Module 4: Understanding babies

In this module you will gain a fuller understanding of babies under 12 months from a number of different perspectives. We will cover how they enter the world, what life is like from their perspective in the early months, how babies communicate, how they behave, the reflexes they are born with, normal developmental milestones and common health issues for babies.

Entering the world

Life in the womb

Life in the womb

In order to understand babies, we need to understand the world that is all they have ever known until the day we meet them for the first time. For the first nine months of their existence they live inside your body in the womb (uterus) and when they meet us for the first time, they have just experienced a massive change that plunges them into a different world where, not only is everything around them different, but their body works differently too. Before we can understand that transition and adaptation, we must understand what it is like for a baby inside it's mother. Although technically, a baby is known as a foetus whilst still in the womb, we will use baby throughout the section.

A baby's needs

Many people say that all of a baby's needs are met in the womb and this is true. However, there is an important distinction to be made regarding this so that we can understand babies. In the womb a baby's hunger is not satiated, their discomfort is not comforted, their cold is not warmed. They do not experience any of these things. They are inside a perfectly designed home filled with liquid at the perfect temperature for them, that cushions them from discomfort. They are weightless meaning that they can move positions easily, even without good motor function. They are supplied oxygen and nutrition directly to source (blood supply, cells), constantly and waste is removed from their system as it is produced. They never feel hungry, tired, nor a need to evacuate their bowels and can easily move themselves into the perfect comfortable position, without assistance.

What do they feel?

It is important to understand the the sense of touch is the first sense to develop in utero. Babies feel when they are inside the womb. So what is it that they feel?

In the womb, babies are naked, curled in the foetal position in a soft membrane containing amniotic fluid. The amniotic fluid is warm and a reasonably constant temperature. This is a limited but flexible space in which they are contained with no sense of the external world and its' forces. They have no concept of up or down or indeed that they are (in most cases) the other way up than they will be most of the time after birth. They are held in a relatively weightless environment in which movement, though increasingly restrictive is supported and more controlled than after birth. When the mother moves throughout the day the baby moves as well, gently supported by the amniotic fluid.

Therefore we can gather that, in the womb, babies feel warmth, softness, containment, weightlessness, rocked/swayed and can move their bodies instinctively to ensure comfort.

What can they hear?

Evidence shows that babies' hearing develops at around the 5th month of pregnancy. Inside the womb there are two different types of sound. Those sounds that are coming from the outside world, through the mothers' skin, uterine wall and amniotic fluid and those inside the mother's body. Sounds from the world outside will be muffled by the intervening tissues and liquid. This will ease loud noises and reduce the negative effects of sudden noises. Studies have shown that babies respond well to sounds such as a familiar persons' voice and familiar music that they have heard in utero after their birth so we know with reasonable certainty that babies can hear outside sounds. Research suggests that babies in the womb respond to familiar voices at approximately 6 months.

In the womb the baby will also be able to hear the sounds of the mother. They will of course hear her voice very often and more clearly (and differently) than that of those around her as they will hear it internally as well. Imagine you are laying your head on someones chest as they speak to gain some perspective. Furthermore the baby will  clearly be able to hear the mother's heartbeat, the sounds of her breathing and all the noises of the digestive system. These noises will form a fairly loud but constant and consistent background noise for the baby. 

What can they see?

Babies open their eyes and start being responsive to light changes at month 4 of pregnancy.  Dark but not pitch black, with light changes but mild, red glow

Babies eyes begin to be responsive to light changes by week 16 of pregnancy. They can make slight movements from side to side in response to bright lights from this time even though the eyelids are still closed. This can usually be observed by more distinct foetal movements at around 22 weeks. By the end of the second trimester (approx. 26 weeks) a baby will be able to open their eyes. There isn't much to see inside the womb and vision is blurry. Baby will simply be surrounded by a reddish glow that changes in lighter and darker red, depending on the light outside the mother.

What can they taste?

Early in development (within the first 8 weeks), neutrons in the brain and taste buds are form and connected but the ability to taste is not present until about week 16 when taste pores are developed within those taste buds. At this stage a baby will begin to swallow amniotic fluid. As the fluid is swallowed, the molecules in the liquid interact with the taste buds on the tongue allowing baby to experience their first taste. Throughout the remaining gestation baby will increase slowly the amount of amniotic fluid she swallows and the number of tastes they are exposed to will increase. 

Even though your digestive system is separate from your baby’s, molecules of the food you eat make their way into the amniotic fluid — not only vitamins, minerals, fats and proteins, but also some of the molecules that give foods their unique tastes. The flavors your baby tastes inside the womb, though, won’t be quite as strong or distinct as those you taste. That’s because much of what you think of as the flavor of a food is actually its smell, which is transmitted to your nose through the air. Since your baby is surrounded by amniotic fluid, she only tastes molecules from your bloodstream and doesn’t have the sense of smell yet to amplify those flavors. But even with this blunted sense of taste, your baby's brain will start to differentiate tastes.

Research has shown that the foods you eat during pregnancy influence the foods that your baby will like for years to come. In one study, mothers who drank carrot juice during the last trimester of pregnancy had babies who, once they started weaning, made fewer negative faces when fed carrot juice. Another 2012 study found that pregnant rats that ate lots of junk food and had diets high in fat, salt and sugar gave birth to babies who preferred these foods and disliked healthy foods. Some scientists say that the foods you eat during pregnancy could literally shape your baby’s eating habits throughout the rest of her life. We are not sure this is true but it is interesting.

Here are links to those studies:

Prenatal and postnatal flavor learning by human infants

Ontogeny of taste preferences: basic biology and implications for health

A maternal “junk-food” diet reduces sensitivity to the opioid antagonist naloxone in offspring postweaning

Here is an interesting read about this in The Guardian

The most interesting part of all of this is how it compares to life outside of the womb, which we will look at in the next sections...

Birth

What effect does birth have on babies

This is something that I find very interesting and am currently researching. My intention is that this section will at some point have a wealth of research and information behind it and we will be able to draw some conclusions and more importantly understand that in most areas of this, we will mainly find more questions.

For now, I want you to understand that it is clear that how birth happens has an effect on babies in the hours and days after birth, both on a physical level and on an "emotional" level. What I mean by that is that it can have very obvious physical effects (bruising, dislocation of limbs, increased weight from fluids, cranial and spine adjustment etc) and can affect the way a baby behaves. This is most obvious in births that include some form of major intervention such as the use of forceps, ventouse, a caesarian section (particularly in an emergency) or the use of drugs in labour that transfer through the placenta.

