Differential Diagnosis and Treatment: Newborn Irritability

I have had so many people contact me privately who recently welcomed new blessings into this world (Mazel Tov!) to ask questions about newborn irritability/gas/discomfort/fussiness and how we came to our diagnosis, treatment, and, as a result, MUCH happier and healthier newborn. Because I know there are so many out there who just had a baby, are pregnant, or know someone who is pregnant, I wanted to share the information I gathered along my journey to help my Harrison during his first couple months of life, hoping this will help another Momma out there. Please feel free to share this with anyone you think may benefit from the following information. 

First things first. 

Differential Diagnosis.

What makes things tricky is that any or all of the following can affect a newborn: 

Normal Infant Irritability. It is normal for babies to cry. It's how they communicate their needs to us. It's their way of sharing that they are tired, uncomfortable, hot/cold, hungry, gassy, in need of a new diaper, or, possibly, in pain. It's when this irritability becomes excessive, or is coupled with other symptoms, that suggests something else may be going on. 

Colic. Unfortunately, I think many a pediatrician are too quick to throw this term around without ruling out other potential causes of newborn irritability. From my research, colic is a "predictable period of significant distress in an otherwise well-fed, healthy baby. Babies with colic often cry more than three hours a day, three days a week for three weeks or longer" (source). For many newborns, this period is in the evening hours. Again, this is tricky though, because the evening hours are also commonly known as the "witching hour," when most babies become a little fussier. 

Reflux. It is normal for all babies to spit up. It is also normal for all babies to become upset over gas pains. Babies' digestive systems are not fully developed when they are born; so, some gastroesophageal reflux is normal. However, this can become problematic for some infants. Some babies exhibit projective vomiting (think the scene from Exorcism) while others have the "silent" type, where contents from the stomach come up but are swallowed again. Other symptoms of reflux include back arching and body writhing before or after feedings and choking episodes. 

Foremilk/Hindmilk Imbalance. The content of breastmilk is made up of foremilk (i.e., the thinner, lower fat, high lactose milk) and the hindmilk (i.e., the thicker, higher fat, lower lactose milk). If a breastfeeding mother has an oversupply, her baby may fill up on foremilk and then have trouble digesting the increased content of lactose in the absence of the fattier foremilk. As a result, gassiness, discomfort, and green, watery stools occur. Over time, there may be blood in the stools as well due to irritation of the intestinal walls called by the excessive lactose (source). One way to help to clarify if this is an issue, besides looking at the color/content of stools, is to become aware of what the content of your pumped breastmilk bottles look like. The thinner foremilk is more transparent while the fatty hindmilk is much thicker. If your bottles are mostly of the thin, foremilk variety, this may be the issue. 

Protein allergy. Some babies have a sensitivity to proteins that come in the form of dairy from specific cow's milk antibodies. This sensitivity can cause colic-like symptoms as well as "eczema, wheezing, vomiting, diarrhea (including bloody diarrhea), constipation, hives, and/or a stuffy, itchy nose" (source). Also, about 50% of these babies also display an allergy to soy. There is a stool test that a doctor can quickly perform to determine if there is blood, even of the microscopic variety, in the stool. 

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So. Now that the potential problems have been identified, let me highlight what I've learned about treatment for each. 

Treatment.

Normal Infant Irritability. If you haven't already, stop what you're doing and order "The Happiest Baby On The Block" DVD. It is 45 minutes long, and I very strongly recommend you buy it and watch it with your spouse. You will learn the 5 S's that are key to helping you survive those rough days and nights when your unhappy, but seemingly healthy, little one just.won't.stop.crying. I promise you, you will thank me a hundred times over. It'll be the best $15 you've ever spent. 

Colic. If all of the aforementioned conditions have been ruled out (as well as any others I may have left off the list), your baby may, indeed, have colic. Although there is not tried and true treatment, I've been told that probiotics help. And actually, the same probiotics are recommended for babies with reflux; so, you could be killing two birds with one stone. The specific probiotic that came highly recommended by both my pediatrician and GI specialist is by Gerber and it's called Soothe. Baby is given it once a day (5 drops either applied directly to the breastfeeding momma's nipple or in a bottle). It is expensive ($23 for a 0.17 ounce bottle). But. I was told to buy one bottle, use it in its entirety, and that should be all we'd need. 

Also, for those whose babies truly have colic, I've been told mental health breaks are KEY to maintaining sanity. Have your spouse watch your baby for even 20-30 minutes while you get out of the house, go for a walk, have a glass of wine, take a nice, long shower, etc. And know that this too shall pass. 

