Healthy Sleep Habits, Happy Child Read online

  Because these babies are difficult to soothe, breast-feeding in the family bed may be the best or only strategy that works. Although the mother's sleep may be fragmented by frequent feeding for both nutrition and soothing, this is probably the most powerful soothing method for these babies. During the first four weeks, your baby is not really “sleeping like a baby.” Placing your baby in the crib is usually stressful. During weeks four through eight, your baby will become even more wakeful and alert and have more evening fussiness, causing the parents to be at an even greater risk for distress. About 27 percent of these infants are at risk for becoming overtired four-month-olds.

  There is some research to suggest that parents who made the commitment to use the family bed from day one, and stick with it, will wind up with better-rested babies than those families who initially wanted to use the crib but later brought their baby into their bed because it was the only way the parents could get any sleep. In the former group, sleep problems are less likely to develop as the children get older. But in the group where it was used only in response to soothing or sleeping difficulties, the family bed appears to be a short-term solution, but in reality it creates a long-term sleep problem. What really is happening is that parents who are overwhelmed by the fussy/crying behavior and have limited resources for soothing their baby, reluctantly use the family bed to gain some relief, but the limited resources for soothing persist and may often cause sleeping problems in older children. (This will be discussed more in Chapter 5.)

  Breast-feeding the Fussy Baby

  by Nancy Nelson, RN, IBCLC

  One of the most difficult things for many breast-feeding mothers is not knowing how much milk your baby is getting. When you are the mother of a “fussy baby” it can be even more of a concern. When a baby is crying, most well-meaning observers will comment that the baby must be hungry. As the mother, these comments may cause you to feel frustrated and guilty. After all, you are responsible for feeding the baby! To allay your fears, keep track of the baby's output of urine and stool. After the sixth day of life, your baby should be producing six or more wet diapers and one or more stools in a twenty-four-hour period as a sign of adequate intake of breast milk. Babies usually need to feed eight to twelve times in a twenty-four-hour period during the first few weeks of life. In the beginning they may cluster feed. This means they may want to feed very frequently for a few hours and then go into a sleep stretch of four or five hours. As they become more efficient, they decrease the number of feedings. The baby should be back to birth weight by two weeks of age and should gain a minimum of five ounces a week for the next two to three months.

  If you are concerned that your baby is fussy because you have a low milk supply, it would be helpful to see a lactation consultant who will do a feeding observation. This includes a study of your baby's ability to transfer milk from your breast by a strong nutritive suck followed by audible swallows. A pre-and postfeeding weight should be included in order to get an idea of how much milk the baby is taking in during the feeding. The baby should be weighed both before and after the feeding with a diaper on so as not to lose the weight of urine or stool that may have been produced during the feeding. This can be reassuring if the baby gains between two and four ounces during the feeding. If the baby gains less, it might alert you to a problem with either the baby's method of transferring the milk or your milk supply. If the milk supply is low or the flow is too slow, a supplemental feeding system may help to improve the suck and give the baby the additional calories he needs. Use of a hospital-grade electric breast pump can augment the breast milk supply as well. Some mothers may decide to feed the baby additional pumped breast milk by bottle or feed formula if they are unable to pump enough milk to meet the baby's needs.

  Occasionally breast engorgement may cause the baby to be fussy at the breast. To deal with engorgement, use warm compresses or take a warm shower prior to feeding the baby. Use breast massage as well. You may be able to express some milk by hand or with a good-quality breast pump to take out a little milk and make the breast softer and easier for the baby to latch on to. Do not pump too much milk because it could continue an oversupply problem and prolong the engorgement. In between feedings, use cold compresses on your breasts to decrease the swelling and give pain relief. Engorgement may occur within the first week after your baby is born or later when the baby begins to skip feedings as he gets older.

