UnsettledBabyIntake | Carol Smyth IBCLC & CBT

Unsettled Baby Consultation Intake Form

Name *

Email *

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Your Baby's Name

What age is your baby?

Please give details of the issues that you are having?

If there are weight gain issues, you can either fill in details of the weight gain above, or upload a picture of the weight chart here

About you and your baby

The unsettled baby consultation looks at 5 areas: Feeding, Sleeping, Co-Regulation, Play/ Connection and your enjoyment in parenting. Each area has been divided into 3 options. The options are Thriving (where there are no real issues present), Developing (where things are mostly fine but there are a few issues or you have a few queries). Finally Striving (where you have many issues or you are struggling with a particular aspect). Please read through the options and select the description which fits you and your baby best. It's normal to have a spread across categories.

Feeding - Thriving

Baby's Weight Gain following a centile curve. Feeding pattern as expected. My baby is content when feeding and after feeds. They drink well, with no signs of stress, no leaking, or fussing. No signs of discomfort or allergy.

Parent / Carer – Most of the time feeding is pain free (if breastfeeding) and enjoyable (all feeding). Bottle feeding Some queries about feeding, but overall all is going well.

Feeding - Developing

Baby – Weight gain veering off the centile curve. Some feeds ok, sometimes baby is unhappy when feeding or shortly afterwards. Sometimes seems stressed or struggles with flow. Some difficulties with latching but not in most feeds. Can be some leaking occasionally but not most feeds. Can be occasional mucus in stools. No signs of discomfort or allergy.

Parent/Carer – Sometimes feeding is difficult. If breastfeeding some feeds may be painful or have difficulty latching. Some feeds enjoyable, some feeds not. Wondering whether pattern of feeding is normal. Some minor anxiety around feeding.

Feeding - Striving

Baby – Weight Gain moving through centile lines. Baby is unhappy when feeding or shortly after feeds at most feeds. May be leaking milk when drinking, or stressed when feeding at most feeds. Reflux or allergies suspected. Difficulty latching or staying latched most of the time. Seems uncomfortable / gassy most of the time. May be smelly gas or stools. May be excessive mucus in most stools or blood apparent. May be unable to transfer milk effectively. If bottle feeding, may chews on bottle teat.

Parent / Carer – Most of the time feeding is difficult. If breastfeeding feeds may be painful, trauma apparent or may have difficulty with latching for most feeds. Most feeds are not enjoyable. Feels that baby is not feeding on an expected pattern. Feels stressed by feeds.

Sleeping - Thriving

Baby – Sleep time and pattern is as expected for age. Sleep environment is safe and appropriate (including safe cosleeping). Baby often sleeps on someone or in a sling. Baby goes to sleep easily when soothed. Baby is alert and appears adequately rested.

Parent / Carer– Feeling confident in understanding what is normal infant sleep for age of baby. Feels able to identify sleep cues. Feels that they have the skills to soothe baby to sleep. Feel they are getting adequate sleep themselves the majority of the time. May be able to rest during the day for short periods.

Sleeping - Developing

Baby – Baby not getting quite enough sleep and seems tired during the day. Sleep environment is safe and appropriate (including safe cosleeping). Some contact napping. Baby can get overtired at times and is difficult to soothe to sleep.

Parent – Struggling with expectations of sleep being different to how baby is actually sleeping. Sometimes can identify sleep cues, but at other times finds it difficult. Unable to get enough sleep, and feeling tired during day.

Sleeping - Striving

Baby – Not getting enough sleep and is overtired & unsettled. Sleep environment may not meeting safe sleep guidelines. Baby is difficult to soothe to sleep. Very little contact napping - Baby is almost always put down to sleep

Parent / Carer – Expectations of sleep very different to what they are seeing in baby. Unsure how to identify when baby is sleepy. Finds all aspects of baby sleep stressful. Unable to get adequate sleep themselves. Exhausted. Unable to rest during day.

Regulating - Thriving

Baby – Generally content. Cries less than 2 hours a day overall. Spends much of the day on a caregiver’s body (being carried or in a sling) for regulation day and night. Carried >50% of the day. Can be easily soothed most of the time. Physically well.

Parent - Confident about using baby calming strategies. Feels generally relaxed most of the day. Minimal worry about parenting, about themselves or their baby. Good social support network.

Regulating - Developing

Baby – Mostly content. Cries 2-3 hours a day overall. Is carried for parts of the day but sleeps alone. Usually responds to normal settling techniques when crying, but may have some periods of inconsolable crying.

Parent/Carer – Has periods of worry about the crying or baby's wellbeing, but overall feels that the baby is well. Some worry about their parenting techniques. Good social support network.

Regulating - Striving

Baby – Generally unsettled. Cries more than 3 hours a day overall. When crying, normal settling techniques do not work. Crying is inconsolable much of the time. No medical cause for crying.

Parent/Carer – Exhausted and stressed by crying. May be suffering from anxiety / depression. May be feeling socially isolated due to the crying. May feel guilt / blame and question their role.

Play & Tummy Time - Thriving

Baby – Makes good eye contact and initiates connection. Enjoys play. Engages > 80 mins tummy time a day (including on a body). Calms and soothes on carer's body

Parent – Enjoys eye contact and connection with baby. Feels confident in how to facilitate tummy time and play. Feels confident in knowing when baby has had enough and is cueing that they want to end games. Feels they mostly understand baby’s communications.

Play & Tummy Time - Developing

Baby – Sometimes makes good eye contact and initiates connection. Spends 30-80mins tummy time a day.

Parent / Carer – Sometimes feel very connected to baby, but at other times I struggle more with the relationship. Can facilitate tummy time but feel that baby doesn’t really enjoy it. Feel that I understand baby’s communications 50% of time.

Play & Tummy Time - Striving

Baby – May not make good eye contact. May not enjoy tummy time at any time. Spends <30 mins in tummy time a day. Baby does not get stressed if parent leaves. Happy to be left with anyone.

Parent – Feeling disconnected from baby or questioning the bond. Doesn’t feel confident in strategies to help baby enjoy tummy time. Doesn’t feel confident in playing with baby or with what baby is communicating.

Enjoying - Thriving

Baby generally happy and content. Parent / Carer feels confident in parenting/caring and enjoying caring most of the time.

Enjoying - Developing

Mix of previous categories across all 3 levels with no one level dominant. Parent / Carer feeling confident in some aspects of parenting and not in others. Enjoying caring around 50% of the time.

Enjoying Striving

Most of previous categories in Striving category Parent / Carer feeling a lack of confidence in parenting/caring. Not enjoying baby most of the time. Struggling with mental health.

Thank you for the answers

Thank you for filling in the intake form. This will help me to plan for your consult. If you have any other information you would like to add about what specifically is worrying you with your baby, please do add it in the text box below so that I can really tailor the consult to exactly what you want and need. I look forward to seeing you soon.

Please enter any specific issues you are having with your baby that you want to look at, and what is worrying you most.