by Dr Kiran Rahim
As a Paediatric Doctor, if there is one thing I know well, it’s the Fourth Trimester; those wonderful and weary first few months of adjusting to life with a new born baby. A period where babies are adapting to life outside of the womb and undergoing some important neurodevelopment changes. Also a period that is incredibly overwhelming and tiring for the adults caring for them and filled with lots of emotions of anxiety, self-doubt, fear and finding your feet.
It’s easy to spot parents in their fourth trimester; in they walk to see me, usually 2-3am, blurry eyed, sleep deprived and desperately trying to navigate their parenting journey. Unlike other mammals, babies aren't born knowing how to walk and talk, so they rely on the first few months of life to learn to control their behaviours and movements and seek attention from their carers, constantly. Although it’s overwhelming, it’s also an incredibly exciting time for you to get to know your baby and learn new things.
The commonest thing I see in the fourth trimester is an unsettled and crying baby and its one of the most frequent reasons parents seek support from a Doctor. In many of these cases, almost 95%, there is absolutely nothing wrong with baby and what I see is a perfectly healthy, thriving baby who is in her 4th trimester.
So why do I care? Because crying causes significant parental anxiety and impacts families greatly. Crying babies impact parental mental health and studies show a strong association with crying and postnatal depression. Persistent crying also influences feeding choices and stops the successful establishment of breastfeeding as well as contributing to over diagnosis of pathology in some cases. This is why education and understanding your baby in the 4th Trimester in so important and understanding what is ‘normal’ for baby and when you should seek help.
Crying is a normal part of a baby's development and it’s important that as Doctors, Parents and other health care professionals, we normalise it.
What is Normal crying?
On average, babies cry for 2-3h a day in the first 6 weeks of life– that’s a lot of crying, so no wonder inexperienced parents get worried! Normal crying follows a circadian rhythm which means it is often worse in late evenings and early morning. In other words 70% of the crying happens between noon and midnight, and is often associated with inconsolable bouts, where nothing you try seems to work!
My rule of thumb for parents is based on evidence from a study by Wessel et al and is called the Rule of 3s. If your baby cries for more than 3hours a day, for more than 3 days a week, over a period of 3 weeks, you need to get some help. Whether this is your health visitor, your GP or speaking to a paediatrician crying like this needs addressing. Most likely your baby is fine, but its best to make sure there isn’t something else going on!
What you need to look out for as a parent in the 4th Trimester
As I’ve said before, crying is a common occurrence in the first 12w of life but here are some things to look out and to see a Doctor about if you suspect your baby has them.
Reflux is a normal process and it occurs in 4 out of 10 babies and is associated with bringing up milk shortly after a feed! It happens several times a day and usually begins around 8weeks of age! Although it’s very common, in some babies it can lead to hours of inconsolable crying, feed refusal and even weight loss.
Your baby may have reflux if they:
- spit up/posset during or after feeds a lot
- arch their backs a lot after feeding
- cry a lot during or after feeds
- draw up legs after feeding
Some babies may not have any of these signs and may just be irritable a lot during the day. This is sometimes called silent reflux. If you suspect your baby has reflux, keep a diary of what they experience, when and whether it’s related to feeding and discuss your concerns with your GP or a Paediatrician!
This is an allergic response to the protein found in cow’s milk and usually presents in the first 4w of your baby’s life.
Your baby may have CMPA if they have an eczema like rash, vomiting, very runny or bloody poos or if they cry excessively and refuse feeds.
It usually affects babies that are fully or partially formula fed and generally occurs in babies whose parents have a history of allergies, asthma or eczema.
It’s really important if you think your baby has CMPA that you consult a doctor BEFORE you make any changes to their diet or yours!
This is probably the commonest thing I see as a Paediatrician and in my experience most if not ALL babies are ‘colicky’ at some point in the first few months of life.
Colic follows the same pattern as normal crying but there’s just more of it in an otherwise well baby! The hallmark is usually inconsolable bouts of crying, particularly in the evening. Colic is also a word that is used a lot and usually means different things to different people.
I always tell parents that in my experience, all babies have colic in that they cry a lot, are usually inconsolable at some points and that colic is a bit like a spectrum meaning some babies cry more than others on this spectrum, and others less.