Reflux. There are prescribed medications used to treat reflux. Most pediatricians start out with Zantac. For some babies, this is all they will need. Most babies will show symptom relief within a day or two. However, some babies' symptoms may improve for a week and then spike again. In this case, a different medication, such as Prevacid, may be prescribed. Unfortunately, it can take a full week for symptoms to really show any improvement with this medication. For the record, these medications act differently: one neutralizes stomach acid. One reduces stomach acid production. 

Gripe Water (I like Mommy's Bliss) and gas drops (I like Little Remedies) are also helpful. Additionally, the same probiotic I mentioned above (Gerber Soothe) is recommended. It is also recommended that babies with reflux are kept in an upright position for 20 minutes after eating. This is when things like the Fisher-Price Rock 'N Play sleeper or a bouncer chair or other similar piece of baby equipment is helpful for napping as well as sleeping at night. 

Foremilk/Hindmilk Imbalance. To treat this imbalance, block feeding is recommended. This means nursing from only one side for all feedings for a certain block of time (e.g., 3+ hours), which will allow baby access to both the foremilk and hindmilk. 

Protein allergy. If your baby is diagnosed with a protein allergy, the breastfeeding momma will have to make some serious dietary changes in order to remove that protein from her system, and thus from her breastmilk. Specifically, a dairy- and soy-free diet will be necessary should she want to continue down the breastfeeding path (which is highly recommended, by the way. For those who are formula feeding, it is important to know that most formulas contain either dairy or soy. There are just a few that are specially made without these components, and I've been told that they are expensive and not exactly tasty for baby). Unfortunately, soy is in many, many products. Fortunately, there are a number of awesome blogs and websites with great recipes for everything from appetizers and snacks to entrees and desserts. It should also be noted that it takes approximately two weeks for dairy/soy to be eliminated from the momma's body; so, don't expect positive changes over night. Further, most mommas are encouraged to stick with this diet for 3-4 months and then slowly reintroduce dairy/soy back into the diet to see how baby reacts. 

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So. There you have it. A murky, complicated, overlapping picture of what may or may not be going on with an irritable babe. 

In case anyone's interested, here's what transpired with my Harrison:

Around 3-4 weeks old, Harrison started exhibiting significant irritability and fussiness. Although he did not have any projectile vomiting, he did spit up quite a bit and often seemed to have intense stomach and gas pains, as he would be happy and content and then would suddenly start screaming out of nowhere,  shooting his legs out and writhing in pain. I could often hear his stomach gurgling, and he had a few choking episodes at times. He also appeared to have some eczema and had red, itchy eyes on occasion. We tried gripe water and gas drops which helped to a small degree but was nowhere close to treating the underlying issue. My poor, precious little buddy was just in so much pain, and I felt absolutely helpless as to how to help him. 

We saw our pediatrician, who prescribed Zantac based on my symptom description. This worked great for about 4 days and then seemed to stop working completely. Harrison was then started on Prevacid and given a referral to see a GI specialist at a children's hospital. During that appointment, they did a stool test and determined that he had both mucus and microscopic blood in his stool, both signs of a protein allergy. It was recommended that he continue the Prevacid and start a probiotic. In addition, I was to start a dairy- and soy-free diet to eliminate the protein from my breastmilk. 

Today, we are almost 4 weeks out from the official diagnoses and treatment of reflux and protein allergy. And let me tell you, my Harrison is just the happiest little buddy these days. He is a different baby. Now. Whether it's the dietary changes, the reflux medication, the probiotic, or the normal maturation of his infant digestive system that is the cause for such amazing change, I'll never know. But. I do know that whatever it was/is, it has made all the difference for my sweet boy. 

Also of note, interestingly, Banks also had reflux as a baby but of the projective vomiting type. He was prescribed Zantac, which he tolerated well and was weaned off of by 6 months without any further problem. He never showed any signs of a protein allergy nor did Raleigh, who never had any issues with reflux either. She had a blocked tear duct and has anisocoria, but that's another story for another day. :) 

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I really, really hope that helps! Trust me. I know firsthand how hard it is. There is nothing worse than seeing your baby in pain. But. You can get through it. You will have a healthy, happy baby one day, hopefully sooner rather than later. It just takes a little investigation and a little momma persistence. Oh, and wine. Let's not forget the wine. 

Hang in there, momma! And please feel free to contact me if you have further questions! We mommas gotta stick together. :)