Settling babies can be difficult for many parents.

"Unsettled" is the commonly-used term for behaviour in babies aged up to twelve months which parents can find difficult to live with and clinicians can find difficult to treat.

Unsettled infant behaviours include:

• prolonged episodes of crying
• inconsolable crying
• resistance to soothing
• difficulties settling to sleep
• waking after short sleeps
• frequent overnight waking.

At least one in four families experience problematic infant crying and fussing behaviours. Up to one in three families experience a problem with infant sleep.

Infant crying is highly arousing to care-givers. If the baby is responsive and rewards the mother by quieting to her soothing or smiling, interacting, suckling easily, and developing along an average trajectory, the baby provides gratification and promotes self-esteem.

In contrast, an infant who is difficult to soothe, cries inconsolably, does not breastfeed easily, or sleeps poorly, can be experienced as critical and unappreciative.

Much contemporary infant care advice encourages parents to trust their intuition or instincts¹ and to provide care that feels appropriate. However, when caring for an inconsolable infant, and having a comfort repertoire that only includes feeding or unsustainable sleep associations like rocking and suckling, parents can feel ineffective and helpless².

Confidence can diminish rapidly and parents are less likely to experience interactions with their infants as pleasurable³. Prolonged infant crying has been shown to contribute directly and independently to deterioration in the familial emotional environment⁴ and to precede mental health problems in women⁵.

Unsettled infant behaviour is a common reason for repeated help seeking from primary health care professionals, medical specialists and hospital emergency departments with high costs to the health sector. Parents also seek assistance from self-help books, DVDs and websites. These sources include a wide range of views about the causes of unsettled infant behaviour and the best responses to it. The quality and reliability of this information, particularly in relation to its evidence base, effectiveness, safety and risk is often unknown, contributing to confusion and uncertainty for parents.

Reponses to unsettled infant behaviour can be grouped broadly into two positions on a spectrum. In the Intuitive Parenting position parents are encouraged to trust their instincts and respond to all unsettled behaviours with active comforting including rocking, 'wearing' the baby in a sling or pouch, holding, and suckling, including to sleep. There is limited systematic evidence available about the effectiveness of these strategies in reducing unsettled infant behaviours⁶.

The other position on the spectrum, Infant Behaviour Management, holds that unsettled infant behaviour causes significant problems for many families; is not usually attributable to organic illness or always readily explainable. In this approach, after excluding health-related explanations, parents are given active strategies to shape caregiving behaviours to establish a feed-play-sleep routine of daily care which promotes infant sleep and from which reductions in crying and fussing usually follow.

These include:

• recognising behavioural cues of tiredness
• separating feeding from sleeping
• having predictable pre-sleep routines of quieting and soothing
• placing the baby in bed awake
• ensuring that the safe sleep space is in a darkened room and that there are no distractions
• using rhythmic patting until the baby is quiet
• ceasing unsustainable sleep associations like rocking or suckling to sleep,
• leaving the room when the baby is quiet so that the baby can learn to settle to sleep
• re-settling if the baby wakes after a single sleep cycle of about 45 minutes⁷.

Infant Behaviour Management strategies can be taught in primary care. Parents benefit from support and encouragement as implementing these techniques can be anxiety-arousing. It is helpful to arrange progress reviews which focus on problem-solving and tailoring the techniques to the family's particular situation.

Parents can be reassured that these evidence-based techniques are associated with increased infant sleep, reduced crying and fussing and improvements in maternal mental health and mother-infant relationship and are not associated with short or long term harm.⁶

These strategies are outlined on the What Were We Thinking website (www.whatwerewethinking.org.au)⁸, which many parents will find useful. 

Talking Women - Soothing the unsettled baby144.87 KB

References

1. McKay P. 100 ways to calm the crying. South Melbourne: Lothian Books; 2002.

2. Armstrong K, O'Donnell H, McCallum R, Dadds M. Childhood sleep problems: Association with prenatal factors and maternal distress/depression. J Paediatr Child Health. 1998;34:263-66.

3. Beebe S, Casey R, Pinto-Martin J. Association of reported infant crying and maternal parenting stress. Clin Pediatr (Phila). 1993:15-9.

4. Lehtonen L, Gormally S, Barr RG. 'Clinical pies' for etiology and outcome in infants presenting with early increased crying. In: Barr R, Hopkins B, Green J, editors. Crying as a sign, a symptom, and a signal. London: MacKeith Press; 2000. p. 67-95.

5. Lam P, Hiscock H, Wake M. Outcomes of Infant Sleep Problems: A Longitudinal Study of Sleep, Behavior, and Maternal Well-Being. Pediatrics. 2003;111(3):e203-7.

6. Fisher J, Rowe H, Hiscock H, Jordan B, Bayer J, Colahan A, et al. Understanding and Responding to Unsettled Infant Behaviour: A Discussion Paper for the Australian Research Alliance for Children and Youth (ARACY) 2011; http://www.aracy.org.au/publicationDocuments/ARACY%20Unsettled%20Infant%20Behaviour%20report%20FINAL.pdf.

7. Hiscock H, Bayer JK, Hampton A, Ukoumunne OC, Wake M. Long-term mother and child mental health effects of a population-based infant sleep intervention: cluster-randomized, controlled trial. Pediatrics. 2008 Sep;122(3):e621-7.p>

8. Fisher J, Rowe H. What Were We Thinking [accessed 06 Sptember 2011]; Available from: www.whatwerewethinking.org.au.

Content updated 7 October 2011