New Parents Need Help with a Crying Baby

(Sample E-newsletter from The Roadmap to Breastfeeding Success lactation support program.)

Huge tears rolling down Maria’s face say it all. “Anna cries all the time, and so do I!” this young mother tells her husband. As if on cue, Anna seems to wind up for a big one. Her face gets red, her hands start to tremble, and her legs stiffen. Though Maria knew that all babies cry, she never imagined how overwhelmed she would feel when her tiny newborn enters the fussing/crying, "Rebooting Zone."

Maria's husband comments, "That baby must be hungry!" And, though Maria has been committed to breastfeeding she now wonders if her baby might need a little formula. Surely a bottle or two a day of that expensive "gas-free" formula would help her crying baby.

But, Maria vaguely remembers that the birth center's lactation consultant (LC) had mentioned something about extra crying spells during their prenatal breastfeeding class. Didn't that "Roadmap" handout say something about crying? Maria shuffles through some papers beside the couch. Yes, it  says to "anticipate increased crying" at two weeks. Maria decides to get a bit more advice before buying even one can of formula. 

"I'm desperate! Just tell me what TO DO!" Maria asks the LC when she and her husband arrive at the clinic the next day.

The Science: "Just Tell Me What T.O. DO!"
Most normal, healthy babies begin to cry more around forty-two weeks gestation, or two weeks after birth (if the baby was born full-term). Babies typically move from crying two hours a day to crying three hours a day by six weeks of age. Then their crying tapers to about one hour a day by twelve weeks of age.

The LC shares with Maria some easy-to-remember tips she just learned:
 Talk to your baby. Lean over and use a persistent, sing-songy voice close to her ear. Give your baby a few seconds to notice and respond to your voice. 
– Observe your baby's efforts to contribute to his own calming. Many parents are surprised to learn that babies have instinctive behaviors that help them calm down. She might bring her hand to her mouth (perhaps with your help) and suck her finger or thumb. Or she may make sucking movements and start to quiet. 

Another baby may look like she’s taking up sword fighting (the fencing reflex): Her head turns to the side, one arm and one leg extend, while the other arm and leg flex. This instinctive maneuver helps some babies start to calm. Finally, some babies use behavioral SOSs (Signs of Over-Stimulation) to turn off the excessive stimulation around them. The baby may stare into space or appear drowsy and then begin to settle. 

DO – If the baby is still crying, a parent's help is needed. Hold her arms against her chest and continue that quiet, persistent talking. Encourage the baby to suck your finger or the breast, or swaddle her safely. Techniques for safe swaddling include:
  1. Bend the knees upward and rotate them outward to protect the hips. (Here is the International Hip Dysplasia Institutes's link to safe swaddling.)
  2. Do not swaddle tightly, or for long periods of time.
  3. Monitor the baby's temperature to avoid over-heating.
  4. Never put a swaddled (or un-swaddled) baby to sleep on his stomach.
  5. Stop swaddling baby once she can roll over (at about 3-4 months old).
If parents take these actions, one step at a time, mothers and fathers will soon discover what is most comforting to their baby. 

Click here to watch a music video of a father using skills he learned to comfort his crying baby.

An "Ah-Ha" Moment for these Young Parents
When little Anna starts to cry at her clinic visit the next morning, the LC leans over the baby and speaks quietly into her ear. Anna looks surprised but continues to cry. She smacks her lips a moment and then quiets right down when the LC holds her tiny but strong arms securely against her chest. 

Maria and her husband can’t believe their eyes (or ears!). Anna's father gently holds his baby's hands in this comforting position and sees his now peaceful baby look right up into his eyes. Maria then brings the baby to the breast for a good feed before their ride home. “We are a good team,” she tells the LC. “We’ll work this out togetherand without any formula!"

(Click here for further information about online lactation training and resources.)

© HUG Your Baby 2015

Variables Impacting Breastfeeding Duration


By Jan Tedder, BSN, FNP, IBCLC; President of HUG Your Baby; See Roadmap to Breastfeeding Success Online Course

Research confirms that a woman's misunderstanding of normal child development is an important, and often over-looked, cause for abandoning breastfeeding. Though these issues are covered in depth in The Roadmap to Breastfeeding Success online course, we must be aware of the other, complex variables that may impact a woman's ability to initiate breastfeeding and to continue to breastfeed.

Demographic variables
Demographic variables that make women less likely to begin and continue breastfeeding include: prenatal smoking (Bertino et al., 2012); lower socio-economic, racial or ethnic status; having an unplanned pregnancy or not having a partner; being less-educated (Li et al., 2008); participating in a WIC program (Thulier & Mercer, 2009); and being obese, which is associated with a delay in milk coming in (Stuebe et al., 2014).