  A baby can be fussy at the breast if the mother has flat or inverted nipples. Breast shells may be worn in between the feedings in order to evert the nipples. Using a breast pump for a few minutes prior to putting the baby to the breast will help to pull the nipples out and also start the flow of milk so the baby will get milk right away and be more likely to continue sucking instead of pulling off the breast and crying. Occasionally, nipple shields may help to keep the baby at the breast until the nipples are more everted. This should happen after about two to four weeks of breast-feeding. Seek the help of a lactation consultant as soon as possible if you are having difficulty with the feedings because of flat or inverted nipples.

  A baby may be fussy at the breast because of poor positioning. Both mom and baby may be uncomfortable, which can lead to inadequate letdown and poor milk production. With a fussy baby, the football or the cross-cradle holds work best because you have more control over the baby's head. You can direct him to the breast and keep him there with these two positions. The baby's nose and chin should indent the breast. Babies usually nurse better when they are held more firmly by the mother. A firm pillow that supports the baby at the level of the breast is preferable to a soft pillow. A chair that gives good support is better than a soft couch. I cannot emphasize enough that a fussy baby will respond better to being held tightly and close in to the breast. Contact a lactation consultant if you are uncomfortable during breast-feeding. This may be the reason why your baby is fussy.

  Almost all babies have some degree of gastroesophageal reflux. This is a medical term and simply means that the sphincter muscle, which leads to the stomach, is immature and may not close completely all the time. This allows some milk, along with stomach acid, to come back up into the esophagus, leading to a feeling we call “heartburn.” As anyone who has experienced this can attest, it is quite uncomfortable. Just as sitting upright can help an adult with heartburn feel better, holding the baby upright usually helps the baby feel better, too. Sometimes these episodes can occur during breast-feeding. Holding the baby more upright during the feeding or interrupting the feeding for a short time to comfort the baby by holding him in an upright position should help. Using a swing or a car seat may also help. As the baby matures, so does the muscle, and the episodes become less frequent. Sometimes a baby has a severe problem with reflux and is unable to feed well at all. This may be a case where prescription medication will be needed. Your health care provider should be consulted.

  All new babies experience gassiness. When the baby begins to feed, it sets off a reflex that produces gas so that the baby will be able to pass whatever waste products are produced during the feeding more quickly. This avoids problems with constipation. Because breast milk needs little digestion it moves through the baby's system very quickly. You can often hear the sounds while the baby is still feeding. Although all babies are gassy, some babies are not as upset by it as others seem to be. The time of day may be a factor as well. It often seems as if this gas problem becomes worse at the end of the day. This is often called the traditional “fussy” time of the day. Babies seem to want to stay at the breast constantly and this may exacerbate the gas problem. The baby may need comforting or some cluster feeding. It is a good idea to pump a bottle of breast milk in the morning when the baby is calmer and not feeding so often. Have this milk available during this fussy time to allow another family member to feed the baby so you can get a break. As babies mature this problem resolves.

  The milk at the beginning of the feeding from the breast is higher in lactose. This is called the “foremilk.” The milk that com
es after ten to fifteen minutes of nursing from that same breast is called the “hindmilk.” It is higher in fat and balances out the lactose so as not to produce so much gas. If the baby takes in too much foremilk and no hindmilk, it may result in lactose overload and more gas production. Try to keep the baby on one breast for at least twelve to fifteen minutes in order to get the hindmilk. As the baby gets older and becomes more efficient at nursing, he will be able to get to the hindmilk in a shorter period of time. Hindmilk can have a sedating effect on the baby and help a fussy baby to fall asleep. Most new babies will naturally fall asleep at the end of a feeding because of the sedating effects of the hindmilk. Recently there has been advice given to awaken the baby at the end of the feeding in order to allow them to fall asleep in the crib on their own. I feel that as babies get to be three or four months old, they will remain more awake at the end of the feeding. This is the time for them to learn how to put themselves to sleep. This pattern should be allowed to develop naturally.

