4 good (and common) reasons for baby restlessness

An episode that Im really fond of, on a topic that I really like to deal with in practice – restlessness in babies.

I am not talking about the baby who started crying two hours or two days ago but about babies, usually younger than 4 months, who over a period of time (it is difficult for me to set a set period of time, certainly over 7-10 days) suffer from restlessness, unusual nervousness or unexplained pain .

I love this topic, because ultimately in parenting advice on baby restlessness, the doctor only has his ears (for taking a clear illness story from the parents), the head (for thinking), the hands (for a thorough physical examination) and the ass (for experience).
In most cases these or other laboratory tests or imaging are not necessary or do not help.

Again, emphasizes – a young baby from the age of 4 months who is restless that exceeds the limit of good taste for a period of long days / weeks.

For the purpose of focus, in this chapter I will write about 4 common diagnoses (each relatively of course) in this context.
For each of the diagnoses I will suggest typical patterns that will make it easier for the parents to suspect a particular diagnosis and of course solutions.

At the end of the chapter I will summarize main points that summarize the differences in the different representations of these four situations when the goal is to give parents a "toolbox" that will help them reach the pediatrician and with it reach a correct diagnosis, intervene and facilitate.

Some basic points I would like to emphasize in the context of a Restless Baby:

  • Restlessness and crying is an integral part of raising healthy babies. This behavior is one of the ways the baby can signal to his parents that he needs something. Therefore, it is difficult to determine where the line of good taste passes between normal restlessness and pathological restlessness. I would recommend parents to consult a pediatrician for any prolonged restlessness beyond reasonable.
  • Parents / families who are not calm can never expect a calm baby. Precisely the baby who is restless, needs (beyond proper diagnosis and treatment depending on the situation) calm and containing parents, a regular agenda and not a stressful and stressful family. Easy to say, hard to do, I know.
  • Sometimes, there is not just one diagnosis in the baby and some of the babies suffer from two problems. In addition, I recommend that parents finish and read about the four conditions and understand the differences between them before jumping in and deciding that their baby is suffering from one medical condition or another.
  • These are four common diagnoses for me, but they are not the only ones in pediatrics. Please tell your pediatrician the full story of the disease and let him decide with you what the correct diagnosis is, so that you will not miss another important diagnosis.

These are in my opinion the four most common diagnoses in these babies:

The baby suffering from flatulence:

What else can I renew with gases (synonymous – colic)? And why did I start with this banal and annoying diagnosis?
Well, this is the most common cause of restlessness in infants and I have such definite things to say about this condition, that it was impossible to start in one of the other three conditions.

In light of the fact that this is a super common situation, there is also a separate chapter on the website for gas , At the following link.

According to pediatric textbooks, the incidence of abdominal pain for this reason is about 20% of infants.
But in real life I hardly know any babies who have not suffered from overeating to one degree or another. The cause of colic is simply unknown and there is no difference between breastfed babies and those fed formula.

As for the definition, I have found two beautiful definitions in the professional literature:
Practical definition according to the 3rd law – a healthy and prosperous baby, events that start at 2-3 weeks of life, last at least 3 hours a day, at least 3 days a week, at least for 3 weeks and pass without treatment until 3-4 months of age.
More scientific definition – a baby who meets the following three criteria:

  • how? Recurrent episodes of restlessness that include crying, for no apparent reason. Lasts over 3 hours a day, at least 3 days a week.
  • When? Started before the age of 5 months.
  • for who? A healthy baby who is gaining weight well, without fever or any other pathological medical condition in the background.

Clinically practical these are infants, usually from the age of a few weeks (but can certainly start earlier), who are restless and sometimes cry for long minutes or hours. Most parents know how to direct the doctor towards the abdomen as a source of the child’s discomfort.

Symptoms peak at 6 weeks of age according to medical books. In practice not all babies read the textbooks…

Typically most families report aggravation of the restlessness in the evening or early night.
And most importantly, in order not to miss another important diagnosis – this is a baby who is gaining weight well, achieves developmental milestones, his physical examination is normal and there is no suspicion of disease or other medical condition in the background (in a sense it is a negative diagnosis).
These abdominal pains cause great discomfort to the baby and his family, loss of sleep hours, irritability and frustration.

In many families, attempts are made to change diets, which usually only puts the family in another "dizziness".
Some parents report relief by touch; By lifting the baby and attaching it to one of the parents or by gently massaging the abdomen (clockwise). Sometimes rocking or riding in a stroller / car alleviates the discomfort.

Treatment – I’m sorry but except for the confirmation of the diagnosis and sedation, there is no real treatment aimed at relieving the symptoms of the suffering baby.
The role of the pediatrician in treating this condition is to reassure the parents with the help of a correct diagnosis, an explanation of the condition and especially emphasizing that the condition is transient and not dangerous.
A regular agenda for baby and family can help in this regard.