Social Variables

Other research moves demographic data to a wider screen by identifying particular social variables that impact initiation and duration of breastfeeding: worries about breastfeeding in public (Stuebe & Bonuck, 2011); lack of partner support and marital distress (Stuebe & Bonuck, 2011; Hinsliff-Smith et al., 2014); giving birth at a non-Baby-Friendly hospital; and returning to work.

We know that breastfeeding rates increase when pregnant women get together with successful breastfeeding mothers. In addition, an important study demonstrates that women who observe breastfeeding role models through videos (and who receive praise from their partners or their own mothers for breastfeeding) have significantly higher levels of confidence in and commitment to breastfeeding than do mothers who lack this kind of support (Kingston, 2008).

It is important to ask what kind of help and support new mothers need. A study from China showed that a grandparent in the home, among other variables, is associated with shorter breastfeeding duration (Liu et al., 2013). Research in Japan showed that the more fathers were involved with care of their infant the less anxiety their partners had—but the more formula the baby received (Ito et al., 2013). Both of these studies may indicate that loved ones need to be shown ways other than feeding to connect with a baby and help a new mother.

Biological Variables
Biological variables that impact breastfeeding include: a mother having physical challenges such as sore nipples, engorgement, mastitis, or plugged ducts before a baby is four weeks of age.

Remember that a woman who identifies any breastfeeding concerns at day 3 and 7 postpartum is less likely to be successfully breastfeeding at 2 months (Wagner et al., 2013). Mothers with early complaints need careful follow-up and ongoing support.

Interesting work by Kathleen Kendall-Tackett makes a connection between a woman’s experience of postpartum pain and its impact on breastfeeding (Kendall-Tackett, 2007). She explains that pain increases the body’s inflammatory process. This inflammatory process causes neuro-hormonal changes that are associated with depression. Kendall-Tackett concludes that pain from c-sections, or with breastfeeding, may create the conditions that result in postpartum depression.

Studies also show that mothers who have pain the first two weeks postpartum—and do not receive the help they need—are more likely to have postpartum depression at two months (Watkins et al., 2011). These studies confirm the importance of getting immediate lactation help for women having postpartum pain.

As one would expect, physical problems in the baby—such as prematurity, illness, or tongue-ties—also contribute to decreased breastfeeding duration and require both special medical care and more lactation support.

Psychological Variables
Though more research has been focused on how psychological variables impact the initiation rather than the duration of breastfeeding (De Jager et al., 2012), current literature suggests that at least four psychological issues influence breastfeeding success: postpartum depression, a mother’s intention and confidence to breastfeed, her sensitivity to her baby, and maternal-child attachment.

Postpartum depression occurs in 13% of mothers (Borra et al., 2014). Work by Kathleen Kendall-Tackett and others explores how the hormones of pregnancy help protect women from postpartum depression, a process, they say, that explains why women who breastfeed have a lower incidence of depression (Kendall-Tackett, 2010). 

In addition, other research shows that women with postpartum depression or anxiety often misread their baby’s body language (Arteche et al., 2011). Studies show that a woman with postpartum depression or anxiety can accurately identify her baby’s distressed face, as do mothers without these psychological conditions. However, the depressed or anxious mother will see her baby’s neutral face as distressed. And, this same mother seems unable to see her baby’s happy face (Arteche et al., 2011) Therefore, helping a mother with postpartum depression accurately read her baby’s body language may increase both that mother’s confidence and her breastfeeding duration.

Second, a women’s intention to breastfeed is a contributing factor to breastfeeding duration. Women who decide prenatally to breastfeed are more likely to be successful breastfeeding mothers (Meedya et al., 2010). Besides identifying an expectant woman's intention to breastfeed, helping her also say how long she plans to breastfeed has been shown to be important.

However, it is important to bear in mind that if a woman intends to breastfeed, and then is unsuccessful in meeting her breastfeeding goals, she will suffer a higher incidence of depression than if she had not intended to breastfeed in the first place (Borra et al., 2014). This research reinforces the need for immediate and effective breastfeeding support as soon as any breastfeeding problem arises.

Lack of confidence leads many women to give up breastfeeding when there are challenges to overcome. Fortunately, work by Dr. T. Berry Brazelton and others (Kadivar & Mozafarinia, 2013) demonstrates the remarkable power of using the baby’s behavior to enhance the confidence of young parents (Brazelton & Sparrow, 2006; Nugent et al., 2007).

