After a few weeks or months, breastfeeding has often settled into an easy rhythm. But what if you're still dealing with a fussy breastfed baby or breastfeeding feels a struggle? Assuming any illness has been ruled out by your baby's doctor, contacting an IBCLC lactation consultant can help brainstorm why your baby seems unsettled at the breast at any age or stage. There are many possible reasons—from your baby having a sensitive personality or being easily distracted by the world around him, to being hungry and just needing more breast milk. Cows' milk allergy, reflux or temporary lactose intolerance could also be involved in unsettled behaviour as could sensory processing issues or high muscle tone. This article reviews some of the common causes of fussy, restless behaviour in a breastfed baby.

#1 Positioning

Before looking for a more complicated reason, it can be helpful to rule out positioning or latch (the way a baby attaches to the breast) as a cause of fussy behaviour. If a baby feels unstable, has to turn their head into an awkward angle, or is prevented from using their feeding reflexes; they may find it difficult to latch and might cry or pull away from the breast. Conversely, when a baby feels stable and can use their feeding reflexes to help them, they will usually latch more deeply (take more breast tissue into the mouth as well as a nipple). A deeper, more stable latch helps babies control the flow and supply of milk from the breast more easily. For help with positioning see Breastfeeding Positions for Newborns, Latching Tips and Breastfeeding Videos. A breastfeeding specialist is the ideal partner to help with good positioning.

baby breastfeeding on their tummy
Before looking for a more complicated reason, it can be helpful to rule out positioning or latch as a cause of fussy behaviour

#2 Underweight or hungry baby

A restless baby who constantly feeds or has trouble sleeping may not be getting enough breast milk, especially if these behaviours are accompanied by poor weight gain (see Understanding Your Baby's Weight Chart). Dr Jack Newman, a Canadian paediatrician and breastfeeding expert, believes that the most common cause of fussiness at the breast is when a baby is frustrated with slow milk flow resulting in hungry babies who fuss, cry, pull at the breast or keep coming off the breast.1 Difficulty with driving the milk supply or with getting enough milk can be due to a poor latch, or poor positioning (see #1 above)—although there are other reasons for low milk supply.

Get skilled help

An IBCLC lactation consultant is the ideal specialist to help you identify the reasons for low milk supply or help identify other causes for fussy behaviour related to breastfeeding. For self-help with slow flow of breast milk, or low milk supply see How to Make More Breast Milk, Is My Baby Getting Enough Milk? and What is Breast Compression?

Babies who fuss, cry, pull at the breast or keep coming off the breast may not be getting enough milk ⓒMurielleB/Adobe Stock

#3 Bottle preference or nipple confusion

If a baby has started to have quite a few bottles as replacement feeds whether with expressed breast milk or formula, some babies can seem to start to fuss at or turn away from the breast in preference for the bottle. This is sometimes called bottle preference or nipple confusion. Bottle preference is more likely to happen if a baby associates breastfeeding with frustration and slow milk flow but finds the bottle more rewarding, or if a baby has a lot of bottles before they have got the hang of breastfeeding. If your baby is having more and more bottles and is starting to seem grumpy or unsettled at the breast, options to try include:

  • Cut back on the number of bottles for a while and give baby lots of opportunity to breastfeed, or
  • Try our Tips to Bottle Feed the Breastfed Baby and see Best Bottle for a Breastfed Baby?
  • Consider whether a supplemental nursing system or cup feeds could be alternatives for supplementary feeds if needed
  • See How to Get Baby Back to Breast if your baby is actively refusing feeds.

#4 Normal behaviour mistaken for fussing

Sometimes what may seem like fussy or sensitive behaviour is normal baby behaviour. For example it is normal for a newborn baby to protest when they are put down; they love to be held and feel safest next to an adult body. It's normal for newborn babies to feed very frequently, they are doubling their weight in a matter of months! It's normal for an older baby to go through a phase of hating to be strapped in a car seat. The Womanly Art of Breastfeeding has several useful chapters on ages and stages which explain the normal behaviour of a breastfed baby as he grows. For example in the chapter "Six Weeks to Four Months: Hitting Your Stride" we are reminded that babies are individuals with different characters and with different needs:

Maybe you've got a sparkler – an intense, sensitive baby who needs input, input, input! His only settings are high and off. That's the downside. The upside is how truly bright and curious he is likely to become. You'll work hard as a mother to this baby. Look for other mothers of sparklers, to share notes with. Keep your sense of humour and try not to compare your busy days with those of your placid-baby friends. And keep your little sparkler close to you – your presence and touch will often go a long way toward calming him.

#5 Fussy baby at four months

If your baby has been breastfeeding well for several months but then becomes a fussy baby at four months (or five or six or older!) it can be puzzling to find a reason for the change. Around this age is a common time for babies to refuse some breastfeeds and become easily distracted with noises, activities, new surroundings and siblings—particularly during the day time.The Womanly Art of Breastfeeding calls this The Four-Month Fussies. It's a stage that will soon pass but you may need to remind your busy baby to breastfeed in the day and it may help to cut down on distractions at feed times such as closing the curtains to lower the lighting or putting subtitles on the television to reduce background noise.

baby on tummy in a cute hat
Babies enjoy and need a variety of sensory experiences and being confined to a low sensory environment in the home can create unsettled behaviour

#6 Allergies as a cause of fussy behaviour

Babies who are allergic to something from their mothers' diet passing into breast milk may appear unhappy at the breast—they might pull off and/or cry once milk starts to flow because it hurts their inflamed oesophagus (eosinophilic oesophagitis) or gives them tummy ache. They may prefer to breastfeed in unusual positions and may be very tense and seem to clamp down or bite the breast causing pain and sore nipples2. They may have symptoms of reflux (#8) and/or tend to have very runny, copious and often green dirty nappies with symptoms of  lactose overload (#9). Allergy is thought to be a possible cause of infant colic (unexplained crying). Author Maureen Minchin describes a characteristic set of allergy-related fussy behaviours including disturbed sleep, erratic and persistent crying:

  • [Babies] who are either hyperactive before [in the womb], and persistently miserable after birth, or
  • [Babies] who start screaming in the second or third week of life, and
  • [Babies] who give many indications of gut discomfort
  • [Babies] who progressively develop other minor symptoms, like night sweats, cradle cap, or patches of rough skin
  • [Babies] who do not respond more than briefly to mothercraft skills

See Milk Allergy in Babies for an in depth discussion of dairy or other allergies in breastfed babies.