Parents who are able to go out one evening a week, disengage from these frustrating abdominal pains, will find that when they return they are more relaxed and contained.

What about giving painkillers?
I always wonder how much guilt parents have before giving a baby acetaminophen in this diagnosis. So this is the place to say out loud – it makes sense to give, it is allowed to give and lots of parents give. No need to start giving your baby acetaminophen continuously, but on difficult days (usually nights) you can definitely give and then try to rest because it usually helps for a short time.

What about giving probiotics in babies with colic?
For the most part most of the probiotic strains tested in the context of gas in infants have no research evidence that can help. However in good double-blind controlled trials, including a meta-analysis examining several studies, a specific strain called Lactobacillus rotary protectis (Lactobacillus reuteri DSM 17938) has been shown to improve colic symptoms in breastfed infants.
Therefore, in breastfed infants, full or partial breastfeeding, there is room to consider trying the individual preparations (or formula) that are sold in Israel and contain this specific type of bacteria.
What is less helpful for colic in infants? Almost everything we tried (you and I).

Formula replacement – Usually does not help, unless another diagnosis is hidden in the background. In practice I see that most parents (except parents of breastfeeding-only babies) have found themselves considering switching, or have already switched, to another formula.
Replacing a formula gives the impression that something is being done in an attempt to address the baby’s distress ("a new broom is a good broom"), but for the most part it does not really help.
The companies that produce baby food invent new morning formulas with special formulas with shiny names, low lactose and the like. But research (and in my opinion also in the real, non-research world) changing formula does not help except in specific and very specific cases.

Remedies for gas relief in infants – Again, nothing really helps in the medium or long term. True, most of these over-the-counter "medicines" have sugar and it calms the baby down a bit for a few minutes, but nothing really changes the course of these abdominal pains.
Remember that it is most difficult as a doctor to stand in front of a family looking for solutions for a suffering baby and say "there is nothing to do".
But the main message to parents “and the most correct” treatment in this situation is to calm the family set up in order to get through these four difficult months.

The hungry baby

Not a common diagnosis but one that is relatively easy (in most cases) to detect and its treatment or intervention is simple. In addition, improvement can be felt almost immediately and gives a lot of satisfaction (to parents and caregiver).
First of all it is worth putting things in proportion to anyone who moves uncomfortably when reading the headline "The Hungry Baby".
This is not about a hungry, ravenous, dehydrated and poor baby. This is simply a baby who could and should have eaten more than he actually receives and therefore suffers from restlessness with typical patterns.

I see in this category two populations of infants:

Babies who are breastfed – It is clear to all of us that it is impossible to estimate exactly how much milk the baby receives through direct breastfeeding (other than by pumping and through a bottle). Sometimes the baby does not get all his needs while breastfeeding and suffers from restlessness as a result.

Bottled babies – These are babies who receive pumped milk or formula in a measured amount in a bottle, but the amount is not enough for them. These will usually be babies who finish all the amount they received at most meals during the day. Usually, the parents prepare the measured amount (which in retrospect is not enough) according to the instructions or recommendations they received in different classes (baby ward, "tipat halav", friends / family, does not really matter).

However, in my view, a baby (at any age, even three days after birth) should leave a certain amount of milk in the bottle, at least at most meals. If the baby finishes the entire amount in several consecutive meals, and develops restlessness before the next meal, then the amount should be increased at the next meal. You can of course calculate how much you should feed a baby per day or at a meal (150 ml / siss per day per kilogram of body weight, do not forget to divide this amount by the number of meals per day). This is a good figure to teach students in the faculty with, but in life there is no set number that is true for all babies (even those who weigh the same and are the same age).

What is the typical pattern in these cases?
Most babies who are restless because of "hunger" tell a story of restlessness that is relieved after a meal but begins about two hours later. In mammals sometimes the hint is the fact that the baby hangs on the tit for quite some time, and eats every hour or two.
In those who are fed from a bottle in most cases I will hear that they get “round” amounts of formula (60, 120 et) at every meal and almost always finish the whole bottle. And here and there when a righteous member of the household (usually an experienced grandmother) gave them more, they also took the extra amount and calmed down a bit. As for the rate of weight gain then it would have been nice if I could say that it is not satisfactory in all cases and that it is an important clue to this situation, but it is not always so.
There are babies who rise not bad in the weight curves but are still restless because they could have enjoyed a larger amount of breast milk / formula.

How is this situation resolved? The role of the pediatrician is to convey to the parents that no catastrophe has occurred and that the baby has not been harmed, God forbid. Parents who at the end of the day make this diagnosis in their baby are beating up on sin and can be frustrated. But this situation can happen to anyone, especially when you get bad advice. In the vast majority of cases no damage is done, and these babies very quickly regain their weight curves and get along very nicely with proper intervention.

