., Esser, G., Schmidt, M. H., Ihle, W., Löffler, W., Stöhr,
R. M., Weindrich, D. & Weinel, H. (1992) ‘Risikokinder’: Zur
Bedeutung biologischer und psychosozialer Risiken für die
kindliche Entwicklung in den beiden ersten Lebensjahren [‘Risk
children’: the importance of biological and psychosocial risks for
child development in the first two years of life]. Praxis der
Kinderpsychologie und Kinderpsychiatrie [Praxis of Child Psychology
and Child Psychiatry], 41, 274–285.
Limperopoulos, C., Robertson, R. L., Sullivan, N. R., Bassan, H. & du
Plessis, A. J. (2009) Cerebellar injury in term infants: clinical
characteristics, magnetic resonance imaging findings, and
outcome. Pediatric Neurology, 41, 1–8.
Lindberg, L., Bohlin, G. & Hagekull, B. (1991) Early feeding problems
in a normal population. International Journal of Eating Disorders,
10, 395–405.
© 2011 Blackwell Publishing Ltd, Child: care, health and development, 37, 4, 493–502
Marlow, N., Wolke, D., Bracewell, M. A., Samara, M. & Epicure Study
Group (2005) Neurologic and developmental disability at six years
of age after extremely preterm birth. New England Journal of
Medicine, 352, 9–19.
Messer, D. & Richards, M. (1993) The development of sleeping
difficulties. In: Infant Crying, Feeding, and Sleeping: Development,
Problems, and Treatment (eds I. St James-Roberts, G. Harris &
D. Messer), pp. 194–210. Harvester Wheatsheaf, London, UK.
Mortensen, E. L., Michaelsen, K. F., Sanders, S. A. & Reinisch, J. M.
(2002) The association between duration of breastfeeding and
adult intelligence. Journal of the American Medical Association, 287,
2365–2371.
Owen, C. G., Martin, R. M., Whincup, P. H., Smith, G. D. & Cook,
D. G. (2005) Effect of infant feeding on the risk of obesity across
the life course: a quantitative review of published evidence.
Pediatrics, 115, 1367–1377.
Papousek, M. & von Hofacker, N. (1995) Persistent crying and
parenting: search for a butterfly in a dynamic system. Early
Development and Parenting, 4, 209–224.
Papousek, M. & von Hofacker, N. (1998) Persistent crying in early
infancy: a non-trivial condition of risk for the developing
mother-infant relationship. Child: Care, Health and Development,
24, 395–424.
Papousek, M., Schieche, M. & Wurmser, H. (2008) Disorders of
Behavioral and Emotional Regulation in the First Years of Life. Early
Risk and Intervention in the Developing Parent-Infant Relationship
(K. Kronenberg Trans.). Zero to Three, Washington, DC, USA.
Perrin, E. C., West, P. D. & Culley, B. S. (1989) Is my child normal
yet – correlates of vulnerability. Pediatrics, 83, 355–363.
Posner, M. I., Rothbart, M. K., Sheese, B. E. & Tang, Y. (2007) The
anterior cingulate gyrus and the mechanisms of self-regulation.
Cognitive, Affective & Behavioral Neuroscience, 7, 391–395.
Prechtl, H. F. R. (1968) Neurological findings in newborn infants
after pre- and paranatal complications. In: Aspects of Prematurity
and Dysmaturity – Nutricia Symposium (eds J. H. P. Jonxis,
H. K. A. Visser & J. A. Troelstra), pp. 303–323. Stenfert Kroese NV,
Groningen, Leiden, the Netherlands.
Räihä, H., Lehtonen, L., Huhtala, V., Saleva, K. & Korvenranta, H.
(2002) Excessively crying infant in the family: mother-infant,
father-infant and mother-infant interaction. Child: Care, Health
and Development, 28, 419–429.
Ramchandani, P., Wiggs, L., Webb, V. & Stores, G. (2000) A
systematic review of treatments for settling problems and night
waking in young children. British Medical Journal, 320, 209–213.
Rao, M. R., Brenner, R. A., Schistermann, E. F., Vik, T. & Mills, J. L.