There is some research and rhetoric that claims that even more natural births can have a psychological impact on babies and further articles discussing the possibility of the consequences of birth, particularly of trauma in birth, being long-lasting and affecting personality traits throughout life. These are areas that require more study but I wanted to include some information here to help you to understand that how babies arrive in the world makes a difference to their wellbeing and that this may be considered when parents are thinking about how to help their babies.

NOTE: If helping a family antenatally, remember that everyone wants different things and a natural birth isn't everyone's ideal. There are ways to make a Caesarean more baby friendly and pointing to some resources for that could be helpful.

Into a new world

After birth... and into the wider world

So after a baby has been through the birth process, they have entered an entirely different world from the one that they have known for their entire existence. The only thing that is very familiar is the birthing or gestational mother. We will now explore what life is like for a newborn baby in the same way that we discussed life in the womb and hopefully you will be able to draw some important conclusions about how we can support babies to feel more calm.

A baby's needs

I could list a babies' needs here but I won't. I think the important distinction to make is that suddenly a baby actually has needs that can go unmet, and the meeting of almost all needs is more delayed than it previously was. For example, previously the baby did not feel hunger, it was supplied with a constant source of nutrition. Now, even if the mother is very clued in to her baby's cues and feeds on demand with the speed of a super human, the baby is still experiencing the sensation of hunger before even offering a hunger cue and therefore there is already increased delay. This will help you to realise why babies go from zero to starving within seconds and taking five seconds to undo your nursing bra is just completely unacceptable to most babies.

This is the case with pretty much all of babies' needs post-birth.

What do they feel?

For the first time babies feel major changes in temperature. The world can be very cold (especially when they are taken out of their blankets and clothes for changing or bathing. 

Now that their nutrition is not delivered directly into their bloodstream and their waste is not removed directly and immediately, babies experience hunger, thirst and elimination sensations for the first time. It is likely that they therefore experience them more acutely than we do due to it being a new experience and one that their under-developed brain cannot rationalise.

Babies are also experiencing for the first time a real sense of discomfort. This may be discomfort from the contents of their nappy, from having clothes against their brand new skin, from being less able to move their limbs outside of their weightless environment, from experiencing gravity; being placed on a surface that puts pressure (even slight) on their body.  a difference between being wet and dryAlone

Similarly babies are experiencing being moved, handled, and manipulated (fiddled with) for the first time, this must be a very strange sensation and certain handling can cause the startle reflex to be triggered, something that must be quite stressful for babies. For this reason, as part of the carrying babies module both online and during training we will discuss optimum handling of babies.

What do they hear?

Babies hearing is almost completely developed at birth and therefore they hear very well. Whilst this is useful in some ways (it is easy to comfort babies with the sounds of parents voices etc) it means that when suddenly exposed to the outside world, sound can be intense for babies. Outside the confines of the womb, sounds are clearer and louder. Furthermore, babies are suddenly left without the constant background noise from the mother's body that they are used to during their time in the womb. This means that the world can seem unnaturally quiet to them most of the time but also they have no buffer for sudden and unexpected noises.

What do they see?

Babies eyesight at birth is only clear up to about 8-10 inches. This is not so coincidentally the approximate distance between a mother's face and a baby's face when held in the mother's arms at breast height. Further than that and the world is a bit blurry. 

Although it is blurry, it is significantly brighter outside of the womb, both through natural daylight and by unnatural light that humans are not designed to cope with biologically. There are also many more colours available to the eyes than there were in the womb sight is not filtered through the red glow of the mother's womb.

While newborn babies may look intently at one particular point that stands out, they have not yet developed the ability to easily tell the difference between two points or move their eyes between the two images. Shapes and movements are a new phenomenon.

What do they taste?

Your baby already has a developed sense of taste. In fact, newborns seem to have more taste buds than adults do. Sensitivity to sweet and bitter tastes is present at birth, but reactions to salty foods don't come until about 5 months. From tasting amniotic fluid n the womb, babies expect to experience a variety of tastes and this is best for their development. Breastmilk provides this variety in taste for babies, where as formula provides just one taste.

What do they smell?

When babies are born, they will smell for the first time. Smell is fundamentally connected with taste so it will not be a completely strange experience. Babies are born covered in vernix that smells distinctly like the amniotic fluid that they lived in. This can provide a comforting sense for newborn babies in the first days of life and so cleaning the vernix from the skin should be delayed if possible for as long as is reasonable. 

Babies are understandably attracted to the smell of their mother's breastmilk. Studies show that 5-day-old newborns will turn toward a pad soaked with breast milk, indicating that they can smell it, and a few days later they show a preference for the smell of their mom's milk. You may notice your baby wiggle toward your breast using her sense of smell.

Babies will also turn away from bad smells (dirty nappy for instance) from quite a young age.

The fourth trimester

The fourth trimester

When we look at the difference between womb and world we can see how this is a difficult transition for babies. The story this doesn't tell is why other animals are more ready for the world when they are born, some walking hours after birth and being much more independent much sooner.

There are a number of scientific theories about why humans seem to be born "too early" in their development. It is commonly said that this has to do with the ratio of the size of the human head (accommodating our large brains) with the size of our pelvis (narrow for walking upright). Recent research has shown that this is less likely than the human body's metabolic rate (energy provision for growth) being insufficient to continue pregnancy any longer than it does. regardless of why it happens, it is clear that human babies are born highly vulnerable and require intense care from their mother (or another caregiver) for a significant period after birth. From an evolutionary perspective, it is human nature for human babies to be kept close at all times and to be carried around at all times.

We describe the period of 3-4 months after birth as the fourth trimester (we realise "tri" means three but it's ok) because whilst the baby is now outside of the womb, it requires a continued period of intense nurturing to enable the essential early development of the body and brain in a place of security.

Rosie Knowles (GP, carrying consultant and infant expert) describes the fourth trimester as:

"gentle transitioning from the peace and stability of the womb towards active involvement in a new world. A newborn needs to be supported to gain skills and strength at a steady, individual pace from the security of an unshakeable foundation and place of comfort and familiarity"

During this critical period responsiveness is key. Parents who are attuned and responsive as their baby communicates their needs, create a baby who learns that they are valued and loved. The baby learns to trust that if they are hungry they are fed, if they are uncomfortable they will be comforted. Meeting all of a baby's needs does not make them clingy, it creates a secure foundation from which independence and confidence is created.

