Living with unsettled baby behaviours: Qualitative interview study exploring parental perceptions and experiences of help-seeking

Aim: To explore parents' perceptions/experiences of help-seeking for unsettled baby behaviours, including views and experiences of obtaining advice from primary health-care professionals. Design: Semi-structured qualitative interviews. Methods: Recruitment occurred via social media, general practice and health visiting teams. Remote semi-structured interviews were conducted with parents of babies. Babies were under 12 months old at time of interview, and parents had perceived unsettled baby behaviours in their first 4 months of life. Interviews were transcribed and data analysed using reflexive thematic analysis. Results: Based on interviews with 25 mothers, four main themes were developed. ‘The need for answers’ highlighted parental uncertainty about what constitutes normal baby behaviour, leading to help-seeking from multiple sources. ‘The importance


| INTRODUC TI ON
Parents commonly report unsettled behaviours in babies under 1 year, such as excessive crying and posseting (Douglas & Hill, 2011;Pérez-Escamilla et al., 2023;Vilar-Compte et al., 2022).These symptoms occur along a continuum and are usually part of normal baby behaviour but are often interpreted as problematic by parents (Vilar-Compte et al., 2022).This influences how parents manage behaviours and how they feed their babies.
Unsettled baby behaviours are associated with potential negative outcomes such as parental mental health problems and unwanted cessation of breastfeeding (Pérez-Escamilla et al., 2023;Vilar-Compte et al., 2022) and in some cases risk of injury (Barr, 2014).It is suggested that unsettled babies are also often over-labelled or mis-diagnosed with a medical cause (The Lancet, 2023).This can lead to unnecessary medication use, and significant resource use and health service costs (Mehta et al., 2022;Van Tulleken, 2018).For example, cow's milk allergy (CMA) is labelled in up to 40% of babies (Chalmers et al., 2020) and 73.6% of babies have two or more guideline-defined CMA symptoms by 12 months of age (Vincent et al., 2022).However, cohort studies estimate the prevalence of CMA as <1% (Schoemaker et al., 2015).
National Health Service (NHS) prescription costs in England for specialist formula increased from £4.6 million to nearly £60 million between 2007 and 2018, without any apparent increase in disease prevalence (Mehta et al., 2022).Similarly, gastro-oesophageal reflux is very common in babies; 78.1% of a sample of 1225 babies at 3 months of age were vomiting (Vincent et al., 2022).It can generally be managed with feeding advice, yet often parents receive a prescription (Scherer et al., 2013).Recent research suggests that prescribing for reflux has also increased significantly in recent years.Between 2010 and 2016, prescribing rates increased for alginate (15.7% to 24.7%), ranitidine (2.3% to 9.7%) and omeprazole (0.9% to 3.2%) (Cowie et al., 2018).

| BACKG ROU N D
It is important for health professionals to be alert to the possibility of CMA, and 'over-labelling' or 'misdiagnosing' also has negative consequences for many parents, babies and families (Vilar-Compte et al., 2022).For example, there is limited evidence for the transfer of allergens through breastmilk (Allen & Boyle, 2022;Munblit et al., 2020).However, parent concern about CMA can lead to changes in feeding such as dietary exclusion (mother and baby), early cessation of breastfeeding or introduction of combination feeding (Allen & Boyle, 2022;Ghio et al., 2022).These changes have been linked to poor parental self-efficacy and poorer parental mental health (Allen & Boyle, 2022;Brown, 2018), and there are links between use of specialist formula and risk of tooth decay and obesity (Mehta et al., 2022).Medications for reflux, particularly acid suppressants, are often found to be ineffective, to cause additional problems and place babies at risk of serious illness.For example, in a randomized controlled trial of medications and a prospective cohort study, there were significantly more adverse events in babies receiving medication.These included lower respiratory tract infections (RCT, placebo comparator) and gastroenteritis (cohort study, compared to no medication) (Hudson et al., 2012).
A recent systematic review of qualitative research about parental experiences of excessive infant crying identified 22 papers that mainly focussed on the emotional impact of crying on the family and parental management and coping strategies (Muller et al., 2023).The review revealed an evidence gap for how parents assess, make sense of or 'label' unsettled baby behaviours, and about parental information seeking and help-seeking.Since this review, a qualitative analysis of parents' discussions in online forums has been completed (Ghio et al., 2022), highlighting that uncertainties about 'normal' baby crying may lead parents to seek a medical diagnosis or label.There was also a perceived importance of showcasing credibility by sharing detailed experiences online.
Further research with parents is needed to explore their helpseeking.For example, who they turn to for support and advice, when and why they seek support, and the support and advice they take away from these interactions.This would then help to inform future research to better support families managing unsettled baby behaviours.