Very occasionally there are some serious medical causes for crying and parents should ALWAYS see a doctor if there baby has any of the following:
- Fever >38°C
- Reduced wet nappies (<2 a day)
- Feeding <50% of normal
- Persistent or projectile vomiting
- Blood in nappy
- Sleepy/lethargic baby
Be a Baby Whisperer
Whilst crying may seem like it will never end, its reassuring to know that for most, if not all babies, crying is usually a phase that will pass! It may not seem like it at the time and in the depth of the night, but we rarely see adults walking around crying, for hours on end, every day of the week!
As parents, grandparents and those look after your beautiful new bundles there are things you can do in the fourth trimester to help your baby to stop crying! The secret is in creating a secure, cosy environment, similar to what the baby experienced inside the womb.
- Swaying/Swinging: mimics the gentle rocking movements baby would have experienced as Mummy walked around
- Sling: evidence shows that carrying babies for three or more hours a day and keeping them close to you reduces crying by about an hour!
- Sucking: this is normal infant reflex and many babies suck their fingers and thumbs in the womb! IF you are breastfeeding, let your baby suckle as often as they would like or offer a pacifier/dummy. You will not spoil your baby, you are providing them with comfort!
- Shushing: mimics the muffled noises baby would have heard in the womb. You can also sing or use white noise to create a similar effects
- Swaddling: provides the security and confinement baby had in the womb. Please ensure you know how to safely swaddle a baby!
- Massage: There is emerging evidence that regular infant massage is associated with less crying
Looking after YOU
Whilst much of what we’ve covered in the blog post focuses on your baby, as a Paediatrician I want you to know that your health and your partner’s health are equally important. Particularly when it comes to establishing a close bond with baby!
Pregnancy and birth are exhausting and it’s really important you sit down and talk to your partner about how you are feeling, particularly if birth did not go quite as planned. I often see parents who are experiencing birth trauma but don’t know it and would benefit from talking about their thoughts and emotions. In my experience women and men BOTH experience birth trauma, postnatal anxiety and indeed postnatal depression.
Whilst having some baby blues and anxiety is normal after birth it’s really important both parents check in with themselves and discuss their mental health either with their midwife or GP.
Some of the places you can access support for your mental health are:
I hope you’ve enjoyed reading this blog post. If you have any questions please feel free to reach out to me on my Instagram page TheMunchingMedic.
Sending you love and solidarity!
Dr Kiran Rahim
Wolke D, Bilgin A, Samara M. Systematic Review and Meta-Analysis: Fussing and Crying Durations and Prevalence of Colic in Infants. J Pediatr. 2017 Jun;185:55-61.e4. doi: 10.1016/j.jpeds.2017.02.020. Epub 2017 Apr 3. PMID: 28385295.
McKenzie SA. Arch Dis Child Educ Pract Ed 2013;98:209–211.
Wessel MA. Paroxysmal fussing in infancy, sometimes called “colic” Pediatrics 1975;14:421-435.
Taubman B. Parental counseling compared with elimination of cow’s milk or soy milk protein for the treatment of infant colic syndrome: a randomized trial. Pediatrics 1988;81:756-761.
Pawel B and Henretig F. Crying and colic in early infancy (ch16) in: Fleischer and Ludwig, Textbook of pediatric emergency medicine, 6th ed. 2010.
St James-Roberts I, Alvarez M, Csipke E, Abramsky T, Goodwin J, Sorgenfrei E. Infant crying and sleeping in London, Copenhagen and when parents adopt a "proximal" form of care. Pediatrics. 2006 Jun;117(6):e1146-55. doi: 10.1542/peds.2005-2387. PMID: 16740816.
Hunziker UA, Barr RG. Increased carrying reduces infant crying: a randomized controlled trial. Pediatrics. 1986 May;77(5):641-8. PMID: 3517799.
Underdown A, Barlow J, Chung V, Stewart‐Brown S. Massage intervention for promoting mental and physical health in infants aged under six months.
Cochrane Database of Systematic Reviews 2006, Issue 4. Art. No.: CD005038. DOI: 10.1002/14651858.CD005038.pub2. Accessed 07 July 2021