What is the difference at 3-4 months?

After the first few months of life babies begin to respond to their world and seem much more aware. Their development allows them to interact and be slightly more independent in some subtle ways. They often cry less by 3-4 months and begin to sleep better (at least when not experiencing a leap).

Womb to world matching

Please match these statements to their counterparts. One side describes how life is in the womb whilst the other describes how this differs in the world.

  • The womb is dark
    The world is bright
  • The womb is a reddish glow
    The world has many colours
  • The womb has constant background noise
    The world is quiet with sudden loud noises
  • The womb is a constant warm temperature
    The world can be hot or cold
  • The womb moves me around gently while I am in a soft sack of water
    The world sometimes moves me suddenly and sometimes leaves me completely still
  • The womb supports my whole body
    The world puts pressure on certain parts of my body
  • The womb provides nutrition without me asking
    The world waits for me to ask for food
  • The womb feels small and safe
    The world feels big and empty
  • The womb keeps my arms and legs near me
    The world lets my arms and legs move far away

Why do you think it is important for parents to understand the fourth trimester concept?

Behavioural states

Introduction to behavioural states

Behavioural states

Dr. T. B. Brazelton, an American paediatrician with a long-standing career working with newborns, identified six states of consciousness in newborns, described below.  Helping parents to understand these states gives them opportunities to understand their baby and read their behavioural cues, recognising their needs. All babies cycle through these states repeatedly throughout the day. Each baby is unique in their rate of change between these states; some babies oscillate quickly between them while others may spend considerable time moving between the states.  The rate of change will also depend on the stage of development. Each state exhibits different behaviours hence they are often referred to as "behavioural states". These states include two sleep states, three awake states and one transitional state.

Quiet Sleep

"Quiet sleep," also called "deep sleep," occurs when your newborn is most relaxed. Your baby's eyelids remain closed and still, and he remains relatively unresponsive to outside noise. He may stir some, but very little. According to Heidi Murkoff in "What to Expect the First Year," your newborn alternates between quiet and active sleep every 30 minutes.

Active Sleep

During "active sleep," sudden noises can startle your newborn awake. His eyes move rapidly beneath closed lids and may even flutter open before quickly closing again. Your newborn's arms and legs twitch and jolt, and he may also move his mouth around, making sucking or chewing movements and other funny faces.

Quiet Alert

Newborns in the "quiet alert" state make small, infrequent movements, if any at all. The eyes remain open wide in watchful awareness. Marshall H. Klaus and Phyllis H. Klaus, authors of "Your Amazing Newborn," explain that newborns in the "quiet alert" state "can follow a red ball, gaze at a face, turn to a voice" and even begin imitating facial expressions. Your baby may seem subdued in this state, but he is actually very busy learning about the world around him.

Active Alert

Newborns reach the peak of movement during the "active alert" state. They move with purpose, rhythmically stretching their arms and kicking their legs. This movement reinforces the connection between your baby's brain and body muscles. Your baby's eyes also frequently dart around during this state, and he may make small "cooing" sounds. Mild fussing occurs within this state as well.

Active Crying

Within the "active crying" state, your newborn's movements switch from rhythmic to chaotic. His eyes shut, his face twists and his arms and legs flail around. Your baby cries when he feels hunger, discomfort, frustration or loneliness. According to Klaus and Klaus, picking up your newborn within 90 seconds after he enters the crying state typically switches him to the "quiet alert" state. The movement involved in transitioning from lying flat to resting upright distracts and calms most babies.

Drowsiness

Drowsiness occurs as a transition between the alert and sleep states. As newborns wake up or fall asleep, they enter the drowsy state. Your baby may make a few bodily movements, such as stretching, as well as a range of facial expressions -- from scowling to smiling to yawning. His eyelids always begin drooping in this state, however, and his eyes take on a glazed, unfocused look.


Adapted from ‘The Earliest Relationship’, by T. B. Brazelton & B. G. Cramer

Sleep states (deep and light)

Quiet sleep (deep sleep)

Lack of body movement/ activity

Smooth, regular breathing

Eyes are closed

Lack of facial or eye movement

Bursts of sucking movements

Occasionally startles


Difficult to waken

If awakened can quickly return to sleep

Intrusive procedures not recommended

Feeding is unsuccessful

Generally unresponsive

Active sleep (light sleep)

More body activity

Irregular breathing

Facial movements

Possible movement of the eyes under the lids (REM)


Easier to waken

Feeding may be difficult

Baby may smile

More responsive

Transitional stage (drowsy)

Drowsiness

Variable activity

Irregular breathing

Eyes may be open or closed

Eyes may be glazed

Delayed responsiveness


Easy to waken

Difficult to tell if baby is awake or asleep

If left alone baby may settle to sleep

Feeding is possible but may be difficult

Can awaken or go back to sleep

Awake states (quiet, active and crying)

Quiet alert

Minimal body activity

Regular breathing

Face is bright and shiny

Most attentive to stimuli

Observant


Good time for reciprocal interaction

Learns best in this state

In the hours after birth most newborns have an intense period of this state followed by deep sleep

Active alert

Much body activity

Irregular breathing

Facial movement

Sensitive to stimuli


May signal for a change; feed, reposition

Fussiness

Difficult to interact

Crying

Irregular breathing

Facial grimace

Cries

Colour changes


Limits have been reached

Needs a change

Needs consoling

Variable sensitivity to stimuli

Please select all of the behavioural states

  • Happy
  • Quiet alert
  • Quiet sleep
  • REM sleep
  • Transitional
  • Receptive
  • Active alert
  • Crying
  • Engaged
  • Disengaged
  • Active sleep

In which state are you most likely to be successful in doing an activity with your baby and why?

Communication

Introduction to communication

Introduction to infant communication

Babies are born able to communicate with us. They do this in a number of key ways, the most obvious of which is crying but this is not the only way. Informing parents about the ways in which babies can and do communicate can be empowering for them, but if we are not careful, it can also be disempowering. Parents need to be taught some of the key concepts but in a general enough way that they are being given the tools to read their own babies. Otherwise parents may feel that you "understand" their baby better than they do or that they have failed in some way to communicate with them.