(2004) Long term cognitive development in children with
prolonged crying. Archives of Disease in Childhood, 89, 989–992.
Riegel, K., Ohrt, B., Wolke, D. & Österlund, K. (1995) Die
Entwicklung gefährdet geborener Kinder bis zum fünften Lebensjahr
[The Development of Children Born at Risk until Their Fifth Year of
Life]. Ferdinand Enke Verlag, Stuttgart, Germany.
Samara, M., Johnson, S., Lamberts, K., Marlow, N. & Wolke, D.
(2010) Eating problems at 6 years of age in a whole population

sample of extremely preterm children. Developmental Medicine and
Child Neurology, 52, e16–e22.
Schmid, G., Schreier, A., Meyer, R. & Wolke, D. (2010) A prospective
study on persistence of infant crying, sleeping, and feeding
problems and preschool behaviour. Acta Paediatrica, 99, 286–290.
Short, E. J., Klein, N. K., Lewis, B. A., Fulton, S., Eisengart, S.,
Kercsmar, C., Baley, J. & Singer, L. T. (2003) Cognitive and
academic consequences of bronchopulmonary dysplasia and very
low birth weight: 8-year-old outcomes. Pediatrics, 112, e359–e367.
Sondergaard, C., Olsen, J., Friis-Haschè, E., Dirdal, M., Thrane, N. &
Toft Sorensen, H. (2003) Psychosocial stress during pregnancy and
the risk of infantile colic: a follow-up study. Acta Paediatrica, 92,
811–816.
St James-Roberts, I. (1987) Linking prenatal and perinatal adversities
with child development. Child: Care, Health and Development, 13,
207–225.
St James-Roberts, I. (2008) Infant crying and sleeping: helping
parents to prevent and manage problems. Primary Care, 35,
547–567.
St James-Roberts, I. & Halil, T. (1991) Infant crying patterns in the
first year: normal community and clinical findings. Journal of Child
Psychology and Psychiatry, 32, 951–968.
St James-Roberts, I., Sleep, J., Morris, S., Owen, C. & Gillham, P.
(2001) Use of a behavioural programme in the first 3 months to
prevent infant crying and sleeping problems. Journal of Paediatrics
and Child Health, 37, 289–297.
Tabachnik, B. G. & Fidell, L. S. (2007) Using Multivariate Statistics.
Pearson Education, Boston, MA, USA.
Thunström, M. (1999) Severe sleep problems among infants in a
normal population in Sweden: prevalence, severity, and correlates.
Acta Paediatrica, 88, 1356–1363.
Voigt, M., Schneider, K. T. M. & Jährig, K. (1996) Analyse des
Geburtengutes des Jahrgangs 1992 der Bundesrepublik
Deutschland. Teil 1: Neue Perzentilwerte für die Körpermasse von
Neugeborenen [Analysis of the total number of births in 1992
in the Federal Republic of Germany]. Geburtshilfe und
Frauenheilkunde [Obstetrics and Gynaecology], 56, 550–558.
Wake, M., Morton-Allen, E., Poulakis, Z., Hiscock, H., Gallagher, S. &
Oberklaid, F. (2006) Prevalence, stability, and outcomes of cry-fuss
and sleep problems in the first 2 years of life: prospective
community-based study. Pediatrics, 117, 836–842.
van der Wal, M. F., van Eijsden, M. & Bonsel, G. J. (2007) Stress and
emotional problems during pregnancy and excessive infant crying.
Journal of Developmental and Behavioral Pediatrics, 28, 431–437.
Wolke, D. (2003) Frequent problems in the infancy and toddler years:
excessive crying, sleeping, and feeding difficulties. In: Health
© 2011 Blackwell Publishing Ltd, Child: care, health and development, 37, 4, 493–502
Crying, feeding and sleeping problems 501
Promotion and Disease Prevention in the Family (eds K. E.
Bergmann & R. L. Bergmann), pp. 44–88. Walter de Gruyter,
Berlin, Germany.
Wolke, D., Gray, P. & Meyer, R. (1994) Excessive infant crying: a
controlled study of mothers helping mothers. Pediatrics, 94,
322–332.
