One of the most common discussions in my pediatric practice is what to do when your infant is fussy. Most healthy babies will reach their peak fussiness between 4 and 6 weeks of age. Because I have a large newborn practice, I encourage all of my patients to come in for a 4 week check, in large part so that we can talk about what behaviors to expect over the next 3-4 week period. Most of what we discuss is related to the topic of fussiness.
I generally advise nursing moms that their babies may tend to feed more frequently, called cluster feeding, at about 3 weeks and 6 weeks of age. This is a normal process that comes around the time of a growth spurt and generally helps nursing moms increase their milk supplies. Moms may notice that their infants are fussier and suddenly want to nurse every hour. Since these cluster periods usually last a day or two, it is helpful for new moms to anticipate these growth spurts.
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Another topic I bring up at the four week check is the phenomenon of the witching hour. This is when your 4-6 week old baby may experience extra crying and fussiness in the late afternoon or early evening. This is a common and normal behavior for most babies and will resolve on its own over the course of a few weeks. The fussiness comes at the time of day when babies and parents are overly tired. It is helpful for parents to know the potential for the witching hour so that they can anticipate these rough times.
A small number of fussy babies will have signs and symptoms of gastroesophageal reflux (GERD) and/or milk protein intolerance. For these babies, a detailed history, physical exam and several office visits are often needed to make a diagnosis. We sometimes will implement treatment for GERD (smaller, more frequent feeds, good burping, keeping babies upright after feeds and if necessary an antacid).
For babies with signs of milk protein intolerance (bloody stools, stools with mucus or persistent green/slimy stools) we will often try eliminating milk protein from a baby’s diet. This might include taking a nursing mom off of dairy or putting a formula fed baby on a hypoallergenic formula. A pediatric allergist and/or gastroenterologist can sometimes be a help for the pediatrician and family.
For babies with sudden onset of fussiness or inconsolability, a more immediate visit with the pediatrician or emergency room doctor may be needed to evaluate for infection or intra-abdominal disease. Other reasons to call the doctor include fussiness with fever, difficulty breathing, color changes, pain, inconsolability, blood found in spit up or stool or for any other parental concern.
For those babies who are growing well, but do not calm easily, do not have reflux or milk protein allergy, I usually recommend other comforting measures such as tummy massage, using a sling or front pack, a bouncy chair, vibrating chair, swing, going for a walk, car ride or using white noise. I often recommend Dr. Harvey Karp’s Happiest Baby on the Block for additional soothing techniques.
For most babies, fussiness and gassiness is a temporary issue and for others it may last for months. In general, babies who are in a calm and non-stressful environment tend to be calmer babies. Babies surrounded by stress often times pick up on tension and can respond by being fussy and clingy. When possible try turning down the lights, putting on calming music and if all else fails, call a friend or relative to come over and hold your baby to allow you to the time to take a shower, lay down for a nap or go outside for some fresh air.
Dan Brennan MD, CLC, FAAP is a board certified pediatrician and certified lactation counselor at the Sansum Clinic and is a member of the medical staff at the Cottage Children’s Hospital in Santa Barbara, California. In addition to being a general pediatrician, Dr. Brennan is also a health care columnist and proud father of two boys.
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