The Possums 5-domain approach to helping a baby who cries a lot

What are the main problems which can result in babies crying a lot in the first few months of life?

Here are the main things that can cause babies to develop a conditioned reset of their stress response thresholds, down to sensitive or reactive, in the first 16 weeks of life. Fortunately, babies (and families!) are incredibly resilient. This period of exquisite sensitivity passes and our little ones who've been so sensitive typically follow usual developmental trajectories.

• Breastfeeding problems, including health system misunderstandings about breastfeeding, are very common and often fundamental to excessive crying in the first weeks and months of life.

• Not enough sensory motor nourishment often results in excessive infant crying. Our health system's tendency to worry about 'overstimulation' of babies paradoxically makes babies cry more, because their biological hunger for rich and changing sensory motor stimulation isn't met.

• Inappropriate medical diagnoses and treatments resulted in a failure to address the clinical problems which underlie excessive infant crying.

• Sleep training approaches, which remain dominant in our health system, commonly result in increased parental stress and distress, and infant crying, which becomes conditioned for some babies during this highly neuroplastic and sensitive first few months of life.

Things to think about when your baby is crying alot, and what's been shown not to help

Things to think about in the 5 domains of the Possums approach	Why this matters	What has been shown not to help
Baby's health and gut
Has your doctor checked your baby over and excluded medical conditions?	About 5% of babies who cry a lot have an underlying medical condition, such as a urinary tract infection.	Anti-reflux medications, antacids, maternal elimination diets if you're breastfeeding your baby, and the various colic or wind potions you can buy over the counter.
Is your baby gaining about 200-250 gms each week on average?	In the first eight weeks of life, large studies of normal healthy breastfed babies, which were used to create the WHO percentile charts, showed babies gained on average 30 to 35 grams/day. Babies cry if they are not receiving enough calories.	Spacing out feeds.
Does your breastfed baby have a true lactose overload?	This is an uncommon cause of excessive crying, but we don't want to miss it.	May be overdiagnosed, but also may be misdiagnosed as allergy.
Are you burping or holding baby upright after feeds?	There's no need to do this actually	Burping and holding baby upright after feeds rouses baby awake, instead of allowing baby to remain dialled down or sleepy, which makes sleep harder than it needs to be.
Have you tried a probiotic?	The probiotic Lactobacillus reuteri has been shown to help breastfed babies cry less.	None of the studies which show benefits of probiotics for crying breastfed babies take into account lactose overload, which causes a low-grade gut inflammation and would be expected to benefit from a probiotic - except that the sensible treatment in this case is to manage the lactose overload, not add in a probiotic.
Caring for you
Are you responding to your baby, experimenting and trying to get in before she dials up high?	Even though your responses mightn't seem to dial him down, experimenting by changing between your two superpowers or tools is a precious gift you are giving your very sensitive little baby, and will help your little one get through this time as best as possible.	Advice to space out feeds or delay responses to your baby's communications can make everything worse.
Are you looking after your own needs as best you can? Do you have good support from your local GP or other health professional?	It's incredibly upsetting and exhausting to have a baby who cries and fusses a lot. You might look through the Possums Mental Health & Wellbeing pages, starting here.
Feeds (your #1 dial-down superpower)
Is your baby's position unstable when breastfeeding?	This shows up as fussing, back arching, difficulty coming on or frequently pulling off the breast. You can find out how to deal with this here.	Positional instability with breastfeeding is often misdiagnosed as reflux, allergy, lactose, gut pain, or gut dysbiosis.
Are you trying to space out feeds or to get certain amounts of milk in?	Frequent flexible feeds (whether from the breast or bottle if you're unable to breastfeed) work best, often short and small volume, just to dial baby down before he gets into a crying loop.	Spacing out feeds can make babies cry more. Trying hard to get certain amounts of milk in can accidentally backfire, and result in a conditioned dialling up with feeds.
If your baby is bottle fed, are you using paced bottle feeding?	This means baby may take smaller and irregular volumes of formula, with more discarded, but can help your baby become much more dialled down. It's important never to pressure baby with feeds. You can find out more, starting here.	Spacing out feeds.
Does your baby have a conditioned dialling up with the breast or bottle?	This is surprisingly common, and upsetting for everyone.	Conditioned dialling up with the breast or bottle is often misdiagnosed as reflux, allergy, lactose, gut pain, or gut dysbiosis.
Sensory motor stimulation (your #2 dial-down superpower)
Does your baby receive lots of rich and diverse sensory motor experience?	This mostly happens by spending big parts of the day outside the home, if your the primary carer. It's scary when I say that, I know, because your baby seems to be always crying. You'll find lots of ideas to help with this in The Possums Sleep Program and The discontented little baby book.	Despite what you might hear, there's no evidence to prove that bodywork therapy, massage or wrapping or swaddling help make babies more dialled down over time.
Have you tried the baby carrier?	Baby carrier use can make the days much easier, if you're the primary carer.
Sleep
Have you been trying out some sleep training?	The Possums Sleep Program is designed to help your baby dial down, so that sleep is as easy as possible. When families have a crying baby, I strongly recommend trying out The Possums Sleep Program, even if just for the next two weeks.	In my clinical experience over many years, sleep training often dials both babies and parents up, and increases the chances of excessive night waking. The evidence is now also suggests this is the case.

Acknowledgements

This is a vintage Possums logo (2012), made from a lino-cut print by the late artist and children's book writer-illustrator, Narelle Oliver. It shows mother and baby ringtail possums (which we love in Australia, since they live in dreys in the scrub and run across our roofs at night), surrounded by the five domains that we need to think about when we want to help dial down a baby who cries alot in the first few months of life, using the Possums approach.

Selected references

Douglas P, Miller Y, Bucetti A, Hill PS, Creedy D. Preliminary evaluation of a primary care intervention for cry-fuss behaviours in the first three to four months of life ("The Possums Approach"): effects on cry-fuss behaviours and maternal mood. Australian Journal of Primary Health. 2013; 18:332-338.

Douglas P. Diagnosing gastro-oesophageal reflux disease or lactose intolerance in babies who cry alot in the first few months overlooks feeding problems. J Paediatr Child Health. 2013;49(4):e252-e256.

Douglas PS, Hill PS. A neurobiological model for cry-fuss problems in the first three to four months of life. Med Hypotheses. 2013;81:816-822.

Douglas P, Mares R, Hill P. Interdisciplinary perspectives on the management of the unsettled baby: key strategies for improved outcomes. Australian Journal of Primary Health. 2012;18:332-338.

Douglas PS, Hill PS. The crying baby: what approach? Curr Opin Pediatr. 2011;23:523-529.

Douglas P, Hill P. Managing infants who cry excessively in the first few months of life. BMJ. 2011;343:d7772.

Douglas PS, Hill PS, Brodribb W. The unsettled baby: how complexity science helps. Arch Dis Child. 2011;96:793-797.

Douglas P, Hiscock H. The unsettled baby: crying out for an integrated, multidisciplinary, primary care intervention. Med J Aust. 2010;193:533-536.

Douglas PS. Crying Baby. Hecate. 2007;33(2):74-75.

Douglas PS. Excessive crying and gastro-oesophageal reflux disease in infants: misalignment of biology and culture. Med Hypotheses. 2005;64:887-898.