Wolke, D., Meyer, R., Ohrt, B. & Riegel, K. (1995) Co-morbidity of
crying and feeding problems with sleeping problems in infancy:
concurrent and predictive associations. Early Development and
Parenting, 4, 191–207.
Wolke, D., Sohne, B., Riegel, K., Ohrt, B. & Osterlund, K. (1998) An
epidemiologic longitudinal study of sleeping problems and feeding
experience of preterm and term children in southern Finland:
comparison with a southern German population sample. The
Journal of Pediatrics, 133, 224–231.
Wolke, D., Rizzo, P. & Woods, S. (2002) Persistent infant crying and
hyperactivity problems in middle childhood. Pediatrics, 109,
1054–1060.
Wolke, D., Skuse, D. & Reilly, S. (2006) The management of
infant feeding problems. In: Feeding Problems and Eating
Disorders in Children and Adolescents, 2nd edn (eds P. Cooper &
A. Stein), pp. 41–76. Harwood Academic Publisher, Routledge,
UK
Wolke, D., Schmid, G., Schreier, A. & Meyer, R. (2009) Crying
and feeding problems in infancy and cognitive outcome in
preschool children born at risk: a prospective population study.
Journal of Developmental and Behavioral Pediatrics, 30, 226–
238.
Wurmser, H. & Papousek, M. (2008) Facts and figures: database of
the munich interdisciplinary research and intervention program
for fussy babies. In: Disorders of Behavioral and Emotional
Regulation in the First Years of Life. Early Risk and Intervention in
the Developing Parent-Infant Relationship (K. Kronenberg Trans.),
pp. 27–52. Zero to Three, Washington, DC, USA.
Wurmser, H., Rieger, M., Domogalla, C., Kahnt, A., Janine, B.,
Kowatsch, M., Kuehnert, N., Buske-Kirschbaum, A., Papousek, M.,
Pirke, K. M. & von Voss, H. (2006) Association between life stress
during pregnancy and infant crying in the first six months
postpartum: a prospective longitudinal study. Early Human
Development, 82, 341–349.
Zero to Three (2005) Diagnostic Classification: 0–3. Diagnostic
Classification of Mental Health and Developmental Disorders of
Infancy and Early Childhood: Revised Edition (DC: 0-3R). Zero to
Three Press, Washington, DC, USA.
502 G. Schmid et al.

Appendix
Table A1. Pre-, peri- and post-natal predictors of regulatory problems at 5 months – crude odds ratios (ORs) and 95% confidence intervals (CIs)
are reported
Multiple
regulatory
Single crying Single feeding Single sleeping problems
(n = 239)* (n = 554)* (n = 494)* (n = 275)*
OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI)
Predictors before pregnancy
Optimality 0–8† 0.99 (0.83–1.17) 1.07 (0.95–1.19) 1.02 (0.91–1.16) 1.01 (0.87–1.19)
Prenatal predictors
Smoking status Never 1 1 1 1
Stopped 0.96 (0.64–1.45) 1.15 (0.89–1.50) 0.93 (0.71–1.24) 1.02 (0.70–1.48)
Persistent 1.42 (1.03–1.96) 1.07 (0.84–1.36) 0.62 (0.46–0.83) 1.23 (0.90–1.69)
Optimality 0–14† 1.08 (0.97–1.21) 1.05 (0.97–1.13) 0.89 (0.81–0.97)‡ 1.05 (0.95–1.17)
Parity Primiparous 1 1 1 1