  When the baby is just learning how to breast-feed, the letdown reflex may be overwhelming and lead to gagging and choking. This may cause the baby to pull off the breast and become fussy. Put firm pressure over the breast for a minute to stop the rapid flow and put the baby back to the breast. Try to pump a little milk prior to the feeding to see if you can elicit the letdown before the baby goes to the breast. This may not help too much because usually the baby will elicit a more forceful letdown, but it is worth a try. The football hold or holding the baby in a sitting position on your lap might help. The baby straddles your body with his legs and faces you directly. As the baby gets older, he will be able to handle the letdown reflex without a problem in any feeding position.

  Allergic reactions to foods in the mother's diet are rare but sometimes occur. The most common cause of allergy is cow's milk. Besides extreme fussiness with feeding, there is frequent spitting up, blood in the stool, and poor weight gain. The baby's health care provider should be contacted if these symptoms occur. If you must go on an elimination diet, make sure that you get information about how to supplement your diet so that you remain in good health and can continue to produce enough breast milk for your baby. It usually takes at least two weeks to see results from an elimination diet.

  Rarely will soaps or creams being used on the breast or nipples cause the baby to fuss and pull off the breast. If you have started using something new on your skin and the baby fusses, clean it off and start over.

  Yeast infections can occur in the baby's mouth or on the mother's nipples. You might see white patches in the baby's mouth. The baby may also develop a diaper rash. Your nipples could be very red or itchy. There is a burning sensation of the nipples following the feeding. Your baby may be fussier during his feedings. See your health care provider. If a yeast infection is diagnosed, both you and the baby should be treated. If the baby is using bottle nipples or pacifiers, these should be replaced with new ones. They should be washed daily with hot soapy water and allowed to air dry. Change your diet by eating more yogurt or drinking acidophilus milk daily.

  Some babies become fussy if they are overstimulated. They may have better breast-feeding sessions if the lights are dim and they are allowed to feed with only ambient sounds.

  If you have implemented these suggested techniques and you still have a fussy baby, it may be that the baby is not hungry. She may be drawn to the breast for comfort, but once she starts to nurse does not really need to feed at that time. Remember, a baby under twelve weeks of age does not have much ability to self-soothe. As parents, we need to meet these needs just as much as we need to provide them with the other necessities of life. Many of the things that seem to help soothe them are measures that imitate the in utero environment. Make sure that the baby is comfortable—not too warm or too cold. A clean diaper should be provided. The baby may be comforted by being held tightly and cuddled or rocked. Besides cuddling and rocking, swaddling, or ongoing sounds like music, dryers, or fans may help. Perhaps a pacifier will give your baby some additional soothing. The use of a soft side or front carrier will give you the chance to get other things done while you are providing comfort for your baby. Another person—the father or a grandparent—may be enlisted to calm the baby without the baby being stimulated by the smell of the breast milk that envelops the mother. This also gives the mother a chance to get a little time for herself. Try to take a nap or get some exercise. These activities will help you feel refreshed. Later, after the baby has been calmed by other methods, the mother will be ready to breast-feed more calmly.

  It takes time and the trying of different techniques to find out what your baby needs and how best to meet those needs. Feel free to experiment. The baby may respond to certain things at one time and to other things at another time. Remember, it is a learning process, so don't expect you or the baby to be perfect.

  Take good care of yourself during this time. Eat well. Take your prenatal vitamins. Stay well hydrated and get some outdoor exercise, if not daily at least five days per week. Try to use relaxation techniques—yoga, meditation, massage, or a warm bath—to help you get through the difficult times. Share your feelings with the baby's father or other family members and let them take turns walking, rocking, and cuddling the baby. Set small goals for yourself—like reading one chapter in a book or taking a fifteen-minute walk.

  New-mother support groups help a lot because you learn that other mothers and babies are going through the same adjustment period that you are. Most reasons for infant fussiness will be worked out within the first six weeks of life. A few may take a little longer, but by three months of age it is usually resolved. Remember, overall, this is a very short time in the life of you and your baby. Try to hug and cuddle your baby as much as you can in order to help him get through this rough time. Together you can do it.