| Aim(s), objective(s) and research question
This study aimed to explore parents and carers' views and experiences of help-seeking for unsettled baby behaviours such as crying and posseting/vomiting.Although parents and carers were invited, all participants were parents, so only 'parents' are referred to hereon.

| Theoretical framework
Using a generic qualitative approach (Kahlke, 2014), this study was conducted by a team of academics and clinicians who pragmatically explored how and when parents seek help for their babies' symptoms, and the advice they take away from these interactions.
No specific theoretical framework was used for analysis.
Although an inductive analysis was performed, findings were interpreted through a theoretical lens of the common sense model of illness self-regulation (Leventhal & Brisette, 2012).

| Study setting and recruitment
The study was advertised to parents in the community (social media).It was also advertised via primary/community healthcare in England; GP practices (the primary place of contact for families with primary care doctors (GPs) and nurses), and via health visitors who provide universal community care for children under 5 years old.The online reply form linked to the participant information sheet, which defined excessive crying as 'not stopping crying for hours without being settled'.The form also asked questions to confirm eligibility for inclusion.Optional questions were included to enable purposive sampling to ensure a maximum diversity sample, including ethnic background, parent and baby age, unsettled baby behaviours and when they started, and whether the baby had any diagnostic labels.If paper reply slips were returned, these questions were instead asked when the researcher contacted the potential participant.
Over 100 potential participants expressed an interest.It was not possible to record the number of participants who were invited but did not express an interest (nor their reasons for not participating).The researchers did not know who had been invited until parents contacted the research team directly to express an interest in taking part.Some who expressed an interest in taking part were not selected for interview, due to purposively sampling others or because they were ineligible.Some were selected but did not continue because of time constraints or participant non-response.We tried to purposively sample two fathers who expressed an interest.
However, no father interviews took place, due to time constraints or because the mother was interviewed instead.

| Sample size
As Braun and Clarke discuss (Virginia Braun & Victoria Clarke, 2021), the meaning of data is interpreted by the researcher, rather than the data itself.Therefore, there was no anticipation of a required sample size for 'data saturation' ahead of data collection.Pragmatically, an approximate target sample of 20 to 25 participants was instead estimated before data collection.This was anticipated to provide sufficient information power (Malterud et al., 2016) for researcher interpretation of the data.The maximum number was met with 25 interviews conducted.At this point, new main themes were no longer being developed.

| Inclusion and/or exclusion criteria
Parents of babies aged up to 12 months were included if they had experienced common symptoms in their first 4 months of life, or if they had considered CMA, reflux or colic (regardless of whether a diagnosis had been given).In study invitation materials, we described common baby symptoms as excessive crying, vomiting, fussing unless being held, rash, changes in stool consistency/colour, gas/wind or nasal congestion.
Parents of babies with serious or life-limiting conditions were excluded to try to ensure that the unsettled behaviours discussed by parents were the primary concern.

| Data collection
knew the participants prior to the interviews, nor were they involved in their care.Participants were not informed that AD is a health visitor (a UK health professional who supports families with children under 5 years old) in case this would influence interview responses.
The interviews took place remotely to facilitate recruitment of busy parents across a wide range of locations across the country.
They were via video call or telephone, based on participant preference and lasted up to an hour.No one else contributed to the interview, although some of the parents had their babies with them.
A semi-structured topic guide (Data S1) was developed iteratively within the research team (based on academic, clinical and personal knowledge from researchers, public contributors and clinicians) and used to guide the interviews.Interesting areas for exploration arising from earlier interviews were added as probes as data collection progressed.Questions asked about perceptions of baby behaviours, feelings and experiences about this, help-seeking (with healthcare professionals, online and in the community) and about feeding practices.Field notes were kept by the interviewer after each interview.All but one of the interviews were audio or video recorded (via Microsoft Teams) and transcribed verbatim.A professional transcriber was used.Transcripts were checked by SH for accuracy before coding.The interview that was not audio/video recorded was due to participant preference, and detailed notes were taken instead.Unfortunately, it was not within this study's capacity to return transcripts to participants for checking.

| Data analysis
Alongside data collection, interview transcripts were analysed inductively using Braun and Clarke's reflexive thematic analysis (Braun & Clarke, 2006, 2019, 2022).Braun and Clarke's reflexive thematic analysis (Braun & Clarke, 2006, 2019, 2022) was used to allow for an inductive latent approach working within the paradigmatic framework of interpretivism and constructivism.This enabled us to be flexible and responsive to the data during the analytical process (Braun & Clarke, 2019).
All transcripts were coded by SH (bottom-up approach), and a coding framework was developed to facilitate sharing and contribution of ideas through team discussion.As new concepts were drawn from the data, this was developed iteratively throughout the analysis in discussion with SH, IM, MS, AD, KHS, DG, LL and SA.
NVivo software was used to handle data, and themes were developed with the use of thematic maps.See Figure 1 for the final thematic map and Figure S1 for an example of the thematic map during the development of themes and subthemes.For the interview that was not recorded/transcribed, the interview notes were compared to the themes/subthemes after the themes/subthemes were nearly finalized.