Third, research indicates that prenatal women who establish their intention to breastfeed exhibit increased sensitivity to their infants’ cues. In addition, these mothers show an increase in both their duration of breastfeeding and in their exclusive breastfeeding rates (Thulier & Mercer, 2009; Tharner et al., 2012).

Helping a father experience his baby’s ability to interact, or a mother see her baby’s ability to turn toward her face when she calls her name, are techniques that have been shown to increase parent-child bonding and to boost parent confidence. Other studies show that mothers who are highly confident about breastfeeding are more likely to be exclusively breastfeeding at one week and at four months postpartum (Blyth et al., 2009).

Fourth and finally, the issue of maternal-child attachment and breastfeeding is important, both to parents and to the health care providers who serve them. A 2012 study used the well-accepted Ainsworth Sensitivity Scales to assess the impact of breastfeeding on attachment and continued breastfeeding. Mothers who breastfeed to six months demonstrate the highest levels of maternal sensitivity and secure attachment to their baby (Tharner et al., 2012).

REFERENCES:
Arteche, A., et al. (2011). The effects of postnatal maternal depression and anxiety on the processing of infant faces. Journal of Affective Disorders, 133(1-2), 197-203.

Bertino, E., Varalda, A., Magnetti, F., Nicola, D., Cester, E., Occhi, L., Perathoner, C., Pradi, G., Soldi, A. (2012). Is breastfeeding duration influenced by maternal attitude and knowledge? A longitudinal study during the first year of life. Journal of Maternal-Fetal and Neonatal Medicine, 25(53), 32-36.

Blyth, R., Creedy, D., Dennis, C. et al. (2009). Effects of maternal confidence on Breastfeeding duration: An application of Breastfeeding self-efficacy theory. Birth, 29 (4), 278-284.

Borra, C., Iacovau, M. & Sevilla, A. (2014). New evidence on breastfeeding and postpartum depression: The importance of understanding women’s intention. Maternal Child Health Journal, Retrieved from http://link.springer.com/article/10.1007%2Fs10995-014-1591-z#page-1

Brazelton, T. & Sparrow, J. (2006). Touchpoints: Birth to 3. New York, NY: Perseus.

De Jager, E., Skouteris, H., Broadbent, J., Amir, L, Mellor, K. (2013). Psychological correlates of exclusive breastfeeding: A systematic review. Midwifery, 29(5), 506-518.

Hinsliff-Smith, K., Spencer, R., Walsh, D. (2014). Realities, difficulties, and outcomes for mothers choosing to breastfeed: Primigravid mothers’ experiences in the early postpartum period (6-8 weeks). Midwifery, 30(1), 14-19.

Ito, J., Fujiwara, T., Barr, R. (2013). Is paternal infant care associated with breastfeeding? A population-based study in Japan. Journal of Human Lactation, 29(4), 491-9.

Kadivar, M. & Mozafarinia, M. (2013). Supporting fathers in a NICU: Effects of the HUG Your Baby program on father’s understanding of preterm infant behavior. Journal of Perinatal Education, 22(2), 113-119.

Kendall-Tackett, K. (2010). Four research findings that will change what we think about perinatal depression. Journal of Perinatal Education, 19(4), 7-9.

Kendall-Tackett, K. (2007). A new paradigm for depression in new mothers: The central role of inflammation and how breastfeeding and anti-inflammatory treatments protect maternal mental health. International Breastfeeding Journal, 2(6).

Kingston, D., Dennis, C., Sword, W. (2007). Exploring breastfeeding self-efficacy. Journal of Perinatal and Neonatal Nursing, 21(3), 207-215.

Li, R., Fein, S., et al. (2008). Why mothers stop breastfeeding: Mothers’ self-reported reasons for stopping during the first year. Pediatrics 122, S69-76.

Liu, P., Qiao, L., Xu, F., Zhang, M., Want, Y., Binns, C. (2013). Factors associated with breastfeeding duration: a 30-month cohort study in northwest China. Journal of Human Lactation, 29(2), 253-9.

Meedya, S., Fahy, K., Kable, A. (2010). Factors that positively influence breastfeeding duration to 6 months: A literature review. Women Birth, 23(4), 135-145.

Nugent, K., Keefer, C., Minear, S., Johnson, L. (2007). Understanding newborn behavior and early relationships: The Newborn Behavioral Observation System Handbook. Baltimore, MD: Paul H. Brookes Publishing Company.

