The Unsettled Infant

It is very common for new babies to be quite unsettled, and there can be a lot of conflicting advice out there as to the cause - reflux, colic, purple crying, leaps - the list goes on!

Especially in the first 3 months of a baby's life, babies can be quite unsettled. Many people say that it is at its worst up until around week 7, and gradually improves, becoming much better by week 12. Some people refer to this time as the "Fourth Trimester". It is actually quite normal for babies to cry for around two hours per day, however if it is more than that, then there are some things you can do to help reduce this. 

During a consultation with me, I will assess what has been happening for your family and help to rule out any medical causes for unsettled behaviour, including food allergies or intolerances, breastfeeding issues or milk supply issues, and use the 5-Domain Approach of The Possums Clinic to formulate a plan and a way forward. This strategy helps to make a daily plan to make the days enjoyable, the nights as easy as possible and ensures that both parents and baby are as dialled-down, or calm, as possible.

A consultation while you are pregnant is a great idea to get you off to a good start. I can teach you the common causes of infant cry-fuss behaviour as well as strategies to read your babies cues and manage these difficult periods.

The Concept of Sensory Nourishment

While you may have heard about the risk of “over-stimulation”, the reality is our babies are often crying out because they are bored and need something new to do or look at. Their brains are little sponges desperate to learn about the world in which they live.

If you have an unsettled baby, you might find that a simple change in their environment, such as stepping outside and looking at leaves moving in the trees, will quickly dial your baby down. Getting on with your day by bringing your baby and doing things that you enjoy, such as walks or coffee with a friend, is beneficial to you both, as you get to be out and about and baby gets a rich and ever changing sensory environment.

It can be helpful to think of your baby as having two cups that need filling. One is milk and the other is sensory needs. If one of their cups is not full, they will be unsettled. If both cups are full, your baby will settle and sleep easily. If your baby is unsettled, rather than trying to settled them into sleep, think of their two cups and try filling them up. If you try to feed your baby milk and they are not wanting that, switch over to their sensory cup and try filling that. Throughout the day, keep offering feeding or activities that will fill up their two cups, and let sleep take care of itself.

Could it be reflux?

I often get asked if the unsettled behaviour could be due to reflux. The simple answer is, most likely not. Pathological reflux (the disease state) is exceedingly rare in babies. All babies will regurgitate milk at least some of the time, as the valve at the top of their stomach doesn’t start working straight away, and a simple nudge in the wrong direction can see them ‘spilling’, just as a drink bottle would without its lid on. Milk (both breastmilk and formula) is in fact pH neutral for two hours after a feed, so even if it does reflux or regurgitate back up, it is not painful for your baby. Reflux itself is not a problem in infants – in fact it is physiologically normal – and Gastro-oesophageal Reflux Disease (GORD) is a disease that for the most part, just doesn’t affect babies. The exception would be when babies are losing weight, failing to gain weight or have severe irritation of their oesophagus, which can be diagnosed by a doctor experienced with this condition.

Treating reflux as GORD is dangerous for a number of reasons. Giving our babies a diagnosis generally means that we then start treatment. Omeprazole is a common treatment for gastric reflux in adults, but it is not approved for use in infants aged under one year. The safety of omeprazole in young children is largely unknown. Although omeprazole is effective at reducing gastric acidity and oesophageal acid exposure in infants, there is significant evidence that it is not effective in treating symptoms attributed to infant reflux or GORD. Two studies investigating the effects of omeprazole on infant irritability and reflux found that, while treatment groups had significantly reduced oesophageal acid exposure, there was no difference in irritability or crying, regurgitation, feeding difficulties, back arching, coughing and wheezing.  Similar results have been reported with other proton pump inhibitors (PPIs). 

Omeprazole is therefore not recommended for treating irritability, reflux or uncomplicated GORD. Omeprazole should only be considered in cases of severe infantile reflux oesophagitis or if GORD is causing complications such as failure to thrive. The decision to prescribe would usually be made in consultation with a paediatrician or gastroenterologist. Even in these circumstances, the administration of a PPI is unlikely to reduce the frequency of crying and gastric reflux.

Even more concerningly, the risks of taking omeprazole mean that your baby has an increased risk of gastroenteritis and pneumonia requiring hospitalisation, compared to babies who do not take omeprazole. It also places babies at an increased risk of developing asthma in the long term. In a Swedish study of over 3 million babies, there was a 57% increased risk of asthma associated with PPI use, regardless of duration of PPI treatment. It's hypothesised that the PPI disrupts the gut microbiome which hyperactivates the immune system, resulting in airway inflammation. The risk was significantly higher in the groups younger than 6 months, and 6 months to two years. 

Also worryingly, when stopping omeprazole, there may be a rebound acid secretion which then causes dependency on the medication, when there may never have been a genuine need for the medication in the first place.

For the vast majority of babies, the discomfort they display with their normal gut function, is not pathological. It is a combination of their immature nervous system, and the fact that their sympathetic nervous system activation creates more gut activity. This improves with time, and before then, we can help dial down their guts by offering a feed or stepping outside.