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NBAS assessment on a very unsettled baby

28th September 2016

I was contacted by the health visitor of a baby in care with a foster carer who was 5 weeks old.  He was initially in hospital when he was born and then discharged home to the foster carer. He has never really been settled and the health visitor had exhausted all possible avenues so asked me to complete a Neonatal Behaviour Assessment Scale (NBAS). I completed this with the baby, foster carer and social worker.

Unsettled Baby

On first examination the baby was being held by the foster carer and did not seem to settle for any length of time.  She reported to me that he was only sleeping for very small periods and that he was unsettled most of the time.

Baby was awake so none of the habituation assessment could be used. I attempted to complete the NBAS but it soon became evident that he was not going to be able to comply with most of the assessment, he could not tolerate even attempting to elicit any reflexes.  So I used the opportunity to observe his behaviour and to try and help him to calm.

Baby was unable to console himself due to intermittent startles that seemed to be caused by pain. He was crying when I arrived, when he was being held. I held him in the ‘tiger-in-the-tree hold’ and this seemed to help.  Whilst holding him he kept jumping and after approximately 10 minutes he became unsettled again.

Consolability techniques

I attempted to use consolability techniques and he settled during the rocking motion. When he stills he was unable to maintain this and startled lots.  He enjoyed his dummy and this helped somewhat to settle him. The foster carer was happy to try the consolability technique to help settle him. Baby was commenced on Gaviscon, and the social worker and foster carer both saw a little improvement the next day.

I suggested some white noise or background noise as the house was very quiet and he would have been used to noise in the first week of life on a neonatal unit. Baby settled on my chest and had a light sleep, his breathing remained quite rapid at this point.

It was evident during sleep that he remained in a light sleep and was not able to settle into a deep sleep. He continued to move as if unsettled and murmuring was apparent.

Once he had been settled for a while in his light sleep, I showed the foster carer how to put him in his moses basket using the consolability techniques. When I initially put him down he opened his eyes but was obviously very tired.  I held his arms and his legs to comfort him and he settled down, his arms did continue to flail at times so we used a muslin cloth around his middle to help hold his arms still and help him settle – this worked. Safe sleep was discussed and also how to use this technique safely.

Baby settled back to sleep in his moses basket and I left. I contacted the foster carer over the next few days and baby had been lots more settled but was still having long bouts of crying.  We had discussed cortisol levels and she was trying all techniques to help him stop crying and remain calm, he liked his soother but only at times.

Milk intolerance

On my final contact, he had been seen by a paediatrician, a milk intolerance had been diagnosed and a new milk had been tried – this was having a very positive effect on baby, he was much more relaxed and seemed very much contented.

This baby had medical reasons for not being able to settle, the NBAS assessment gave us an insight into how baby was feeling and gave us evidence that he could not settle.  The foster carer used techniques to help her through the difficult stages and helped baby feel as comfortable as possible during this time.

The foster carer commented:

“Sharon I can’t believe it, he settled for a further 50 minutes when you left.  He woke up crying but soon settled when I tried some of the techniques you suggested.”


“I can’t thank you enough for showing me the techniques and hopefully I will be able to do it just like you soon!”

Sharon Swift – Health Visitor, Bridgewater Community Healthcare Foundation Trust

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