Four good (and common) reasons for restlessness in babies

Four good (and common) reasons for restlessness in babies

A post I’m really happy about, on a subject I like to deal with in my everyday life – restlessness in babies.
In addition, from past feedbacks I got from you, I know that this post helped a lot of parents diagnose their baby correctly, after endless and pointless examinations.
Notice that I do not talk about a baby who just started crying 2 hours or 2 days ago, but about babies, generally younger than 4 months, that cry, experience restlessness, unusual fussiness or unexplained pains for a long period of time (hard to say exactly how long but most certainly over 7-10 days).
I like this subject, since a doctor has only his ears (for hearing a coherent anamnesis from the parents), brain (for thinking), hands (for a thorough medical examination), and his bottom (who sat through hours of clinical time and has the experience).
In most cases there is no need for lab work or X-rays.

I want to emphasis this again – this is about a baby who is younger than 4 months who is experiencing extreme restlessness for a period of days-weeks.
For the purpose of being precise, in this post I will address 4 common diagnoses (relatively) in this context. For each diagnosis I will offer specific patterns that are typical of each diagnosis, and of course – solutions.
The goal here is to give parents a “tool box” that will help get the correct diagnosis along with the pediatrician, and to get the right solution.

What are the basic rules to remember regarding restlessness in babies?

Restlessness and crying are an inseparable part of raising healthy babies. This behavior is one of the ways babies signal parents that they need something. It is difficult to say where the line between normal restlessness and pathologic restlessness is. I suggest going and seeing a pediatrician in any restlessness that is behind reasonable.
Restless parents or families cannot expect a calm baby. A restless baby needs (a part from a specific solution to his problem) calm and relaxed parents, a daily routine and not a stressed family. Easier said than done, I know.
Sometimes there is not just one diagnosis but two. My recommendation is to finish reading these 4 conditions before jumping to conclusions.
These are the 4 more common diagnoses in my opinion, but they are not the only ones. Please tell your pediatrician the full story and let him decide with you about the correct diagnosis.

These are the most common diagnoses in a restless baby:

The gaseous (colic) baby

What can I say about the gaseous baby (AKA the baby with Colic) that hasn’t been said before? And why did I start with this annoying and banal diagnosis?
Well, this is the most common cause for restlessness in babies, and I have a lot to say about it, so it was impossible to start with other conditions. Since this is a very common diagnosis, there is a separate post about it, in this link.
According to the text books, the incidence of abdominal pain due to colic is about 20% of all babies. In real life, there are almost no babies I know that hadn’t suffered from colic in some way or another. The reason for colic is unknown and there are no real differences between formula fed babies and breast milk fed babies.
As for the definition of colic I found two options in professional literature:
In a more practice form – the rule of three. A happy thriving baby, events that starts at weeks 2-3 of life, last at least 3 hours, at least 3 days a week, for at least 3 weeks and passes without any treatment when the baby is about 3-4 months old.
In a more scientific form – a baby that fulfils the following criteria:
Recurrent events of crying, discomfort and restlessness occurring without an apparent reason. The duration of the events is over 3 hours for at least 3 days or more in a week.
Symptoms begin and end before 5 months of age.
The baby does not have any background illness (such as failure to thrive, current febrile illness etc.)
Practically these are babies, usually a few weeks old (but can certainly be younger) that are restless and often cry for minutes or hours. Most parents can direct the pediatrician towards the abdomen as a source for the baby’s discomfort.
Symptoms are at their peak at the age of 6 weeks according to the text book. But not all babies read the text books.
Typically most families report exacerbation in the complains at the evening or early night. Most importantly (so you will not miss any other diagnosis) – this is a baby who gains weight, achieves his developmental milestones, with a benign physical examination with no other relevant medical history (in some ways this is a rule-out diagnosis). These abdominal pains are causing great discomfort for the baby and his family, loss of sleep hours and frustration.
In some family there are attempts in changing formula, which usually just cause another cycle of stress and disappointment. Some parents report relief by touch, by lifting the baby and keeping him close to one of the parents, or by gently massaging the abdomen (clockwise). Sometimes rocking the baby back and forth or driving him in the car or baby cart will ease the discomfort.

What is the treatment for colic?

Beside confirming the diagnosis and calming the baby, there is no specific treatment to ease symptoms. The pediatrician’s job in this condition is to calm the parents with confirming the correct diagnosis, provide explanations on the condition and specifically on the fact that it will pass and it is not dangerous. A permanent routine may help the baby and the family.
Parents who can go out by themselves, one night a week, and forget a little bit about the frustrating abdominal pain will find themselves more calm and accepting the restlessness.