Stuebe, A., Horton, B., Chetwynd, E., Watkins, S., Grewen, K., Meltzer-Brody, S., (2014). Prevalence and risk factors for early, undesired weaning attributed to lactation dysfunction. Journal of Women’s Health, 23(5), 404-12.

Stuebe, A., Bonuck, K. (2011). What predicts intent to breastfeed exclusively? Breastfeeding knowledge, attitudes, and belief in a diverse urban population. Breastfeeding Medicine, 6(6), 413-420.

Tharner, A., Lujil, M., Raat, H., Ijzendoorn, M., Bakermans-Kranenburg, M., Moll, H., Jaddoe, V., Hofman, A., Verhulst, F., Tiemeier, H. (2012). Breastfeeding and its relation to maternal sensitivity and infant attachment. Journal of Developmental & Behavioral Pediatrics, 33(5), 396-404.

Thulier, D. & Mercer, J. (2009). Variables associated with Breastfeeding duration. Journal of Obstetric, Gynecologic, & Neonatal Nursing, May/June 38(3), 259-268.

Wagner, E., Chantry, C., Dewey, K., Nommsen-Rivers, A. (2013). Breastfeeding concerns at 3 and 7 days postpartum and feeding status at 2 months. Pediatrics, 132(4), e 865-875.


Watkins, S., Meltzer-Brody, S., Zolnoun, D., Stuebe, A. (2011). Early breastfeeding experiences and postpartum depression. Obstetrics & Gynecology, Aug 118 (2 Pt 1), 214-21.

©HUG Your Baby 2015




















Calming a Baby at Night

By Jan Tedder, BSN, FNP, IBCLC; President of HUG Your BabySee Roadmap to Breastfeeding Success Online Course

It was an honor to be called into this Australian home by the grandmother of a charming 5-month-old baby, Julius. I had met Grandmother in the US while she was attending a conference. We had planned to make time for dinner when Jim and I traveled to her part of the world, but I was delighted to have THIS special invitation also.

She explains that her grandson (her first) has been a "handful" since birth. His mother and father had eagerly anticipated their child's birth and had prepared themselves for early parenthood with education, family support, and all the necessities of a cheerful nursery.

Though they understood that this stage of life could be challenging, they simply cannot believe the level of sustained exhaustion and confusion they've experienced so far.

Julius's mother has committed to breastfeeding. Though she has adequate milk supply, this child is constantly on the breast. That is because the breast has been the only way she knew to comfort her son when he "got going." Lately, even the breast will not calm him down, though. When he is obviously tired at night the parents take turns walking him, rocking him, and singing (until hoarse) to him. Sometimes all of these actions make NO difference. Consoling him and getting him to sleep seem impossible.

When Julius would finally get to sleep, he would sleep soundly for 45 minutes, stir, and then wake up screaming. These dedicated, sensitive parents had seldom seen their child sleep more than one hour at a stretch in all his five months of life.

Clearly this is a crisis. Mom is ready to give up breastfeeding. Dad is struggling to be faithful to his job responsibilities and to care for both his wife and their young one.

I have spent decades hearing and responding to stories like this one, and I've developed a template for evaluating, diagnosing, and treating families in a sleep predicament.

I begin by understanding that children do not sleep well for one (or all) of three main reasons:

  • Developmental Issues
  • Child-Centered Issues
  • Parent-Centered Issues

Developmental Issues refer to the fact that when healthy children during infancy and early childhood have a developmental surge (e.g., they are about to learn something new), they predictably have difficulty with their sleep patterns. Dr. Brazelton refers to these developmental surges as Touchpoints, and I used this information in developing my Roadmap to Breastfeeding Success.
Predictable surges in a baby's development include:
  1. The 2-week-old’s normal increase in crying
  2. The 1-month-old's developing clear Deep and Light sleep patterns
  3. The 4-month-old's increased distractibility while nursing
  4. The 6-month-old's drive to eat solids
  5. The 9-month-old's separation/stranger anxiety
  6. The 12-month-old's learning to walk
  7. The 18-month-old's second round of separation/stranger anxiety
  8. The 2-year-old's negativism 
Parents can be taught to anticipate these development surges, and to appreciate them as SUCCESSES in their child's development. However, parents also need to know how to help their baby through these new, up-at-night activities without increasing breastfeeding as the only way to comfort the child. Although this may sound counter-intuitive, mothers may need to learn strategies beyond the breast—precisely in order to keep breastfeeding!