Most people know that babies' main form of communication is crying but many people mistakenly believe this is the only way that babies can communicate. In fact babies exhibit a number of subtle communications from birth that are referred to as infant cues and increasingly use sound to communicate throughout their first year. In this section we will look more deeply at infant crying, infant cues and pre-language sounds.

Crying

Crying in babies

Crying is well known as "the way that babies communicate" and it is true that it is one of the major tools of communication  that infants use. There are other forms that we will cover in the following sections. There is only one reason why a baby cries and that is because they are communicating a need. They need something or need you to fix something because they can't. Within this simple truth, there are two main categories for these needs:

Physical needs

I need to sleep

I need food/drink

I am physically uncomfortable

I am hot/cold

I am in pain

I am ill

I need a new nappy

Something is wrong (Colic/reflux etc)

Emotional/psychological needs

I need reassurance

I am over-stimulated

I am bored

I am lonely

I need love

I see you are stressed so I am too

I need to release my feelings

I need to feel connected to you

NOTE: This is not an exhaustive list

It is important to understand that new parents sometimes forget to consider that babies may be communicating an emotional need and find these reasons for crying to be the most difficult to understand and deal with. It is easy to identify and solve physical problems (most of the time) but psychological issues are more tricky. This is partly because they are unseen and babies cannot say "I feel sad/lonely/angry" but also because other's emotions, even that of babies, bring up our own emotions and parents are often struggling with their own issues already.

Emotional crying

Some scientists have spent their careers studying tears to understand crying better. They have discovered that there are three types of tears: Basal tears (always present to lubricate the eye ball), reflex tears (response to irritants such as dust) and emotional tears. the production of emotional tears all starts in the cerebrum where sadness/frustration and pain are registered. The endocrine system is then triggered to release hormones to the ocular area, which then causes tears to form.

The phrase "having a good cry" suggests that crying can actually make you feel physically and emotionally better, which many people believe. Some scientists agree with this theory, asserting that chemicals build up in the body during times of elevated stress. These researchers believe that emotional crying is the body's way of ridding itself of these toxins and waste products.

In fact, one study collected both reflex tears and emotional tears (after peeling an onion and watching a sad movie, respectively). When scientists analysed the content of the tears, they found each type was very different. Reflex tears are generally found to be about 98 percent water, whereas several chemicals are commonly present in emotional tears. The first is a protein called prolactin, which is also known to control breast milk production. Adrenocorticotropic hormones are also commonly present which are stress hormones and the secretion of these out of the body suggest that crying may indeed make you feel better. The other chemical found in emotional tears is leucine-enkephalin, an endorphin that reduces pain and works to improve mood. Of course, many scientists point out that research in this area is very limited and should be further studied before any conclusion can be made.

What is important about this is to realise that babies do cry for emotional reasons and probably cry sometimes to release their emotions. This is important because we hear a lot of parents say "I have done everything (feed, change, etc) and she is crying for no reason". There is always a reason and if we cannot physically "fix" it, it is our job to respond with compassion and empathy. Babies who are fed, changed and have slept still need our parental support to help them. The idea that if their physical needs are met, our job is complete is illogical and is not in-keeping with our values.

Supported vs unsupported crying

When a baby is truly distressed, something which happens when they have a need and parents do not respond, research shows us that their cortisol levels (stress hormone) rise considerably. When a baby is left to cry for long periods their cortisol levels get very high and research has shown that when the crying stops, although the mother's cortisol returns quickly to normal, the babiy's cortisol remain high for a significant time after they have become quiet. This tells us that baby's are not "self settling", they are learning not to cry (learned helplessness). There is some evidence to suggest that babies and children who experience high cortisol levels create a state in the body in which cortisol levels will raise more easily, more significantly and for longer throughout life. This is not scientifically certain.

Whilst it is important that parents understand the there may be risks to leaving their babies to cry, if babies cry for long periods whilst parents and caregivers are present and attentive (crying in arms), babies cortisol levels are significantly lower than if they are left.

It is also very important to remember that babies' brains are physically incapable of manipulation. You cannot spoil your baby - that is a myth and one we would love to eradicate from society.

Crying in classes 

Crying babies create a reaction in all of us. It is important to understand yourself as a consultant well enough to know your own triggers and have strategies in place to support yourself in managing your own reactions to crying in classes.

It is essential that you are supportive and empowering in the way you manage crying babies in classes. Here are some tips:

Respect the parents way of dealing with crying in their own way by showing a welcoming attitude to their approach, Even if you do not agree with their approach or it does not fit with the evidence that we teach in BabyCalm. Remember that you will only reach these parents if you welcome them without judgment first and foremost.

Introduction to cues

What are infant cues?

When we talk about infant cues we are taking about observing baby behaviour and noticing anything from tiny behaviour changes to much more obvious actions that are predictable in most babies that indicate a particular state or need. It is important to remember that although many cues are predictable in most babies, all babies will have their own variations and it is much more important to teach parents to look for THEIR baby's cues rather than learn a set of standard ones. Describing cues to parents should only serve to give them ideas of what they might be looking for.

Engagement and disengagement

Cues for behaviour encouraging or discouraging engagement

In this section we will look at those cues that might indicate that a baby either wants to, or doesn't want to engage with you at that particular moment. This can be useful for parents to know so that they can gauge whether to do an activity with their baby. This might be some reciprocal interaction like a nursery rhyme, or it could be infant massage.

Engagement

Eyes are open and bright

Looks away and back at parents

Smiling

Looks directly at parents

Cooing

Sucking contentedly

Laughs

Lying quiet and relaxed

Smoother movements of arms and legs

Reaches out parents with eye contact and smiles

Open body language

Disengagement

Eyes closed in awake state

Yawning / sleepy behaviour

Staring (glazed)

Grimacing

Hicupping

Spitting up

Fussy crying

Arching back and stiffening

Crawling or rolling away

Jerky, uncontrolled movements

Pushing or kicking parents hands away

Closed body language

Feeding cues

Feeding cues

One of the things that babies try to communicate to us right form birth is that they want to feed. Many parents don't realise until they are many weeks in that what they are seeing are early feeding cues and so end up in a situation where their baby gets to the crying stage before parents know it is feeding time. This can lead to baby being too stressed to form a good latch and is more stressful for everyone involved. Offering parents the chance to recognise their baby's early feeding cues is a useful tool for keeping everyone more calm.

How does it normally start?