What about analgesics?

It always surprises me how much guilt parents have, when it comes to giving paracetamol in this diagnosis. This is the place to say it – it makes total sense to give paracetamol, it is allowed and lots of parents do so. There is no need for a continuous administration of analgesics, but some days (and mostly some nights) are very hard, so you can try giving your baby paracetamol (or any other appropriate to age pain killer) and get some relief.

How about giving probiotics to babies with colic?

For the majority of the different types of probiotics, there is no scientific evidence that their use is beneficial in treating colic in infants. The scientific evidence that does exist was able to prove efficacy in breastfeeding infants only, and even then, the improvement demonstrated was minor.

Therefore, I advise you all to put minimal effort, time and money into and have minimum expectations from the different probiotic products available out there, that claim to be beneficial for infant colic.

Does changing the formula helps with abdominal pain or colic?

In most cases it won’t help, unless there is another diagnosis in the background. Practically I see a lot of parents considering changing formula or ones who’ve already done that. Changing the formula often gives the feeling that something is being done (like saying that a new broom is a good broom), but in most cases it wouldn’t help.
Manufacturers are always inventing new formula brands with flashy names and a lot of promises. But past studies did not show that changing formula will help, except for very few and specific cases.

Is there a medicine that can relive colic?

Again, nothing really helps for the long run. It’s true that in most “medicine” sold for colic (without prescription, mind you), there is sugar which relaxes the baby for a few minutes. Nothing really changes the course of these abdominal pains.
Remember that it is very difficult for us as doctors to stand in front of a family looking for solutions for a restless baby and say – “there’s nothing to do”. But the main thing here is that the right “treatment” in these cases is to relax and calm the whole family, so you can get through these difficult months.

The hungry baby:

Not a common diagnosis, but one that is relatively easy to discover (in most cases), and the treatment or intervention is simple. In addition, improvement can be felt rather immediately, which gives a lot of satisfaction to the parents and the doctor. First, let’s address the elephant in the room, to all of you who felt a bit uncomfortable when you read the title “hungry baby”. We are not talking about a famished, dehydrated, poor baby. This is a baby who could and should have eaten more than what he is receiving currently and therefor suffers from restlessness with specific patterns.
In this category I see two types of babies:
Breast fed babies – we all know that you cannot estimate exactly how milk a breast fed baby gets (as long as it is direct breast feeding and not pumped milk given in bottles). Sometimes the baby doesn’t get all he needs while being breast fed and suffers from restlessness as a result.
Bottle fed babies – babies who are being fed by bottles (containing breast milk or formula), but the amount administered is not enough. These are babies that finish the bottle during most meals. Parents often make a measured amount (which in retrospect is not enough) based on various recommendations (from their parents, friends, maternity ward nurses and more).
In my opinion – in most meals, a baby (at any age, even a three days old baby) needs to leave a little bit of milk in the bottle. If a baby finishes his entire bottle in a few consecutive meals, and gets restless before the next one, than you should increase the amount you’re giving him. You can of course calculate how much a baby needs to eat in a day or a meal (150 milliliter for every kilogram of bodyweight, divided by the number of meals a day). This is a good calculation to teach at university, but in life there is no defined number that is correct for all babies (even those who weigh the same are in the same age).

What is the typical pattern in a case of a “hungry baby”?