| Ethical considerations
This study was reviewed and approved by the University Research Governance office and the Health Research Authority (with a proportionate review from the North East-Tyne and Wear South Research Ethics Committee).IRAS reference 309678.
Participants were given a participant information sheet prior to agreeing to take part in the study and gave informed consent prior to taking part in the interview.Participants were given a debrief statement at the end of the interview, which had details of resources for support in case they experienced any concerns or distress by discussing this topic.Participant confidentiality was maintained with the use of unique participant identification numbers.Any potentially identifying information in the interview recordings was removed from the transcripts.

| Rigour and reflexivity
Steps were taken to ensure rigour for our inductive approach within a multidisciplinary team.Notes about the participants' data and researcher thoughts were written after each interview.An audit trail of researcher thoughts and development of codes/themes was facilitated by researcher notes and thematic maps.To ensure multiple perspectives shaped the analysis, analysis included 2GPs, 2 psychologists, 1 HV and a public contributor.Wider team discussions about interviews/findings were regular throughout both data collection and analysis.Discussions reflected on team members' prior and lived experiences (e.g., clinician's experience and parental experiences)

| Public and patient involvement and engagement
Public contributor and co-applicant KHS were involved throughout all stages of the project and attended regular research team meetings.KHS gave input into how to conduct this study in the most meaningful ways to parents.This helped with wording participant facing materials (adverts, reply form, information sheet, consent form and topic guide) and effective ways to recruit parents.KHS was also involved in the development of coding manual, data interpretation and writing the paper.The development of themes was also discussed with a local group of eight parents (with unsettled babies from an area of relative social deprivation) as part of a 'listening café' engagement project with a children's centre.The parents agreed with the study findings, expressing similar thoughts and feelings.

| Characteristics of participants
The 25 participants were all female, and their age ranged from 24 to 39 years.52% were white British, and for 60% of participants, this was their first child (see Table 1).Baby age ranged from 6 weeks to 11 months, and parents perceived a range of unsettled behaviours, mainly excessive crying (88%), vomiting (48%) and perceived pain (48%).Some parents reported a HCP-diagnosed label of colic (16%), reflux (36%) or allergy (28%).Many parents had labelled the behaviours as one or more of these labels.

| Theme 1: The need for answers
Many participants spoke about seeking advice and support whilst looking for answers regarding their baby's unsettled behaviour.
Participants often questioned potential underlying causes of baby behaviours and whether behaviours were 'normal' or not.Parents also often reported feeling uninformed and were desperate for answers and support.These all seemed to be important triggers for support seeking (from health professionals or elsewhere).

Concerns about underlying causes
Often participants described concerns about underlying causes of their babies' symptoms, for example underlying possible medical label or diagnosis, such as allergy or reflux or other illness.This often led to seeking assessment and a label/diagnosis.Sometimes parents suspected that the underlying causes were something that they were doing wrong.On the other hand, some participants felt more informed after attending parent groups or parenting classes like antenatal or post-natal breastfeeding classes/sessions, or parent-led baby massage classes.

Sense of desperation
Often parents described feeling desperate for answers and support.
Some described that they had struggled with their mental health and often parental mental health seemed entwined with their perceptions of baby's behaviour.They wanted to 'fix' the symptoms to help their babies but also to relieve their own stress, which was sometimes described as leading them to 'breaking point'.Parents often said they had tried everything they could and this desperation led them to seek support from multiple sources or anywhere they could for answers about their uncertainties, but also for help to resolve their baby's symptoms: I just was willing to kind of take anything and everything because I just felt like I was at breaking point.
I Participants also commented on normalization (where health professionals advise that the behaviours are a 'normal' part of baby behaviour that will improve with time) and reassurance from health professionals, perceiving this both positively and negatively which impacted their perception of health professionals.All these experiences were perceived with mixed opinions and seemed to be impacted by the communication from health professionals.