If the baby is breastfeeding, a number of interventions can be performed in order to reach a diagnosis and treat, among them:

  • The mother can be asked to pump and give some of the meals in a pumped bottle. Pumping has an advantage and that is that we can know exactly how much milk was in the breast. Of course it does not mimic breastfeeding perfectly but it is understandable that if the pump had an amount of 40 cc for example, then this is not an amount sufficient for a successful meal.
  • Combining breastfeeding and bottle feeding (pumped milk or formula). two options:
  1. Extra after each breastfeeding – At the end of each breastfeeding (or most breastfeeding) you can add a bottle with a desired amount of pumped milk (if any) or formula. If the baby at the end of breastfeeding takes a nice addition of milk in a bottle one can understand, again, that he could have gotten more. I do not have an exact answer what is a nice amount after breastfeeding. Even 30 extra cissies, seven times a day can make the difference in terms of adequate weight gain and meeting the needs of the baby.
  2. Combination of a bottle (pump or formula) once or twice a day. It is also a nice solution for breastfeeding mothers because they can be "filled up" more until the next meal, or the partner can be included in the child’s feeding (there are families on exclusive breastfeeding where the husband is responsible for giving the baby a bottle once a day, for all such benefits).
    If the baby is not breastfeeding, you can simply add an additional 30 cubes to each bottle per meal and see if the baby swallows the whole bottle or leaves. If he finishes the final 30 sissies then you can add more at the next meal.

It is important to say that sometimes when a baby is fed as much as he wants, the amount of daily formula he will receive will not increase significantly. The baby for example will eat more at a given meal but then will develop a longer time interval until the next meal. I find in spacing out the time between meals an advantage.

One of the frequent questions I am asked on this subject is whether there is no fear of overfeeding the baby.
I must say that the use of this term is much more profitable than its diagnosis.
It is not at all common to see families where the baby suffers from overfeeding. Overfeeding is a highly pathological condition in which the parents (usually the mother, sorry) feed the baby continuously and unusually until he almost squirts milk from his ears. Overfeeding is characterized by frequent feedings in large quantities, feeding in sleep (terrible habit), pushing a bottle almost by force to a baby who is not hungry – these are not common cases in pediatrics.

Another criticism I hear is in the context of the satiety mechanism of children and the fact that when we allow them to eat as much as they want then in the future they will become gluttonous. I do not know of any work that involves providing a sufficient amount of milk to a baby for gluttony and incorrect eating habits in old age. Maybe the opposite is true.
Of course, there is no need to feed babies every hour and a half and there is no need to feed a baby who does not want to eat, but that is not what I intended.

The baby was sensitive to cow's milk protein

This is a medical condition that occurs in an incidence of 2-7.5% of infants, and even here, a correct diagnosis and further proper treatment and accompaniment, can save the baby and his family discomfort and even great suffering.

This is the baby’s sensitivity to the milk protein he receives in the formula. Occurs in infants who are given a regular milk formula (also soy, we will explain below) at the specified frequency. A similar picture, usually milder, can also occur in a baby who is exclusively breastfed (an incidence estimated at 0.5%).

The word sensitivity correctly describes this medical condition, more than the word allergy.
It is true that there are cases of severe allergy to this protein that can manifest with more turbulent symptoms including rash, vomiting and diarrhea in significant amounts.
But as I emphasized at the beginning of the chapter these are not the babies with the restlessness I am referring to in this document.

The clinic varies in intensity, from mild cases of abdominal pain, restlessness and mucous discharge here and there to a swollen and sensitive abdomen, a baby who does not gain weight well and suffers from mucous or simulated discharge.

We will stop for a moment to differentiate between watery outlets and mucous or simulated outlets. Marginal outlets can be watery, mucous or simulated. The latter two indicate inflammation of the intestines that is most often caused in older children due to the presence of a bacterium in the feces. In young infants the incidence of bacterial infection is not high and most cases of mucous / bloody diarrhea are caused due to sensitivity to cow’s milk protein. I came to know over the years that even experienced parents do not always know how to identify what is mucous diarrhea, so with your permission, for those who are not mild, below I attach 3 pictures of mucous diarrhea. The presence of such ejaculations in the baby indicates, again, intestinal inflammation and requires medical advice.

The experienced doctor will correctly diagnose this condition by taking the disease story, also with the help of pictures of the ports that the parents can provide (one picture of a mucous port is worth a thousand words).
Later, the pediatrician will help with a physical examination with an emphasis on the abdominal examination – which is often swollen and slightly sensitive in this situation. There is no good laboratory diagnosis of this medical condition, including allergy tests and therefore the diagnosis is a clinical diagnosis.

