Soothing the unsettled baby

Settling babies can be difficult for many parents.

“UNSETTLED” is the commonly used term for behaviour in babies (aged up to 12 months) that parents can find difficult to live with and clinicians can find difficult to treat.

Unsettled 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 caregivers. If the baby is responsive and rewards the mother by quieting to her soothing or by 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 helpless.²

Confidence can diminish rapidly and parents are less likely to experience interactions with their infants as pleasurable.³ 

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 women.⁵

Unsettled infant behaviour is a common reason for repeated help-seeking from primary healthcare 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.

Responses 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, to sleep. 

There is limited systematic evidence available about the effectiveness of these strategies in reducing unsettled infant behaviours.⁶

The other position on the spectrum, ‘infant behaviour management’, holds that unsettled infant behaviour causes significant problems for many families and 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 that 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 minutes.⁷

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 that 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.

Practical advice to give to parents of unsettled infants

- Establish a feed-play-sleep routine

- Avoid over-stimulation

- Recognise their baby’s tired cues

- Separate feeding from sleeping

- Provide predictable pre-sleep soothing routines

- Minimise sleep associations like rocking or suckling to sleep

- Place the baby in bed awake

- Have a safe sleep space in a darkened room

- Have no toys in the cot

- Pat rhythmically until the baby is quiet

- Give brief supported opportunities for the baby to learn to settle to sleep by leaving the room when the baby is quiet

- Re-settle if the baby wakes after a single sleep cycle of about 45 minutes.

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



Dr Jane Fisher BSc (Hons), PhD, MAPS 

Dr Heather Rowe BSc (Hons), PhD

Jean Hailes – Women’s Mental Health Program, School of Public Health and Preventive Medicine, Monash University