  As discussed by Nancy Nelson, lactation consultants can be very helpful and I would encourage you to seek one who has been certified by the International Board of Lactation Consultant Examiners (IBLCE) and is entitled to use the title International Board Certified Lactation Consultant (IBCLC). In general, successful breast-feeding will require the family to make adjustments to fit the needs of the baby, and breastfeeding may not work well if the parents attempt to force the baby to fit into the family's schedule, especially if the baby has extreme fussiness/colic.

  Keep reminding yourself that extreme fussiness/colic is not indigestion. It is not caused by formula or breast milk. Switching from one formula to another will not stop the crying. Some manufacturers of infant formula try to sell their product by claiming that their product will reduce fussiness. The so-called research they cite to support their claims is weak, unconvincing, and has not been reproduced.

  Do not let extreme fussiness make you give up breastfeeding if you want to continue. Your baby is still getting all the benefits of breast milk, even if she seems at times not to appreciate them. If you stick with it, you can look forward to many calm, pleasant months of nursing once the extreme fussiness has run its course.

  Still, nursing an extremely fussy baby is undeniably a challenge. When nursing, infants with extreme fussiness/colic tend to be gulpers, twisters, and forceful suckers. Sometimes they seem to reject the breast entirely. The determined nursing mother is in a bind; it is difficult to nurse a tense, twisting infant, but nursing is one of the few maneuvers that appear to calm such a child (at least temporarily). Non-nutritive nursing, using your breasts as pacifiers, may calm baby, but it is no picnic for mother! Here is a description of the nursing predicament by the mother of one of my young patients.

  The first three weeks of Michael's life led me to believe that having a baby would be a breeze. His behavior was almost identical from day to day. He was very calm, and so were my husband and I. Michael would eat—breast-feeding about eight to ten minutes on each side. He had no problems burping after each meal. Then I'd either hold him for a while, lay him on his back, and talk or play with him. The usual schedule, from the time he got up until he
went to sleep, would be one to one and a half hours. He would usually sleep anywhere from two and a half to four hours. Everyone said to me, “Boy, are you ever lucky to have such a good baby.”

  As the fourth week approached, Michael's behavior changed dramatically. He no longer wanted to sleep during the day. I felt like all he wanted was my breast. I concluded that he either was continually hungry or had strong sucking needs.

  By the middle of each afternoon, I was exhausted. Almost every hour I found myself breast-feeding. Sometimes I could put him off for two hours, but he'd cry a lot. I'd change his diaper, walk him, hold him, tilt him, sing to him, change his position and so on. Nothing would please him except my breast, which was terribly tiring, to say the least. The thing that saved our lives is that he slept long hours through the night—probably from exhaustion after being up all day. The worst times were midafternoon, and again between 5:00 and 10:00 P.M., after which he would sleep for around five hours straight. He would fuss and cry and nothing would calm him except when he was nursing.

  If your situation is similar to this mother's, give yourself some relief by trying the following suggestions:

  Space feedings a few hours apart. One mother said, “I must have Chinese breast milk; he gets hungry just one hour after nursing.” If you last nursed your baby well less than two hours ago (not a snack or a sip), there is no room in his stomach for more milk and your breasts contain little or no milk for him. Nursing too frequently is pointless, and if it causes you pain or exhaustion, it is destructive. See if the baby will accept a pacifier instead.

  Ask your doctor about hydrocortisone ointment. A famous pediatric dermatologist who nursed her own children suggests treating cracked nipples with 1 percent hydrocortisone ointment. It is safe for both mother and baby, and seems to work better than any other treatment. Many of my patients’ mothers have reported rapid healing of sore nipples by using this treatment. After nursing, allow your breasts to air dry. Then apply a thin film of the 1 percent hydrocortisone ointment to the dry or cracked areas. Make sure you use ointment, not cream; the cream might cause a painful burning sensation. When you are about to nurse again, do not wipe or wash off any of the ointment. Most of it will have been absorbed into your breast skin and the small amount the baby absorbs will cause no harm. Basically, the skin of the breast can become very dry, cracked, or fissured from being wet or damp for prolonged periods of time.