  • Smacking or licking lips
  • Opening and closing mouth
  • Sucking on lips, tongue, hands, fingers, toes, toys, or clothing
  • Flexing their tongue in and out as though lapping

Then if baby is not being fed....

  • Rooting reflex
  • Bobbing the head around on the chest of whoever is carrying/holding (breast searching)
  • Trying to position for nursing, either by lying back or pulling on your clothes
  • Fidgeting or squirming around a lot
  • Hitting you on the arm or chest repeatedly
  • Fussing or breathing fast
  • Jerky movement of the arms and legs
  • Tries to suck fists

Then we start to get to crying and fussing. By this time, baby is really hungry and starting to feel desperate.

Tiredness cues and other things to watch for

Tiredness cues

Early tiredness cues are often unique to babies but many babies exhibit some form of ear pulling when they are tired. They also tend to rub their heads and faces and may continuously look away when tired or over-stimulated, as if to say "I cannot cope with any more". The oddest common tiredness cue is hicupping.

Also watch for...

Other cues that are often present and misinterpreted are:

  • Pulling up legs = a reflex action when a baby is upset, does not necessarily mean pain!
  • Going red = again does not necessarily mean pain, usually means crying for too long
  • Blue outline to lips = trapped wind

Elimination communication

Elimination communication

This is not something that we cover with parents at all in BabyCalm as standard practice but it is something that we feel you should have some basic understanding of, in case you are asked about it. Elimination communication is truly a baby-led practice and so whilst it is closely aligned with our value of empathy towards babies, it is considered quite "out-there" by many parents and our need and desire to be accessible to mainstream parents (to reach as many families as possible) means that we need to be cautious about if and when we provide this information to parents.

So what is it?

Elimination communication (EC) is a practice in which a caregiver uses timing, signals, cues, and intuition to address their baby's need to eliminate waste. Caregivers are responsive to their baby's bodily needs and enable them to urinate and defecate in an appropriate place (e.g. a toilet). Caregivers may use nappies as a back-up in case of "misses" some or all of the time, or not at all. In EC, communication between the caregiver and child is essential, helping them both become more attuned to the child's innate rhythms and control of urination and defecation. The term "elimination communication" was inspired by traditional practices of "diaperless" baby care in less industrialised countries and traditional hunter-gatherer cultures. Some practitioners of EC begin soon after birth, the optimum window being birth to four months in terms of helping the baby get in tune with their elimination needs, although it can be started with babies of any age. The practice can be done full-time, part-time, or just occasionally.

Pre-language sounds

Dunstan's claims

Prescilla Dunstan is a trained opera singer with an "ear" for sound. She developed a deep understanding of her babies' communication and applied it to others with success. This is not a "researched" phenomenon. Musicians are often better at hearing these cues due to their ability to hear more subtle changes in pitch and sound.

In her book “Child Sense: how to speak your baby's language” (2010) Priscilla Dunstan claims that between 0-3 months, infants make sound reflexes. According to Dunstan, we all have reflexes, like sneezes, hiccups and burps, that all have a recognisable pattern when sound is added to the reflex. This she calls “Dunstan's Baby Language”. We have selected only three of these sounds that we think are very commonly noted:

Neh – LISTEN FOR THE “N” I’m hungry

An infant uses the sound reflex "Neh" to communicate its hunger. The sound is produced when the sucking reflex is triggered, and the tongue is pushed up on the roof of the mouth.

Owh – LISTEN FOR THE “O” I'm sleepy 

An infant uses the sound reflex "Owh" to communicate that they are tired. The sound is produced much like an audible yawn. Watch for an “O” shaped mouth.

 Heh or Eairh – LISTEN FOR THE “H”  I'm experiencing discomfort  

An infant uses the sound reflex "Heh" to communicate discomfort, most often I hear this when a baby wants to be picked up.

Baby signing

Baby signing

Baby signing is a form of pre-verbal communication. Babies understand language long before they can talk. From as early as 6 to 9 months old, babies can begin to use sign language to communicate with parents. Some parents choose to do a little signing to communicate key things such as milk, sleep, nappy, hot, cold and others use much more complex communication even from a young age.

Babies’ control of their hands develops long before their control of their vocal cords and co-ordination of the movement of lips, tongue and teeth to make understood speech sounds as recognised words (often as late as 18 months).

Baby signing bridges this very wide gap - aiding communication, giving them a means to begin to understand an reciprocate communication effectively. Although you might think that using sign might delay actual speech (because they already have a method pf communication, actually it has been observed that it usually encourages early language development and speech through practice of communication skills. 

Aside from communication factors, baby signing also has the potential to strengthen the child-parent attachment through deep understanding, empathy and reciprocity. Using sign language  reduces frustration, boosts self-esteem and self-confidence: in short making happier parents and calmer babies.

We don't teach baby signing but I would be happy to recommend classes to parents.

Please highlight three key messages that you want to pass onto parents about crying.

Why is it important to teach parents about engagement and disengagement cues?

Please select ALL the things a baby might do when they are first signalling they are hungry

  • Smacking or licking lips
  • Crying
  • Opening and closing mouth
  • Rooting
  • Jerky movements
  • Flexing their tongue in and out as though lapping
  • Sucking on lips, tongue, hands, fingers, toes, toys, or clothing

Is there a scenario in which we would discuss elimination communication within a BabyCalm class?

Please give your personal opinion of Dunstan's baby language

Please name three benefits of baby signing

Reflexes and developmental norms

Reflexes and developmental norms

Reflexes and developmental norms

In the future it is our intention to provide more detailed knowledge in this area but in the interest of getting your modules out this year we have decided just to leave you with this video. This is just background knowledge and not something you will need for your classes unless syoua re asked about them. remember though, if you are asked something you don't know the answer to, just say so and follow up later with the information. You will be able to find it within our community.

Here are two videos to get you started. The second one does go beyond the ages that BabyCalm deal with but the baby information is useful. I will apologise for the very American nature of the videos.

Please describe 4 key newborn reflexes and why we might need to understand them when running a baby massage session?

Please describe the difficulties you might be presented with when welcoming babies from birth to 12 months to a massage session

Common infant heath issues

Introduction to infant issues

Common infant health issues

In this section you will gain some insight into those health concerns that are commonly diagnosed or occur in babies, particularly focusing on the issues that tend to make parents be drawn to baby calming techniques. By gaining a further understanding of these issues we can support parents better but it is essential that you understand that we are not there to diagnose or give advice on any of these issues.

