As a mum of four and a paediatrician, I understand the total exhaustion and worry that comes with trying to soothe a crying a baby. It is one of the most common reasons parents come to the Emergency Department or to see me in clinic. It is especially challenging for first-time parents, but is also confusing when subsequent babies are extremely hard to settle, unlike their siblings. It can also be hard when you’re getting conflicting advice from friends, family and health care professionals. I can so clearly recall pacing the floor all night with a crying baby, not knowing what to do. So, here are some tips to help you settle your baby and to know when to worry.
Why do babies cry and what’s normal?
Crying is a normal way for babies to communicate and does not necessarily mean they are in discomfort or pain. However, some babies cry more than the average two to three hours per day. However, less than five per cent of these babies will have a medical cause for their crying.
Crying usually peaks when babies are around six to eight weeks of age and is often worse in the afternoon or evening, may start or stop for no reason and it can feel like nothing you do seems to help. Babies may also have other non-specific signs of distress, such as drawing up their legs, going red in the face or arching their back.
Crying is thought to be excessive if your baby cries for more than three hours per day for more than three days of the week. These babies are sometimes called “colicky” and are usually feeding well and putting on weight and don’t have an underlying medical cause for their crying. The crying usually improves by three to four months on its own, when babies learn to interpret their bodies’ sensations as normal, for example their bowels moving after a feed. All babies go through this period and it is often called the “PURPLE” period to help parents understand what is happening (see resources below).
What are some of the other reasons babies might be excessively crying?
If the crying is recent in onset, it is best to check with your doctor that your baby doesn’t have an infection or another medical cause. If it’s been getting slowly worse over a few weeks (especially beyond 10-12 weeks), you may need to consider:
Delayed cow’s milk allergy (CMA)/cow’s milk protein allergy
Your baby may have CMA if they have:
- irritability and/or frequent or difficulty feeding
- frequent vomiting
- blood or mucous in their poo
- poor weight gain
- signs of eczema or wheezing or a family history of allergy
CMA occurs in less than five per cent of babies and is a type of food allergy where the cow’s milk protein causes inflammation of the lining of the gut. There is no test to diagnose CMA, rather diagnosis requires careful elimination of dairy from the diet (either by changing to a special formula or taking dairy foods out of your diet if you are breastfeeding) and then re-challenging in two weeks. About a third of these babies also can’t tolerate soy milk. Your baby may be much happier within in a few days without cow’s milk, but it often takes a week or two to really see a difference. It is best to see your GP or paediatrician to discuss the diagnosis and how to manage CMA.
Reflux occurs in all babies under 12 months and is associated with small vomits or “posits” after feeding. It is not usually associated with pain or poor weight gain and has not actually been shown to be a cause of irritability or crying in babies. In most cases, reflux medication doesn’t work for crying. A very small percentage of babies may have gastro-oesophageal reflux disease (GORD) with frequent vomiting and other symptoms such as distress during feeds, choking, coughing and poor weight gain. Some cases of GORD are caused by cow’s milk allergy, so it is best to see your GP to discuss diagnosis and management strategies.
This may be suggested if your baby has frothy, explosive diarrhoea and bad nappy rash, but has not been clearly shown to be associated with crying. Breast milk and formula milk contain a sugar called lactose, which is digested in the gut by an enzyme called “lactase”. A true deficiency of this enzyme is very rare. Rather, babies may get too much lactose by drinking the more sugary milk at the start of the feed, rather than the more fatty “hind” milk at the end of their feed. Sometimes cow’s milk allergy can cause lactose intolerance by causing inflammation of the lining of the bowel and loss of the enzyme. It is usually diagnosed on history or by a poo specimen, which is not usually needed. A lactose-free formula may help, and in breastfed babies, spacing the feeds out more than three hours apart and ensuring that the breast is fully emptied before changing sides can help. A good barrier cream will help with the nappy rash.
What can you do to settle your baby?
For most babies the first step is to make sure that they are not overtired or hungry. It can be very helpful to keep a diary to record your baby’s sleep, feeding and crying pattern. It is important to remember that little babies need lots of sleep and that babies between six weeks and three months get tired after one and a half to two hours and need to go back to sleep. It is helpful to learn to recognise some of your baby’s tired signs, such as:
- rubbing their eyes or frowning
- frenetic or jerky movements or clenched fists
- crying or grizzling and being difficult to settle and soothe – these are late signs!
If a baby’s crying is over-interpreted as hunger, they can end up being fed very frequently (every hour or two). If this occurs, there is often a cycle when the baby is “snacking”, rather than taking a proper feed, which makes them hard to settle. This pattern may also be associated with low breast milk supply and the baby not gaining weight well, and should be discussed with your doctor.
Some techniques to settle your baby and help you cope with the crying
- Try to space your baby’s feeds to allow them to take good feeds less often and to sleep better in between, for example every three to four hours
- Help your baby to self-soothe or settle. These include swaddling, movement (such as patting or rocking in their cot) and sound (rhythmical “shush, shush” or “white noise”)
- Remember, babies cannot be ‘spoilt’ in the first three to four months. If your baby is crying, they need to be comforted; ignoring your baby’s cry will not help at this age. Babies are not born to be able to self-soothe; it’s a learned skill that comes with time (usually after three to four months) Neither can babies under this age be “trained” to sleep, rather you can be taught some of these good strategies to help your baby
- Avoid excessive stimulation or “over settling” to get your baby to sleep
- If some of these techniques are not working, take a break and go for a walk with the baby in the pram or for a ride in the car and try these settling methods again with the next sleep
- Make sure you’re supported. You may choose to use online shopping, find a babysitter, accept and ask for help, and lie down to rest when baby sleeps rather than doing housework
- If you are feeling very exhausted speak to your doctor and consider a mother and baby unit
The first step in tackling your baby’s crying is to understand the normal patterns of crying and sleep and to get some support to learn the settling techniques that will work for both of you. Remember that there is no right or wrong way to settle your baby, only what works for you. It is essential to feel supported by your partner and family and to take time out for you. It is good to talk through these issues with your GP, paediatrician or maternal and child health nurse to work out what’s right for you and your baby and to touch base with them regularly.
- Purple crying: a new way to understand your baby’s cryinghttp://www.purplecrying.info
- Raising Children Network for information on normal sleep, crying and feeding patterns, and sleep and settling techniques
- Mother and Baby Units in Victoria
Please note: Dr Margie is no longer monitoring questions on this blog. If you are concerned about your child, please contact your GP for advice or visit the above resources.