Most babies that are restless because of “hunger” tell a story of restlessness that is relieved after a meal, but begins again 2 hours after. In breast fed babies the main hint is that the baby is attached to the mother all the time and wants to eat every 1-2 hours.
In babies that are bottle fed, I mostly hear that they are eating fixed amounts of formula (60 ml, 120 ml. etc.) in every meal and almost always finish the bottle. Here and there when a more experienced person (mostly the grandmother) feeds them – they eat more than their usual amount and calm a bit. As for weight gain, it would be nice to say that babies who don’t get enough milk are not gaining enough weight, but it is not always the case. Some babies are gaining weight but are still restless and could enjoy a larger amount of milk.
How do you solve this problem? The pediatrician needs to calm the parents, and to insure that nothing bad happened, and that the baby is fine. Parents to the “hungry baby” are frustrated and often blame themselves. This situation can happen to everyone, especially when given a bad advice. In most cases there is no harm done, the babies catch up really fast and gain weight quickly under the right intervention.
If the baby is breast fed, you can try these few interventions to diagnose and treat him:
– Asking the mother to give bottles of pumped milk in some of the meals. This gives us the advantage of knowing how much milk is in the breast. This is of course not accurate but it gives some idea (for example, if a mother manages to pump only 40 ml, then this is not a sufficient amount for a meal).
– Incorporating breast feeding with bottles (breast milk or formula). There are two options:
# Addition after breast feeding: You can add a bottle with the desired amount of pumped milk (if there is enough) or formula after each breast feeding. If the baby eats a good amount of the additional milk or formula, than it is clear that he could have eaten more from the begin with. I don’t have an accurate amount for what is a good amount. But even 30 ml, 7-8 times a day can make the difference in terms of gaining weight and keeping the baby happy.
# Giving a bottle (breast milk or formula) once or twice a day as a routine. This is a nice solution for breast feeding mother who can “fill up a bit” before the next meal, that can also integrate the partner in the feeding schedule of the baby (there are families in which the partner is exclusively in charge of giving a bottle once a day).
If the baby is not breast fed, you can just add additional 30 ml to each meal and see if the baby eats it all or leave some in the bottle. If he finishes the extra 30 ml, then make a little more for the next meal.
It is important to say that sometimes when giving the baby the option to eat how much he wants, the total amount he eats in a day will not go up as much as expected. For example, the baby can eat more in one meal but then will want to eat his next meal a little later than what he was used to. I think that longer increments of time between meals are an advantage.

Shouldn’t I be worried about over feeding the baby?

A common question. I must say that the use of this term is a lot more common than its actual prevalence.
It is not common to see families in which the baby is over-fed. Overfeeding is a highly pathologic condition, when the parents (unfortunately, mostly the mother) are over feeding the baby for a long period of time, in a most unusual way, until milk almost shoots out of his ears. Over feeding is characterized by frequent feeding, large amount of milk, feeding while the baby is asleep (a terrible habit), and shoving a bottle to a baby who is not hungry at all. These situations are not common at all.
Another criticism I hear is about the satiety mechanism of babies, and the fact than when giving as much milk as they want, it can cause them to have bad eating habits in the future. The opposite is correct. Of course, there is no need to feed a baby every hour and a half, and there is no need to feed a baby who does not want to eat, this is not my intention.

The baby who is allergic to cow milk protein:

A specific post on this subject can be found in this link.
This is a medical condition that is prevalent in about 2% of babies. A correct diagnosis and treatment can save the baby and his family a lot of discomfort.
This is also the post for which I received a lot of feedback from parents that realized after reading it and seeing the photos (scroll to the end of this chapter) , that this was the reason for their baby’s abdominal pain.
This is about an allergy for the cow milk protein in formula. It happens in babies who are fed by ordinary dairy formula (and soy based formula as well, explanation follows). A similar clinical presentation, mostly milder, can also happen in a baby who is breast fed exclusively (in about 0.5% of cases). Read more about milk allergy in breast fed babies in this link.
The word sensitivity is more accurate than allergy for this medical condition. It is true that there are cases where the allergy is severe and can present with severe symptoms such as rash, vomiting, diarrhea in a substantial amount. But as I said in the beginning of this post, these are not the babies I aim for in this document.

What is the typical presentation of babies with cow milk protein allergy?

The clinical presentation is different from one baby to another. It can be mild, with abdominal pain, restlessness and mucoid stools here and there, and can be severe with distended sensitive abdomen, a baby who doesn’t gain weight and has bloody, mucoid stools.

What is the difference between watery stools and mucoid stools? How to tell the difference and what does it mean?

Let’s stop for a moment and understand the difference between watery stools and mucoid or bloody stools. Diarrhea can be watery, mucoid or bloody. The two latter characteristics are indicators of inflammation in the bowels, mostly caused in older children by bacteria. In young babies, the prevalence of bacterial infection is low, and most cases of bloody or mucoid diarrhea are caused by cow milk protein allergy. I’ve come to realize over the years that even experienced parents do not always know to tell if it is mucoid stools, so I’ve attached a few photos to this post (not for the faint of heart), so you will have a reference. These stools are indicators for inflammation in the bowels and require medical attention.
The experienced physician will diagnose this situation correctly, by taking a detailed anamnesis along with photos of the stools provided by the parents (one photo is worth a 1000 words). Further on, the doctor will perform a thorough physical examination, especially concentrating on the abdomen – sometimes it is distended and tender. There is no good lab test to preform that will help determine the diagnosis, including allergy testing. This is a clinical diagnosis.
There is a wide span in the age of appearance, since sometimes it is all about the amount. A baby can deal just fine with small amounts of formula, but when larger amounts are introduced (as the baby get older and requires larger meals or when decreasing the amount of breast feeding), than the clinical presentation will appears.
It is interesting to know that this sensitivity is not common in exclusively breast fed babies that are not exposed to formula. So are there proteins in breast milk that are similar to cow milk protein, or are there some cow milk protein that the mother consumes that pass through breastfeeding to the baby? These are good questions. In these cases it is recommended that the mother reduce the amount of milk she consumes. Some textbooks even say to stop consuming milk whatsoever, but this is debatable. Remember that if a mother reduced milk products in her diet, than you should consider supplementing calcium and vitamin D to the mother.

