Unsettled baby: signs, symptoms and treatment

Whether you’re a parent or not, you’ll have experienced a baby crying incessantly. Unfortunately for many parents, this is something they have to contend with every day, over a long period of time. We spoke to Dr David Shortland, one of our most experienced paediatricians, about what causes a baby to be unsettled and the options for treating this condition.

What exactly is an unsettled baby?

All babies cry as a means of communication, often to convey the feeling of discomfort, for example; when they are hungry. It is a well-known fact that adults find it very difficult to ignore the sounds of a baby crying and constant crying can be particularly distressing for parents who may be concerned that their baby is unwell. Also, the sound of the cry itself is distressing to the adult brain, unfortunately babies have evolved in this way, as if they sung a gentle lullaby to communicate distress, we would ignore them!

Sometimes babies cry excessively and for no apparent reason, which is when we describe them as “unsettled”.

What are the main symptoms of an unsettled baby?

The following symptoms are common in unsettled babies:

• Excessive crying, possibly throughout the day and night
• Tense body posture
• Jitteriness
• Arched back
• Unusual/lack of interaction with carers

While many of these symptoms, particularly in isolation, are common in babies that are hungry, tired or just in a bad mood, in unsettled babies many of them occur together, and usual remedies like feeding, burping or changing a nappy won’t work.

When should parents start to worry?

If there is a sudden change in a baby’s temperament, particularly if the baby appears to be unwell or has a high temperature, parents should seek immediate medical advice as this may be a symptom of an evolving medical disorder.

Babies will often have “bad days” where they will appear to be quite unsettled, but if intense and excessive crying persists beyond a few days the parents should seek help from a health care professional. Initially this could be from a midwife, health visitor or general practitioner.

What are effective treatment options for a constantly crying, unsettled baby?

In the first instance it is important to decide whether the crying may be a sign of a significant illness and whether the baby needs immediate medical attention. Fortunately, these scenarios are relatively rare. The more common situation is where a baby has cried excessively for a long period, often from birth. In these situations, the cry usually conveys pain.

There are hundreds of potentially painful conditions in babies but the conditions I see most often are gastro-oesophageal reflux, cow’s milk protein intolerance/allergy or a combination of these two factors. The healthcare professional making an assessment of an unsettled infant will take a detailed history and perform a detailed physical examination in order to decide whether there may be a different cause for the baby’s discomfort. If no other causes are apparent and if treatment is required, it would usually be directed at these two potential causes.

Can gastro-oesophageal reflux and cow’s milk protein intolerance/allergy be treated?

Whilst a significant proportion of unsettled babies have either gastro-oesophageal or cow’s milk protein intolerance/allergy it can be difficult from the history and examination to decide which of these conditions is most likely to be the primary cause. If there is a family history of eczema and the baby has eczema, cow’s milk protein intolerance/allergy is more likely to be the diagnosis. If the baby is vomiting excessively, becomes uncomfortable early in the feed or arches his or her back, gastro-oesophageal reflux is the most likely problem. It is important, however, to recognise that both of these conditions can occur simultaneously in the same baby.

There are many milk formulae available to manage cow’s milk protein intolerance/allergy. It is true to say that most parents I see who have considered that the milk may be causing the baby’s symptoms, will have tried many different standard formulae. There is relatively little scientific rational for switching between standard formulae and it is important to use a different approach when managing this condition. In the first instance a hydrolysed milk formula will be tried. If there is partial or no improvement with a hydrolysed formula then an elemental feed would be tried next. These feeds can provoke gastro-oesophageal reflux (as they are much thinner) and it can be helpful to use thickeners routinely when using a hydrolysed or elemental feed. My personal practice is to try a hydrolysed formula for around five to seven days before moving onto the more specialised formulae.

Whilst there is often a dramatic improvement in the symptoms when a cow’s milk intolerance/allergy is treated by a change of formula, the response to treatment for gastro-oesophageal reflux is usually slower and, despite full treatment, the symptoms may persist albeit less severe. In my experience in secondary care most of these infants have tried Gaviscon or stay-down formulae before they are referred to the paediatric clinic. These approaches can be helpful but quite commonly cause constipation. Symptoms of gastro-oesophageal reflux will usually improve spontaneously at around seven to eight months of age and early weaning with solids (at around five months of age) can be helpful. For younger infants, particularly where the symptoms are severe, medicines are usually prescribed. Omeprazole and Lansoprazole can be helpful but it is important to recognise that the symptoms of reflux are not simply due to “reflux of acid” alone and although effective treatment should reduce the irritability, some of these infants remain “unsettled” until the natural resolution happens.

What can doctors/paediatric specialists do to help?

• Inform families of the cause/s of their baby being unsettled
• Reassure them that there are no serious underlying issues
• Help the family to navigate treatment approaches
• Help the family sift through information found on the internet in order to come up with the best treatment plan
• Help the family to understand the mechanisms of the problem
• Conduct additional investigations if necessary

For mothers who are breastfeeding, there are dietary approaches for the mother that can be helpful. For infants with gastro-oesophageal reflux, doctors can discuss treatment options and the natural improvement that is expected to occur in this condition.

Rarely, the doctor may decide there is a more unusual cause for the irritability and will discuss what type of investigations may be helpful in identifying these conditions.

If you’re having trouble with an unsettled baby, or would like expert consultation on any other paediatric issue, visit Dr David Shortland’s Top Doctors profile and request an appointment with him now!