The age of the show varies because sometimes it is a matter of quantity. I want to say that the baby manages on a certain amount of formula, but when the amount increases at a certain age (or sometimes after a decrease in the amount of breastfeeding and an increase in the amount of the formula), the clinic appears.

It is interesting to note that this sensitivity often occurs even in breastfed infants only who are not exposed to the formula. Are they breast milk proteins that are similar to cow’s milk protein or cow’s milk protein that passes through breast milk? Topic for debate.
In such cases, it is usually recommended to try to reduce the amount of milk protein in the breastfeeding mother’s diet, that is, less running milk. But in most cases there is no sweeping recommendation for a complete discontinuation of dairy products to the mother. Consider giving calcium and vitamin D supplementation to a mother whose milk intake is low for a long time.

In terms of treatment – Changing the composition of the formula to the composition of a broken down protein (semi-completely or completely) brings relief in most cases.
Relief usually occurs within a few days in the simplest cases but can also take a longer period of several weeks. A change to an herbal formula is not recommended as there is a cross-sensitivity in a significant percentage between the sensitivity of cow’s milk protein to soy protein.

A decision on returning to a cow’s milk-based formula as well as subsequent exposure to dairy products will be made by the attending physician on a case-by-case basis.
In cases where there is no benefit in mucosal exits after a change to a disintegrated formula, there is room to consider an extension of clarification including expert advice from a pediatric gastroenterologist.

Before this area was over I promised you pictures of mucous discharge and bloody discharge.

Mucosal / bloody diarrhea pictures

To view, click on the second tab

To watch

Mucous outletMucous outletMucous outletMucosal and bloody diarrhea

The baby who suffers from reflux (or rather the baby who suffers from heartburn)

In my opinion, we must say a word about definitions in order to better characterize the situation. A parent who understands the various definitions will not be confused and will not give his baby treatment that is not related to the problem.

Reflux (In Hebrew it is also called gastro-oesophageal reflux, in English – Gastroesophageal Reflux or GER for short), is defined as the passage / return of gastric contents to the esophagus. Reflux occurs in a normal physiological form every day and in all newborns. Sometimes with emission (regurgitation) and sometimes not. Again, this is a situation proper That happens in all babies. A baby with reflux simply does not suffer and is not restless.

Reflux disease (Or gastroesophageal reflux disease, or GERD), defined as reflux causes a medical problem including pain (actually heartburn), insufficient weight gain (due to the fact that part of the economy the baby eats is excreted) or respiratory symptoms (due to Leakage of gastric contents into lungs).

The concept of latent reflux is a common concept between parents and caregivers in the context of this condition.

According to textbooks, reflux is common in the first months of life, reaches a peak around the age of 4 months and works out by the age of one year. In real life reflux is more common until the age of 4 months, and after that age there is a decrease in incidence. Most children who suffer from reflux (with or without emissions) are cute, healthy and without any pathology. In English it is called happy spitters, it is difficult to translate into Hebrew,

But when stomach contents, usually acidic, rise to the esophagus can cause discomfort to the baby.

The symptoms of reflux disease are crying and restlessness, especially at the beginning of a meal. In addition to avoiding and refusing to eat. When feeding there may be movements in the name of the sandifer which include arching of the back and rotation of the head to one side. Insufficient weight gain can appear later. Many parents report hearing or feeling that food is rising for a child in the digestive tract, even if there is no final discharge. Babies are usually hungry, at first at least pouncing on the breast or bottle but just unable to continue or finish a meal. Later can come the avoidance of eating and aversion (disgust) from the breast / bottle.

It is important to emphasize that not all babies who suffer from heartburn due to reflux disease (well, I will also call it latent reflux) are platonic. In some cases there are emissions and in some cases not.

The treatment is not simple.

Certifying food or moving to an anti-reflux economy does not necessarily help, because it is not necessarily about rising food but about stomach acidity. These formulas can help with reflux, but usually do not help with reflux (heartburn for that matter).

In mild cases you can try to improve feeding techniques or try to find amounts and frequency of feeding that cause the least restlessness in the baby.

In cases of suspected reflux disease there is room for evaluation by the pediatrician, on the one hand to rule out other diseases / medical conditions with similar symptoms and on the other hand to consider drug treatment aimed at lowering gastric acidity. In my personal experience, in infants with a correct diagnosis of reflux disease these medications can help within a few days and change for the better the pain, anger and frustration that accompany this condition. As always, the benefits of drug treatment should be weighed against the minor side effects of these drugs.

In conclusion:

For me a very important and basic chapter, try to find your baby among the aforementioned diagnoses and try to facilitate him in the right way with the help of the "toolbox" I tried to give in this chapter.

To view the table