When I see a fussy breastfed baby,  I think of the following as possible causes (in the following order) of things to try first:

1) oversupply (I don't think I need to go into detail on this as it has been discussed much in the past)

2) milk protein intolerance--not a true allergy, but more of an insensitvity. A common sign of this is blood in the stool. Another observation I have made from my own children (probably is not evidence-based) is a lot of wiggling and grunting/groaning type noise when there are food intolerances. If I ate something I wasn't supposed to, about 8-12 hrs later (and usually early am like 4-5 am my son would just grunt and groan and kick his feet and just could not settle back down to go back to sleep. Yes, it does sometimes take 2 weeks to say whether it is working or not, but often moms see a difference soon after eliminating dairy. As there is a 50% cross-reactivity with soy intolerance, I advise moms to go dairy and soy free initially, and then if improved, add in soy to see if can tolerate. (I found rice milk to be palatable to eat cereal with). I also discuss all the other common food offenders that you often hear about and are thought to cause some babies distress. With my own, I had to stop dairy, soy, garlic, onion and on my son, also chocolate. I always let moms know that it gets easier to do the longer they do it. I also tell them that it is not usually for the entire time they are breastfeeding (although I had one baby who was extremely intolerant and it was closer to a year before mom could eat more normally). I found with mine I was able to eat normally around 3-4 months. 

3)  GER (reflux) Although this will make everyone cringe, I always have a high suspision of reflux when I have a fussy baby. What will clue me in that it is more likely to be and to try treatment are the following symptoms: very wiggly with feeds--arching, coming off the breast and crying, especially if this all occurs towards the end of the feed, or just after the feed finishes. (yes I know oversupply can cause some of the same symptoms, and I do address that first). If baby is spitting up, that can be a clue, but there are also those who have a more silent reflux where it goes just only so far but doesn't make it all the way out. To sort this out, I ask parents if they ever see their baby look they are going to spit up but don't--kind of like a hiccup type motion) and then see them make a sour face and/or cry after. Of course if reflux is one of the issues, you can try positional changes but most will need RX tx. Althought it doesn't make sense, I do see infants w/GERD who manage to tolerate their symptoms at night and still manage to sleep fairly well (mine did). 

4) the fussiness is a temperament issue-some babies are just more "high need"--which although exhausting in the beginning, I tell them these babies go on to be bright and inquisitive. Dr. Sear's "The Fussy Baby Book" is a good resource. 

Of course there is colic, but since it seems to be more associated with feeds, I don't think that applies here. 

Sorry so long a post. Hope this has been helpful. I'm going nomail until the 1st of the year so Merry Christmas/Happy Holidays to all.

Stacy D. Kucharczk, MSN, RN, CPNP, IBCLC
BestFeeding Lactation Services, LLC
Virginia Beach, USA

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