Caitlin O’Connor, ND
The transition to parenthood can be a wonderful time. However, a “fussy” baby can turn this joyful time into one of great stress. Early and appropriate intervention is necessary to help the new family thrive. One in 5 parents reports having a fussy baby, and this accounts for 10-20% of visits to the doctor’s office in the initial 3 months of life.1
The first step is to understand parental concerns. We start with Docere: discussing with the family what behaviors are normal for a baby and what might indicate an underlying issue. Normal infant behaviors are often misinterpreted as problematic by both parents and providers: frequent feedings, crying when not being held, inability to sleep through the night or not on being on a sleep “schedule,” and spitting up/reflux.
Let’s review these behaviors 1 by 1…
Baby Behaviors & Parental Concerns
Feeding Frequency
Breastfed babies should be fed on cue and not on a schedule. During the initial 3 months, “cluster feeding” is quite common. This refers to a period of time where baby is nursing frequently, sometimes multiple times within an hour. This may be misinterpreted by the parents as a sign that something is wrong. They may try to space out feeding in order to adhere to a schedule. The result will be a crabby baby and decreased maternal milk supply.2
Teaching families about normal patterns and encouraging them to follow babies’ cues often reduces fussiness (Table 1). Recognizing and feeding with early cues (eg, rooting) can reduce the likelihood of later more intense signs such as crying. Adequate milk supply is best determined by monitoring weight gain and diaper output, not infant behavior. Unless the naturopathic doctor has advanced training and experience in evaluating infant latch, any concerns with supply should be evaluated by an IBCLC (International Board Certified Lactation Consultant). Families that are bottle-feeding also need to pay attention to cues and should use paced feeding to decrease the tendency towards over-feeding, which can lead to symptoms that mimic colic.3
Table 1. Common Infant Hunger Cues2
| EARLY | |
| Smacking or licking lips | |
| Opening and closing mouth | |
| Sucking on lips, tongue, hands, fingers, toes, toys, or clothing | |
| ACTIVE | |
| Rooting around on the chest of whoever is carrying him | |
| Trying to position for nursing, either by lying back or pulling on your clothes | |
| Fidgeting or squirming around a lot | |
| Hitting you on the arm or chest repeatedly | |
| Fussing or breathing fast | |
| LATE | |
| Moving head frantically from side to side | |
| Crying | |
Physical Contact
Another common concern is that baby never wants to be put down. This can be normal as well, especially during the first 3 months. During this time, the infant is still transitioning from life in the womb and can become easily overwhelmed. Babies rely on their caregivers completely, and close contact helps regulate their nervous systems.4 While this can be exhausting and unexpected, it is not abnormal.
Babywearing offers a way for baby to stay close while parents attend to other business. Using a sling, wrap, or soft-structure carrier is one of the most important ways to help soothe a fussy baby. Babywearing International is a fantastic resource with both online information and local chapters.
Touch is very important to infant well-being. Skin-to-skin contact should not only be prioritized in the days after birth, but throughout infancy as well. Infant massage can be a great tool to promote bonding and relaxation for both parents and baby. Additional hands-on therapies, such as craniosacral, chiropractic, or shonishin can be explored as well, especially if birth was traumatic.
Sleep
Sleep (or lack thereof) is another issue that can cause much distress to the new family unit. There are many myths surrounding infant sleep, and parents can become distraught when they feel their infant is not sleeping well.
During the first few months, babies are developing their circadian rhythms. Commonly, they might not yet see a difference between night and day when it comes to sleep. Often, a regular schedule won’t emerge until 3 months of age. Even then, sleeping through the night is defined as 4-6 uninterrupted hours, rather then the 10-12 many parents hope for. In fact, 50% of 1-year-olds still have at least 1 night waking that requires parental contact.5 The ability to self-soothe does not appear until 4-6 months, at the earliest.6
Much of infant sleep seems to be dependent on temperament. Some families get lucky with babies who are “good” sleepers, while others must groggily wait it out. Routinely, I see the stress and worry about forcing a child into a sleep pattern (through various methods of sleep training) compound the issue and increase misery for all. For families looking for resources on encouraging sleep, I recommend The No Cry Sleep Solution by Elizabeth Pantley.
As far as sleeping arrangement go, co-sleeping is the biological norm. Research shows that families who co-sleep get more total sleep per night then those that do not, and it may even offer protection against SIDS.7 Co-sleeping can mean room-sharing with baby on a separate surface, or bed-sharing, with (usually) mom and baby on a shared surface.
Family sleep expert James McKenna is a valuable resource and provides a checklist for determining co-sleeping safety based on individual risk factors.7 Regardless of where families plan to have baby sleep, most will at some point resort to bed-sharing out of sheer exhaustion. It is important to discuss how to do this safely, especially with babies who may be more fussy and wake more frequently at night.