ⱖ1 prior births 1.12 (0.86–1.46) 1.23 (1.03–1.47) 1.38 (1.14–1.66) 1.03 (0.80–1.32)
Foetal abnormality No 1 1 1 1
Yes 1.42 (1.07–1.88) 1.53 (1.27–1.85) 1.07 (0.87–1.32) 1.72 (1.33–2.21)
Socio-economic status Lower 1 1 1 1
Middle 0.64 (0.48–0.86) 0.95 (0.78–1.16) 1.12 (0.90–1.40) 0.90 (0.69–1.19)
Upper 0.54 (0.36–0.81) 0.98 (0.76–1.27) 2.07 (1.63–2.63) 0.99 (0.70–1.37)
Infant’s sex Female 1 1 1 1
Male 1.28 (0.99–1.69) 0.87 (0.74–1.05) 1.35 (1.11–1.64) 1.32 (1.02–1.69)
Perinatal predictors
Gestational age‡ Term 1 1 1 1
Preterm 1.16 (0.87–1.55) 0.98 (0.80–1.21) 0.82 (0.66–1.02) 0.90 (0.88–1.21)
Very preterm 1.29 (0.72–2.33) 2.25 (1.62–3.14) 0.90 (0.56–1.44) 2.64 (1.75–4.00)
Optimality 0–15† 1.00 (0.93–1.08) 1.02 (0.97–1.07) 0.98 (0.99–1.03) 0.93 (0.87–1.00)
Caesarean section No 1 1 1 1
Yes 1.13 (0.84–1.52) 1.08 (0.88–1.33) 0.77 (0.61–0.97) 0.81 (0.60–1.09)
Weight§ ⱖ10th percentile 1 1 1 1
<10th percentile 1.28 (0.97–1.69) 1.27 (1.05–1.54) 0.72 (0.58–0.90) 1.08 (0.83–1.42)
Length§ ⱖ10th percentile 1 1 1 1
<10th percentile 1.09 (0.79–1.51) 1.16 (0.93–1.45) 0.71 (0.55–0.93) 1.19 (0.88–1.61)
Head circumference§ ⱖ10th percentile 1 1 1 1
<10th percentile 1.37 (1.01–1.85) 1.29 (1.05–1.59) 0.70 (0.54–0.91) 1.22 (0.92–1.63)
Maternal age (years) 25–34 1 1 1 1
ⱕ24 1.31 (0.97–1.76) 0.93 (0.75–1.15) 0.68 (0.54–0.87) 0.98 (0.74–1.31)
ⱖ35 1.25 (0.85–1.85) 1.06 (0.81–1.39) 1.15 (0.88–1.51) 0.94 (0.64–1.38)
Post-natal predictors
Optimality 0–21† 1.02 (0.97–1.07) 1.07 (1.04–1.10)¶ 0.99 (0.95–1.02) 1.05 (1.00–1.09)
Intensity of neonatal treatment index 0–18† 1.02 (0.99–1.06) 1.04 (1.02–1.07) 0.99 (0.97–1.02) 1.06 (1.03–1.09)
Parent–infant relationship index 0–8† 1.11 (0.99–1.25) 1.13 (1.04–1.23) 0.97 (0.88–1.07) 1.11 (1.00–1.24)
Family adversity index 0–8† 1.33 (1.20–1.48) 1.08 (1.00–1.17) 1.13 (1.04–1.22) 1.24 (1.12–1.37)
Psychosocial stress index 0–14† 1.32 (1.19–1.47) 1.11 (1.02–1.22) 1.15 (1.05–1.26) 1.36 (1.24–1.50)
Breastfeeding Never 1 1 1 1
Already stopped 0.78 (0.58–1.04) 0.80 (0.66–0.97) 1.11 (0.87–1.42) 0.89 (0.67–1.17)
Still partly/fully 0.44 (0.25–0.76) 0.47 (0.32–0.68) 5.16 (4.08–6.52) 1.29 (0.90–1.85)

The ORs (95% CIs) in bold are significant at the P < 0.001 level.
*Compared with all infants without regulatory problems at 5 months (n = 3474).
†In continuous predictors: the range is reported.
‡Gestational age: term ⱖ37 weeks of gestation; preterm 32–36 weeks of gestation; very preterm <32 weeks of gestation.
§Adjusted for gestational age and sex.
¶The single item analyses showed that the following items of the post-natal optimality score were predictors of single feeding problems at 5 months:
apnoea/bradycardia 1.50 (1.21–1.87), deficits in development (i.e. neurodevelopmental problems) 1.44 (1.19–1.74) and neonatal seizures 1.97 (1.40–2.77).

© 2011 Blackwell Publishing Ltd, Child: care, health and development, 37, 4, 493–502