Child-Centered Issues refer to a child's basic temperament. Initially, parents do not recognize that some challenging behaviors are temperament-driven. Though Thomas and Chess originally enumerated eight aspects of temperament, I find the following characteristics most relevant to issues of a child's sleep habits: intensity, persistence, sensitivity, and regularity. Helping parents appreciate their child's temperament will increase their ability to make plans that take their particular child's personality into account, rather than imaging how to handle the hypothetical "average" baby.

Parent-Centered Issues refer to the presence (or not) of depression, family stress (such as family violence, alcoholism), and unrealistic parent (and family) expectations. Significant pregnancy losses (miscarriages or infertility) increase parental anxiety, as does a mother's need to return to work sooner than she would like. Remember that fathers as well as mothers can suffer from postpartum depression. All of these factors can be considered "Parent-Centered Issues."

I hear a brief history from the grandmother, the mother, and the father. Clearly this was a planned pregnancy in a stable family that is blessed with ample extended family support. There were some challenges at birth but no significant history of pregnancy loss, and symptoms of depression are present in neither mother nor father. 

So far I gather from this story that one "diagnosis" is sleep association. Since birth, this child has associated breastfeeding with getting from Active sleep back to Deep sleep. 

Initially, Julius is playing contentedly, swiping at a toy in front of him. When he makes a hint of a whimper, his mother immediately leans over, readjusts his blanket, pats him, reassures him, and coaxes him back to his mobile. Though seemingly playing contentedly, his behavior changes significantly when I sit beside him. He glances at me—and immediately moves his arms rigidly to his side and looks at his mother. He then looks back to midline, seemingly ignoring his toy, me, and his "mum" as she and I talk. I "broadcast" his actions and suggest that they show impressive sensitivity for a baby this age. Both parents agree that Julius has always been quick to notice changes in his environment and that he initially retreats from strangers.

During this quiet time I explain to parents how a child's temperament, as well as Active and Deep sleep patterns, contribute to sleep issues. A sensitive child needs his parents to respond more often and more quickly. And, a very attentive mother (as this mother clearly is) may continue to respond so quickly that the child does not learn to contribute to his own settling. As is often the case, this duo has found breastfeeding to be an effective and convenient way to settle a baby, and the baby has been taught to associate breastfeeding with going from Active to Deep sleep. 

My teacup makes a bit of a clang when I set it down on the glass-top table. Julius startles, and then suddenly breaks into THE MOST intense, persistent cry I have seen in a child this age. I am good at calming babies, but I cannot "break through" the intensity and persistence of Julius’s cry.

So the diagnosis becomes clearer:
  • Developmental Issues Emerging cognitive burst expected around 4-5 months. Inability to get from Active to Deep sleep without breastfeeding.
  • Child-Centered Issues Sensitive, intense, persistent temperament traits (ALL characteristics that will bring this child GREAT success later in life).
  • Parent-Centered Issues An extremely sensitive mother who is increasingly (and understandably) anxious.
I conclude that the need for this baby, at this age, is for his parents to take a loving but less robust response to helping him settle and to helping him transition from Active to Deep sleep.

"When you respond to him, you now 1) talk to him, 2) look at him, 3) pat him, 4) pick him up, 5) rock him, 6) breastfeed him. When you put him to bed now, start by dropping off 1) and 2). For a few nights go to him without speaking and glance to the side. Then take your other loving actions as needed. When Julius becomes accustomed to more limited consoling, drop off 6) and then 5). You will be bringing out the best in him by helping Julius learn to contribute to his own calming. Also, when he awakens at night, take this same approach so that he will learn to wiggle back into Deep sleep, on his own. Teaching Julius ‘self-regulation’ will help both him and you.”

The intensely crying Julius immediately gives Mum a chance to practice. She turns her gaze slightly to the side and calms him without speaking. Julius looks puzzled, but he is quickly ready to play again. The strategy of doing more by doing less is working!

I called this mother three days later and was delighted with the results she reported. Julius is now sleeping from 10 PM to 4 AM, at which time he wakes up to breastfeed. The parents hear him stir in Active sleep but leave him to find his own way back to Deep sleep. Mum reports, "Yesterday I felt like a new woman. I made some cookies, took the baby for a walk, and was singing when my husband got home from work." She shares that she now hesitates a moment before responding to her son—and sees his increased “self-regulation” capabilities as both reassuring and exciting.


In closing the phone conversation, I review upcoming developmental changes that are likely to impact this remarkable little guy's sleep again, and I discuss how his parents can best respond to the milestones ahead. The success they are all starting to experience will provide a reliable foundation for this loving family's future parenting successes!

© HUG Your Baby 2015