Colic

Colic

Nobody really knows what colic is, it tends to be used as a catch all term to describe an unsettled crying baby, yet very often the label of ‘colic’ is actually a sign of an undiagnosed problem such as tongue tie, breastfeeding latch problems, an over stimulated baby or a baby protesting at not being close enough to his parents. Colic in itself is not a disease or a disorder; it is really just an explanation of a baby who cries a lot. Diagnosing a baby with Colic doesn’t actually tell us what is wrong with the baby or help us to understand why the baby cries, the cause often remains a mystery.

The official definition of colic is known as the Wessel Criteria, named after the American Paediatrician of the same name. Wessel’s definition was based on observation with no scientific evidence behind it, yet the Wessel Criteria of the “Rule of 3s”, that is baby who cries for more than 3 hours a day, for more than 3 days a week, for over 3 weeks, is still commonly used by doctors around the world today. Wessel’s definition of colic applies to around 25% of all babies, which seems to highlight that there is another problem at play, rather than just the tummy troubles usually believed to be the cause of colic.

Our understanding of colic becomes even more fuzzy when we consider that it usually peaks between 6-8 weeks of age and often resolves by 12 weeks for around 50%, with 90% resolved by 9 months of age. For most babies colicky crying is consigned to the evening, usually between what many call “The Witching Hours” of 6-9pm. Colic is also reported more by mothers who have undergone a stressful pregnancy and have higher levels of stress and anxiety themselves.

Signs of colic include prolonged crying, a baby drawing his legs into his body, his tummy going hard  and going red.

Some limited evidence suggests that limiting the mother’s diet may improve colic symptoms if she is breastfeeding, the main culprits are usually the vegetables (these being cabbage, cauliflower and broccoli) cow’s milk, chocolate, onions and caffeine. However many of the colic remedies available to buy over the counter in chemists and supermarkets have no evidence to show they work any more than placebo. Worryingly the two main colic remedies purchased by parents, those containing Simethicone (used to release gas bubbles in the tummy) and those containing Lactase enzymes (to break down lactose in babies believed to have a lactose intolerance) have not been shown to have any consistent effect on infantile colic in scientific research, which is particularly alarming when you consider that research suggests that around three-quarters of babies today are exposed to some form of medicinal product before 8 weeks of age. Switching to Soy based formula has also not been shown to have any determinable effect on colic symptoms.

(NOTE - See Breastfeeding network hand out ’Treatments for Colic’ for more on this research)

Reflux

Reflux

Many parents suspect their baby has reflux. They are often concerned that their baby is sick regularly (which is perfectly normal in young babies) and seems uncomfortable. However, genuine reflux is grossly over diagnosed in babies, that’s not to say the condition doesn’t exist, because it does and it can be very tough to live with. Our concern is that far more babies than necessary are being prescribed reflux medications when perhaps another underlying issue is really the problem. 

So what is Reflux? Reflux is what happens when the contents of a baby’s stomach comes back up into his oesophagus and sometimes into his mouth, largely because the sphincter action of the baby’s diaphragm is not completely developed. As the sphincter action develops the reflux tends to decrease. This action is pretty common though with up to 50% of babies suffering from reflux;  it is only problematic for a tiny percentage. When it is problematic it can cause a large range of symptoms. Reflux can affect all babies, however they are fed.

Signs of Infant Reflux

  • Excessive crying, particularly after a feed

  • Arching back after a feed

  • Excessive vomiting, often projectile

  • A persistent night time cough

  • A persistent runny nose

  • Very frequent waking during sleep

  • Baby is happier when held in an upright position

  • Acidic smelling breath

  • A hoarse cry, as if he has a sore throat

  • Poor weight gain

  • Excessive irritability
  • Very frequent feeding


Silent reflux is used to describe the same condition, however in this case the most common symptom of projectile vomiting is missing and the baby may show no outward symptoms at all, hence deeming it‘silent’. Silent reflux can be very distressing as it often manifests in a very unhappy baby who wakes extremely frequently during the night and is very hard to settle. However as the outward symptoms are not there it is often much harder to receive a diagnosis.

Tips to Cope With Reflux

  • Try to keep baby upright for at least 30 minutes after a feed

  • Special sleep positioners and wedges can work well for babies with reflux; they help to keep baby 

    in a more upright position making him more comfortable during sleep

  • Wearing a baby with reflux in a sling can be a life saver, not only does the sling hold him in an 

    upright position the close proximity to you can help to calm him and alleviate any pain he may be feeling
  • Avoid putting tight clothing on the baby, particularly around his tummy which may aggravate the 

    problem, loose fitting all in ones and babygros will probably be the most comfortable for him.

  • If the baby is breastfed removing foods that could aggravate their baby’s reflux from their diet may help (common culprits are dairy products, spicy food, caffeine, citrus fruits and seeded fruit such 

    as strawberries)

  • Babies with reflux tend to respond well to more frequent, smaller feeds

  • Baby massage, particularly focusing on the tummy, can be very helpful for soothing babies with 

    reflux.

CMPA/Lactose intolerance

Lactose intolerance and Cow’s Milk Protein Allergy (CMPA)

Many people use the terms lactose intolerance and milk allergy interchangeably, but they are actually quite different.

Cow’s Milk Protein Allergy

About 2% of babies suffer with a cow’s milk protein allergy (CMPA), though the incidence is lower in breastfed babies. Symptoms tend to appear very early, particularly when cow’s milk is introduced to the baby’s diet (which can happen indirectly through the mother’s consumption if she is breastfeeding) although some can be late in onset. A milk protein allergy is very rare in exclusively breastfed babies. Reactions occur in the baby’s body when their immune system mistakes milk protein as something foreign that the body should fight, triggering an allergic response. Nobody really knows why some babies suffer from CMPA, though the general belief is that the problem is genetic in origin. There is unfortunately no one definitive test to diagnose CMPA, usually a diagnosis is arrived at through a series of blood tests, skin prick tests and stool testing.

Cows Milk Protein Allergy Symptoms:

  • Diarrhoea (which may contain blood)
  • Vomiting
  • Excessive irritability
  • Skin problems, such as eczema
  • Failure to thrive and slow weight gain

The only treatment for CMPA is to avoid the source of the problem. Breastfeeding mothers are therefore advised to completely remove dairy from their diet and babies who are formula fed will be prescribed special hypoallergenic formula milk. Most babies usually outgrow CMPA by the age of 4.

