THE CRYING BABY
Babies cry a lot, and this is a common presentation to medical care. There are significant potential effects on breastfeeding. This page will cover only the breastfeeding related aspects of the crying baby.
On average, infants in the first 6 weeks of life cry for 2 hours a day, decreasing to 70 minutes a day by 12 weeks. Fussiness during feeds is common, and therefore many families will stop breastfeeding in an attempt to improve the crying. Many crying babies will either be completely normal, or have colic. Medical professionals often recommend treatment for either gastro-oesophageal reflux disease or cows' milk protein allergy (or both), but there is a high risk of overdiagnosis.
20-30% of babies in the UK fit criteria for colic in the first 6 weeks of life, decreasing to 11% by 2 months of age and 0.6% by 3 months. Rate of colic is no different between breastfed and formula fed babies. No treatments have reached the evidence threshold required for NICE. There is growing evidence that L. Reuteri probiotic may reduce crying time in breastfed babies only - an infant preparation is available to the public in the UK. Specifically, dietary modification in breastfeeding mothers (and changing formula in formula fed babies) does not affect crying time, according to Cochrane review.
Gastro-oesophageal reflux disease (GORD)
First line management of suspected GORD in a breastfed baby is expert face to face breastfeeding support with positioning and attachment. NICE recommends infant gaviscon as second line (which can be difficult for families to administer to breastfed babies but can be mixed with sterile water or expressed milk and given before breastfeeds). NICE recommends ranitidine or PPI as third line, although Cochrane review casts doubt that they are effective in this population and there are associated risks.
Cows' milk protein allergy (CMPA)
CMPA is much less common in breastfed babies than in formula fed babies (0.5% of breastfed babies, and 2-3% of mixed or formula fed babies), and may cause symptoms only when formula is introduced for the first time. If this is the case, and the family is open to it, stopping formula and returning to breastfeeding is likely to resolve the symptoms.
If a breastfed baby has symptoms suggestive of CMPA, the mother should eliminate cows' milk protein from her diet for 2-4 weeks, and then reintroduce it for 2-4 weeks - both elements are required before diagnosis can be made and an elimination diet resumed, as up to 15% of babies have suspected CMPA, but less than 5% will have confirmed CMPA after elimination and re-challenge. The exception would be if symptoms are very severe or IgE-mediated, when re-challenge may not be appropriate, particularly outside of hospital.
If a mother has eliminated cows' milk protein from her diet she should have a dietitian review. Meanwhile she should be advised to take 1000mg of calcium daily, and a vitamin D supplement. If an older baby with CMPA is advancing on the milk ladder the mother can also trial resuming a normal diet.
For an overview of the general assessment of the crying baby, see this blog