What is the treatment for babies with cow milk protein allergy?

Easy. Changing the formula to a semi or fully elemental formula brings relief of symptoms in most cases. The relief occurs mostly after a few days in the simple cases but can take longer, even a few weeks. Changing to plant -based formula is not recommended since there is cross reactivity in high percentage between cow milk protein and soy protein.
The decision on changing back to dairy based formula and of when to expose the baby to milk products will be done by the experienced physician on a case by case basis.
In cases where there is no improvement in symptoms after changing to semi-elemental formula, there is room to investigate a bit more and consulting with a pediatric gastroenterologist.

The baby who has gastroesophageal reflux (more accurately, the baby with heartburn):

First, a word on definitions so we can define this situation better. Parents who can understand these different definitions will not get confused and will be able to give the baby the correct treatment.

What is reflux?

Reflux is also called gastroesophageal reflux, or in short – GER. This is returning of stomach content back to the esophagus. Reflux happens physiologically every day and almost in all newborns. Sometimes it will be accompanied with spit-ups (regurgitation) and sometimes without. This is a normal condition that happens in all babies. A baby with simple reflux is not in any pain or discomfort. If you want to read more on GER, use the next link.

What is reflux disease?

Reflux disease or gastroesophageal reflux disease (GERD) is when the reflux is causing a medical problem such as pain (heartburn), failure to gain weight (since some of the food is spited out) or respiratory problems (since some of the stomach content wrongfully passes to the lungs).
The term occult reflux is a common term between parents and caregivers in this context.
According to text book, reflux is very common in the first few months of life, reaches its peak around 4 months and that passes until the baby is one year old. In real life, reflux is more common until 4 months and then the prevalence decreases. Most babies with reflux (with or without spit-ups) are cute, happy and healthy babies with no problem at all. We call them “happy spit-ers”.
But when the stomach content, which is acidic, reaches the esophagus, than discomfort can occur.

What are the symptoms of a baby with GERD or occult reflux?

Symptoms in GERD are crying and restlessness, especially in the beginning of the meal. In addition – avoidance and refusal to eat. During feeding there can be “Sandifer movements”, which includes arching of the back and turning the head to the opposite side. Failure to gain weight can appear later on. Many parents report to hear or feel the food going up through the esophagus, even if there is no spit-up at the end.
Babies are mostly hungry. At least at first they will start eating vigorously, but they just can’t continue on or finish a meal. After a while food aversion and refusal to eat can develop.
It’s important to say that not all babies that have heartburn due to GERD are having a lot of spit-ups. In some cases there are spit-ups, and in other there aren’t any.

What is the treatment in cases of babies with reflux?

There is treatment, though it may not be that simple.
Thickening the food or changing formula to anti-reflux formula do not necessarily help, just because it’s not about the food going up, but about the acidity of the stomach content. These formulas can help with reflux and spit-ups, but would not help the GERD (heartburn).
In milder cases you can try adjust feeding techniques or finding amounts and feeding frequency that would cause less discomfort for the baby.
In cases where GERD is suspected there is room for the evaluation of a pediatrician. He will need to rule out other conditions with similar symptoms and consider treatment options to reduce the acidity level in the stomach. In my personal experience, in babies with the correct diagnosis, these medications can help in a matter of days, and change for the best the pain, discomfort and frustration. As always, the advantage of treatment needs to be considered versus the minor side effects of these medications.
One key point to remember – the only medication that should be given in cases of real heartburn is Omeprazole. Read about how to give this medicine in this link, since there is a lot of confusion around this subject.

In conclusion: this is a very basic, yet important post. Try to find your babies amongst all the diagnoses listed above, and try to ease the symptoms in the correct way using the “tool box” I’ve assembled for you here.

Mucoid stool

Click on me to view the image

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