Lactose Intolerance

Lactose intolerance is caused by the body’s inability to digest lactose, a sugar found in milk. The intolerance is caused by a lack of the enzyme lactase in the baby’s body. Lactase helps the body to digest the milk sugar lactose.

Symptoms of Lactose Intolerance Include:

  • Diarrhoea
  • Vomiting
  • Tummy Pain
  • Excessive wind
  • Constipation

 Lactose intolerance is not dangerous, in that the body is not reacting in the same way that it does to a Cow’s Milk Protein Allergy. However, it can make babies very uncomfortable.  Many babies who are lactose intolerant can tolerate yogurt, butter and cheese as they contain less lactose than milk itself.  Treatment simply involves avoiding lactose.

Birth trauma and cranial compression

Cranial Compression and Birth Trauma

If a baby is born by Caesarean, ventouse or forceps or the labour has been long and involved malpresentation (the baby lying in the wrong position) there may be a physical cause for the baby’s unhappiness at play. Imagine if your head had been crooked at an unusual angle for several weeks –or even months, and then imagine that somebody was pushing your head down into that position even harder for a good minute every three minutes for fourteen hours or even more, you’d probably have a headache and neck ache. Some babies seem to be in obvious discomfort with torticollis (the medical term for stiff neck) and are unable to turn their heads (which may cause them to be unhappy when feeding from one side).

During labour the baby’s cranial bones move and overlap, this moulding is completely normal, it helps a baby’s head to become as small as possible so that it can fit through the mother’s pelvis (even if that’s not the way he ultimately came out). The baby’s cranial bones usually then return to their normal position over the first few days following birth, mostly via the process of the baby sucking (and the movement of the upper and lower jaw) which stimulates the base of the skull, via the palate. However, sometimes things don’t return to normal and often abnormal skull compression becomes noticeable via the baby’s feeding habits and need to suck much more than usual. Manic sucking being the way your baby tries to resolve the problem himself. If the baby’s vagus nerve (the nerve directly linked to digestion) is compressed this can also have noticeable effects on a baby’s digestive system often causing him pain. All of this is more likely to happen if the labour is long, the baby is malpresented or is born via emergency C-Section, forceps or ventouse.

Therefore visiting a chiropractor or cranial osteopath can make a profound difference for some parents or babies. Unfortunately though there is no clinical research to prove efficacy, only anecdotal experiences from parents themselves.

Positional flat head syndrome

Positional flat head syndrome (Plagiocephaly)

Plagiocephaly is a condition that causes a baby's head to have a flat spot (flat head syndrome) or be misshapen.

The most common form is positional plagiocephaly. It occurs when a baby's head develops a flat area due to pressure. Babies are vulnerable because their skulls are soft and pliable when they're born. Positional plagiocephaly typically develops after birth because babies spend so much time lying on their back in our society.

Starting in the early 1990s, parents were told to put their babies to sleep on their back to reduce the risk of SIDS. While this advice has saved thousands of babies' lives, experts have noticed a five-fold increase in misshapen heads since then. It an also be attributed to the increase in our society for placing our babies in various devices designed to replace parents arms, such as baby gyms and play mats, baby bouncers, bumbos, cots and prams.

Tummy time

For this reason, it is often recommended by health professionals that babies be placed on their tummies often during the day both for their development, and to avoid positional head flat syndrome.

Tummy time pros

  • Can help a baby to feel more grounded and more like “in utero”
  • Helps babies to breath more deeply and take in more oxygen
  • Gives a baby a tummy massage and can help babies with tummy pain
  • Encourages a baby to lift their head which leads to a strong neck and back
  • Is a natural progression to learn how to crawl
  • Can aid independent sitting far sooner than babies who have had no tummy time.

 Tummy time cons

  • Babies usually hate it
  • Parents usually ate it because baby is in distress


BabyCalm tips for happier tummy time

  1.  Lay baby on your chest
  2. Carry baby in a sling facing inwards (this is not quite the same but has similar benefits)
  3. Lay baby across your legs
  4. Use holding positions such as “tiger in the tree”
  5. Roll up a towel under the baby's arms/chin in order to lift them from the floor

 

Note: Babies should always be placed to sleep on their backs, as per SIDS guidelines.

Hip dysplasia

Hip dysplasia

Developmental dysplasia of the hip (DDH) is a condition where the 'ball and socket' joint of the hips doesn't properly form in babies and young children. 

It's sometimes known as congenital hip dislocation or hip dysplasia.

The hip joint attaches the thigh bone (femur) to the pelvis. The top of the femur (femoral head) is rounded like a ball and sits inside the cup-shaped hip socket.

In DDH, the socket of the hip is too shallow and the femoral head isn't held tightly in place, so the hip joint is loose. In severe cases, the femur can come out of the socket (dislocate). 

DDH may affect one or both hips but is more common in the left hip. It's also more common in girls and firstborn children. About 1 or 2 in every 1,000 babies have DDH that needs treating.

Without treatment, DDH may lead to problems later in life, including:

  • developing a limp
  • hip pain – especially during the teenage years 
  • painful and stiff joints (osteoarthritis) 

With early diagnosis and treatment, most children are able to develop normally and have a full range of movement in their hip.

Diagnosing DDH

Within 72 hours of giving birth, a baby's hips will be checked as part of the newborn physical examination. Another hip examination is carried out when your baby is between six and eight weeks old. The examination involves gentle manipulation of your baby's hip joints to check if there are any problems, and shouldn't cause them any discomfort.

An ultrasound scan is usually recommended within a few weeks if:

  • the hip feels unstable 
  • there's a family history of childhood hip problems 
  • your baby was born in the breech position (feet first with their bottom downwards) 
  • you've had twins or a multiple birth
  • your baby was born prematurely – before the 37th week of pregnancy 

Sometimes a baby's hip stabilises on its own before the scan is due.

Treating DDH

Pavlik harness

Babies diagnosed with DDH early in life are usually treated with a fabric splint known as a Pavlik harness. This secures both of your baby's hips in a stable position and allows them to develop normally.

The harness needs to be worn constantly for several weeks and shouldn't be removed by anyone except a health professional. The harness may be adjusted during follow-up appointments and your clinician will discuss your baby's progress with you.