#7 A fast let-down or too much milk

Some babies may find it difficult to cope with a very fast flow of milk causing them to cough, choke and constantly come on and off the breast. Babies have to coordinate sucking, swallowing and breathing during breastfeeding and, when the flow of milk is very fast, they may find feeding quite stressful causing them to be restless and keep releasing the breast to prioritise their breathing. Difficulty with controlling milk flow may be due to:

  • Suboptimal latch and positioning at the breast (#1). When baby's attachment is good they are better able to cope with the flow of milk even a fast let-down.
  • A baby who wants to continue to suck for comfort or to fall asleep after they are full,  but the milk is flowing faster than they want (Newman, 2014)
  • Oversupply or "too much milk". Having plenty of milk is normally a good thing but sometimes the sheer volume of available milk can itself be a cause of unsettled behaviour or cause a temporary lactose overload with signs of discomfort and fussing (see #9 below). For more information see Oversupply of Breast Milk and What is a Fast Let-Down? Babies who are getting a lot of milk quickly may also spit up frequently (#8 below).

#8 Reflux

Spitting up some breast milk after a feed is quite normal or babies and most babies are "happy spitters". However if your baby has reflux and is very fractious and miserable—see Reflux in Newborns for more information. Reflux can be connected to allergy (#6 above) and too much milk (see #7).

Spitting up is a normal event for babies and doesn't usually cause them a problem although more severe forms are possible e.g. GORD or GERD [gastroesophageal reflux disease]. Certain underlying causes such as allergy or oversupply can make reflux worse. Working with an IBCLC lactation consultant alongside your health professional can help find ways to reduce reflux or identify other possible reasons for an otherwise healthy breastfed baby to be miserable and fussy.

#9 Lactose overload

Lactose is the main sugar in breast milk. If lactose is prevented from being digested properly in the intestines it could cause a temporary lactose overload. This might happen if there was any damage to the special cells in the intestinal wall that produce the enzyme that digests lactose, or if the volume of low fat breast milk passing through the intestines overwhelms the available enzyme. An overload of lactose might cause a baby to be unsettled and have tummy ache, wind (farts) and lots of frothy copious green poop. Lactose overload can be caused by/associated with cows' milk allergy (#6 above) and may be one explanation for infant colic. For more information and how to resolve it see Lactose Intolerance in Babies.

#10 Not enough sensory input or physical contact

Sensory deprivation or lack of physical contact can cause a baby to be fractious. Jack Newman attributes this to a fear of "spoiling" a baby and he calls it the English Nanny Approach;

Babies cry for many reasons—it is the only way they have to communicate their needs. Many people believe that if you pick up or otherwise respond to a baby who cries, he will cry more and more; if you ignore his cries, he'll stop. But research has shown just the opposite. The babies who are responded to most quickly and consistently cry less by the time they are a year old. Even more importantly, they tend to talk earlier and make more efforts to communicate, apparently because they have learned they will be listened to.

Most babies crave physical contact; carrying them in a sling and accepting they need to be with you much of the time can help to meet their need for closeness. Babies enjoy and need a variety of sensory experiences and being confined to a low sensory environment in the home can create unsettled behaviour.3 For some babies the opposite—over stimulation—might create an unhappy baby (#11).

#11 Sensory processing or high muscle tone

Some babies may have sensory processing issues, or high muscle tone that may contribute to intense and unsettled behaviour. Reading the linked articles may help to discover whether any of these could be an issue for your baby and what to do.

#12 Other causes of a fussy baby

Other ideas that may explain unhappy or restless behaviour could include minor dehydration (let your baby breastfeed frequently to quench his thirst), baby being too hot, too cold, being smoked over, wearing an overly tight nappy, having sore skin from an allergy, having sore gums from teething or thrush or being poorly e.g. having an ear infection4.

Medications

Parents may notice a connection between their baby's behaviour and certain supplements or medications they take themselves or their baby takes. Fenugreek can affect some nurslings if the mother takes medicinal doses for her milk supply5 while vitamins or iron supplements can affect others causing discomfort6.

Vaccinations

Some babies could be fussy if they have had a reaction to a recent vaccination. Parents can access patient information leaflets listing side effects for vaccines in the UK from the NHS Childhood Vaccines Timeline.

My older baby is still fussy!

Some of the ideas above might still be useful to problem solve the reasons for a fussy older baby, or you may enjoy reading The Fussy Baby Book by Dr William Sears which covers birth to five years. If the fussing is happening particularly at night you may find Baby Waking Up At Night or Sweet Sleep: Nighttime and Naptime Strategies for the Breastfeeding Family helpful.

Summary

There are lots of reasons why a breastfed baby might sometimes seem unhappy or fussy such as being hungry, having allergies, sensory processing issues or lactose overload and more. Checking with your doctor will rule out a medical cause for your baby's unsettled behaviour and the best way to rule out any breastfeeding related reason is to contact a breastfeeding specialist to help you. More prolonged and persistent crying in breastfed babies is discussed in Colic and Breastfeeding.

* Extracts reproduced by permission from Pinter & Martin.