Spitting Up
Spitting up is normal. Spitting up is rarely an indicator of any underlying problem and should not be a concern as long as weight gain is appropriate. Fifty percent of infants age 0-3 months will have reflux, and only 3 of 1000 of those infants will meet the requirement for a diagnosis of gastroesophageal reflux disease (GERD). Most often, this is a physiological reflux based on stomach size, esophageal length, and muscle tone.
Despite this fact, 60% of pediatricians will jump to a diagnosis of GERD when presented with a fussy baby. This is resulting in an epidemic of reflux medication being prescribed to children under the age of 1. This is not to say that fussy babies do not sometimes have issues with their digestion that contribute to their distress, but it is very rarely GERD and very rarely needs pharmaceutical intervention. Parents should be reassured that spitting up is generally a laundry issue rather then a medical issue.
When There Is No “Village”
The truth of the matter is that babies have variable temperaments. Some babies will be more high-needs then others. These kids tend to be more easily stimulated and might need to spend more time at home, more time being held, and more time with their parents. Dr William Sears offers great insight for families regarding the parenting of high-need babies.8 Often, just labeling the pattern and assuring parents that they are doing nothing wrong can go a long way.
It is critical to note that mothers of fussy babies are at greater risk for postpartum depression (PPD). Use a screening tool, such as the Edinburgh Postnatal Depression Scale. Postpartum International is an organization that helps women connect to local therapists and support groups that specialize in PPD. Do not overlook the health of the mother.
Postpartum is a sacred time. Families should be nestled in a community of support that allows them the time and space to figure out their new addition. Unfortunately, American culture often does not acknowledge this need. With inadequate maternity/paternity leave, families living in isolation without a local support system, and an insane cultural focus on “bouncing back” to pre-pregnancy life, it is no wonder that many families struggle during this transition. We were not meant to raise our babies alone, yet most have no village to provide support.
Becoming knowledgeable about local resources, such as support groups, postpartum doulas, lactation consultants, parenting classes, etc, will help you guide your families towards building a solid network. If you are lucky enough to work with families during the prenatal period, help them prepare by setting up meal trains or prepping frozen meals, arranging for childcare if there are other children, and helping with cleaning and housekeeping. There is much focus on pregnancy and birth but precious little on the realities of postpartum. Educating parents on what to expect postpartum is a critical aspect of prenatal care.
After considering the above recommendations, what do we look for when baby does truly seem to be in distress? What should we do if we see crying more then 3 hours per day, distress with feeding, resistance to being soothed, and inability to sleep for even 1-2 hours in a row? Part 2 of this article will explore underlying causes of persistent infant fussiness, such as food intolerances/allergies, colic, true reflux, sensory processing disorder, and other contributing causes to abnormal fussiness and irritability in infants.
Caitlin O’Connor, ND, provides naturopathic care with a focus on women’s and children’s health. She pairs a philosophy of patient-centered, whole-body, individualized care with an emphasis on nutrition, botanical medicine, and a balanced approach to healthy living. Dr O’Connor practices in Denver, CO, where she has also been active in the political process regulating naturopathic doctors. She graduated from Bastyr University in 2008 with a Doctorate of Naturopathic Medicine and a certificate in Naturopathic Midwifery. In addition to teaching at the Nutrition Therapy Institute, she has presented to both lay and professional audiences, including the Colorado Midwifery Association and the Colorado Association of Naturopathic Doctors.
References
- Douglas PS, Hill PS. The crying baby: what approach? Curr Opin Pediatr. 2011;23(5):523-529.
- Bonyata K. Cluster Feeding and Fussy Evenings. Updated March 7, 2016. Kellymom Web site. http://kellymom.com/parenting/parenting-faq/fussy-evening/. Accessed June 15, 2016.
- Lyford E. How to bottle feed the breastfed baby.Updated March 17, 2016. Kellymom Web site. http://kellymom.com/bf/pumpingmoms/feeding-tools/bottle-feeding/. Accessed June 27, 2016.
- Blois M. Hold Me Close: Encouraging Essential Mother/Baby Physical Contact. Excerpted from: Blois M. Birth: Care of Infant and Mother: Time Sensitive Issues. In: Gordon W, Trafton J, eds. Best Practices in the Behavioral Management of Health from Preconception to Adolescence. Los Altos, CA: Institute for Disease Management; 2007. Available at: http://babywearinginternational.org/Research/Blois_research_summary.pdf. Accessed June 15, 2016.
- Burnham MM, Goodlin-Jones BL, Gaylor EE, Anders TF. Nighttime sleep-wake patterns and self-soothing from birth to one year of age: a longitudinal intervention study. J Child Psychol Psychiatry. 2002;43(6):713-725.
- Mckenna JJ. Night waking among breastfeeding mothers and infants: Conflict, congruence or both? Evol Med Public Health. 2014(1):40-47.
- Safe Cosleeping Guidelines. University of Notre Dame Web site. http://cosleeping.nd.edu/safe-co-sleeping-guidelines/. Accessed June 16, 2016.
- Sears W, Sears M. The Fussy Baby Book: Parenting Your High-Need Child From Birth to Age Five. London, England: Thorsons; 2005.