Your hospital will provide detailed instructions on how to look after your baby while they're in a Pavlik harness. This will include information on:

  • how to change your baby's clothes without removing the harness (nappies can be worn normally) 
  • cleaning the harness if it's soiled – it still shouldn't be removed, but may be cleaned with detergent and an old toothbrush or nail brush 
  • positioning your baby while they sleep – they should be placed on their back and not on their side 
  • how to help avoid skin irritation around the straps of the harness – you may be advised to wrap some soft, hygienic material around the bands 

Eventually, you may be given advice on removing and replacing the harness for short periods of time until it can be permanently removed. You'll be encouraged to allow your baby to move freely when the harness is off and swimming is often recommended.

Surgery

Surgery may be needed if your baby is diagnosed with DDH after they're six months old, or if the Pavlik harness hasn't worked. The most common surgical technique is known as reduction, which involves placing the ball of the femur back into the hip socket.

Reduction is carried out under general anaesthetic and may be performed as either:

  • closed reduction – the ball is placed in the socket without making any large cuts (incisions) 
  • open reduction – an incision is made in the groin to allow the surgeon to place the ball in the socket 

Your child will need a hip cast for at least six weeks after surgery. Their hip will need to be checked under general anaesthetic again after this time to make sure it's stable and healing well. After this investigation, a cast will probably be needed for at least another six weeks to allow the hip to fully stabilise.

Some children may also require bone surgery (osteotomy) during an open reduction, or at a later date to correct any bone deformities.

Late-stage signs of DDH

The newborn physical examination and the check at six to eight weeks aim to diagnose DDH early. However, sometimes hip problems can develop after these checks.

It's important to contact your GP as soon as possible if you notice your child develops any of the following symptoms:

  • restricted movement in one leg when you change their nappy 
  • one leg drags behind the other when they crawl 
  • one leg appears longer than the other 
  • uneven skin folds in the buttocks or thighs 
  • a limp, walking on toes or developing an abnormal 'waddling' walk 

Your child will be referred to an orthopaedic specialist in hospital for an ultrasound scan or an X-ray if your doctor thinks there's a problem with their hip.

Preventing DDH

It's important to remember that DDH can't be prevented and it's nobody's fault. A baby's hips are naturally more flexible for a short period after birth.

However, if your baby spends a lot of time tightly wrapped with their legs straight and pressed together (swaddled), there's a risk this may slow their hip development. Using 'hip healthy' swaddling techniques can reduce this risk. Make sure your baby is able to move their hips and knees freely to kick.

NOTE: This information is provided to us by the International Hip Dysplasia Institute. More information can be found here: http://hipdysplasia.org/developmental-dysplasia-of-the-hip/

Tongue and lip tie

Tongue Tie

It is estimated that up to 10% of newborn babies suffer from tongue tie, yet the vast majority ofthese go undiagnosed which can cause weeks or months of misery for both parents and baby.

Tongue tie, or ankyloglossia as it is known medically, is a birth defect in which the baby’s frenulum, thepiece of skin that loosely attaches the tongue to the base of the mouth, is unusually short. This has theresult of holding the tongue down and often dramatically restricting the tongue’s range of movement.Some babies have less obvious posterior tongue ties and some can even have a lip tie. Not all tongueties cause problems though.

Problems potentially caused by tongue tie in young babies include:

  • Poor latch when breastfeeding

  • Bleeding and sore nipples when breastfeeding

  • Mastitis when breastfeeding

  • Problems with bottle feeding if the baby is unable to form a seal around the teat and cannot

    take milk from the bottle easily as a result

  • Babies can be frustrated when feeding

  • Baby’s appetite often not satiated after a feed

  • Failure to thrive/poor weight gain

  • Windy & irritable babies

Mums who think their baby may be tongue tied should visit an International Board Certified Lactation Consultant (IBCLC) or specialist midwife as soon as possible, even if they are notbreastfeeding, the IBCLC or midwife will be able to check and either refer to somebody who will beable to release the baby’s tongue tie or possibly perform the procedure themselves.

In babies a frenotomy, or release (often referred to as “snipping”), is a simple and quick procedure where the tie is carefully cut underneath the tongue, sometimes there may be a small amount of bleeding, but babies can feed straight away afterwards and no special after-care is needed.Parents often report seeing dramatic results immediately after the procedure with babies feeding better almost straight away and other problems diminishing quickly afterwards too.

Lip tie

Lip tie (in which there is frenulum attaching the upper lip to the gum) is becoming increasingly recognised as causing feeding problems for some infants. If the movement of the upper lip is restricted by the tie then creating a good latch can be difficult and babies will often latch and then lose suction, slipping form the breast.

It is not enough of a diagnostic tool though to view the anatomy of a lip tie. In some lip ties that look severe, the attaching skin is very stretchy and therefore movement of the lip is not restrictive and in some cases, what appears to be a small lip tie can be tight and cause severe feeding issues. Any suspected lip or tongue ties should be referred on to a breastfeeding professional, preferably at IBCLC level.

Other issues affecting feeding

Other issues affecting feeding

There are a number of common issues that affect feeding in the early days and many more myths surrounding feeding problems that cause new breastfeeding mothers to think there are issues when actually you are dealing with normal breastfeeding and newborn behaviour. These will be covered in more detail within the infant feeding module which will be sent out once it is completed. These include issues such as:

  • Jaundice
  • Blood sugars
  • Latch issues
  • Under and over supply of breastmilk
  • Weight gain/loss

What causes colic?

A parent arrives at one of your sessions with a baby who has been prescribed Gaviscon and Nutramigen, yet you do not believe that the baby has either reflux or milk intolerance. What action would you take?

Within the BabyCalm course birth debrief, a parent shares that birth was traumatic, they seem quite upset about it. They are also experiencing difficulty in feeding and their baby often cries vigorously when they appear to have no physical needs.

How would you support this mum?

Why is it necessary for babies to have prescribed "tummy time"?

Identify the ways in which tummy time can be made a calmer and happier experience

  • Using slings
  • Avoiding it if your baby hates it
  • Rolling a towel under their chest to support them
  • Putting them on their tummies for the prescribed time even if they hate it
  • Having them on their tummy on your chest
  • Lay baby across your legs
  • Put them to sleep on their tummy
  • Use holding positions tummy down (tiger in the tree)

A mother in your class is clearly struggling with feeding, baby latches and unlatches and makes a clicking sound when they feed. You think you can help her with her latch but actually you suspect a tongue or lip tie

How would you support this mother?