Management and coping strategies
Parents described being advised about multiple different management and coping strategies from health professionals.These included practical non-pharmacological management strategies (massage, cycling of legs, changes to milk/formula, positioning and winding changes), over the counter treatments (colic drops, saline drops), or prescriptions for specialist formula milk or medication such as omeprazole for reflux.Some were advised a combination of these, whereas others focussed more on one of them and at different points in the help-seeking process.Some described focussing more on the management of parental mental health.
I had a telephone consultation with the GP first… he said that it sounds like reflux, silent reflux…so he prescribed us [brand] over the phone and then said, if it wasn't working, to ring back up.erm So we tried [brand] for, I'd probably say, five or six days, erm but then the side effects of the [brand] were a lot worse for her than… Because they make her extremely constipated.P29 Perceptions of advice were taken described differently by participants with both positive and negative views about the advice they had received and about how successful they were for management.
For example, some participants said that they had wanted a prescription for medication, related to a desperate wish to resolve the symptoms and perceiving medication to be the best/fastest solution, or because of lack of success with non-pharmacological approaches.
Others had wanted to avoid or stop medication because they felt non-pharmacological methods or tests should be tried first (and that prescribing was the easiest response for the health professional).
Other reasons for not wanting medication were because they had used medication previously and perceived it as either impractical to give to their baby, unsuccessful or to give side effects.Some wanted it but only because they felt nothing else had worked.
we lost a lot of faith in them, with the fact that the GP was just prescribing us medicine, prescribing us medicine, and then the hospital was just prescribing us medicine instead of running any tests or whatever.P29 They said, 'I think we're going to try omeprazole now.'I was like, 'Okay.Whatever.I will try anything.I just want my daughter to be able to have a bottle without screaming at me'.P15 Non-pharmacological advice was generally described as helpful, even if not always successful and felt like 'trial and error'.However, non-pharmacological advice was sometimes perceived as generic or vague and participants described a wish for more individualized or detailed advice.One participant talked about the need for more breastfeeding advice: in the UK, there is not enough emphasis on breastfeeding and I wish there was.I wish there was more support… It's not difficult just to add a bit of further training for GPs, add a bit of further training for nurses and midwives.Even midwives don't have enough training.They don't recognise tongue tie, and they don't recognise allergies.There's got to be more help and support out there for breastfeeding.P9

Testing and diagnosis
Many parents described the assessments, testing, labelling or diagnosis they received from health professionals.The discussions about these between parent and professionals were described by participants as initiated by the parents or the professionals.Tests for milk allergies were most often done by changing formula following negotiation with a health professional (such as a GP or consultant), a meeting between experts with the professional acting as the gatekeeper.
I remember speaking to my GP and saying to them, maybe, maybe it's, it's the actual formula she's allergic to.Maybe that's what's upsetting her, and I remember asking them and saying please can we, like, I know that there's a dairy-free formula but it's a prescription only, and I remember saying to them, please can we try that, and then the doctor saying, no, she's fine.P12 Labels for colic or reflux were usually given after parents described their baby's symptoms to a health professional.However, some parents described already knowing or suspecting it was an allergy (from experience with their own formula changes or diet changes, or due to recommendations from others) and wanted a health professional to confirm this on their record.Signposting between health professionals was also noted by some.

Reassurance about normal baby behaviour
Participants also discussed the reassurance that they had received from health professionals that their babies' behaviour was a normal part of baby behaviour or development.Although it was clear that many parents wanted reassurance or advice about any potential underlying causes, reassurance about 'normal' baby behaviour was often received differently.For example, some described the usefulness and positivity resulting from this: you kind of feel, you feel a bit more reassured, you feel a bit more calmer after speaking to somebody, and you realise that it's not kind of an emergency as such, it's not something that you need to be so worked up about.P6 Other parents perceived this as being inaccurate, dismissing or that they had been 'fobbed off'.Whilst some parents said advice about normal behaviour was helpful, knowing that they had to 'ride out' unsettled baby behaviour did not give them comfort in the short term when they were struggling: they say the good thing is that they'll grow out of it by three months, and as I said before, that is definitely not reassuring.That is actually very scary because each day going by is difficult.You want something to help your child now.P22 The health professional-patient relationship Parents' perceptions of their relationship with their health professional seemed linked to how they perceived the baby behaviours, how they perceived the health professional advice (such as reassurance that their baby's behaviour is normal), how they sought further help and how they managed behaviours.For example, many parents described a feeling of being 'fobbed off' or dismissed by health professionals when parents felt they were the experts in knowing their baby.
It just felt very much like every time you saw someone it was very, 'Oh, paranoid first-time mum, here we go.' No, something's wrong!P15 Others were sceptical of their health professionals' training or advice.
Many of these factors led to frustration, distress and further helpseeking from health professionals or elsewhere.
when the doctor said to me, it was okay, I was like, I don't know, something in my head just said, it's not okay, you need to find somebody else that's going to help.So then I phoned like I text my health visitor.

P10
Some felt their health professionals' advice was not personalized enough or that they were misunderstood, for example not understanding the financial strain of buying different bottles.
…for the health visitor to just go, 'Just go buy some bottles.'I was like, 'Well, I haven't really got the money to go and just constantly keep buying new things'.P10 Although there were many negative perceptions, some parents perceived a positive relationship and communication with their health professional and highlighted that this helped their situation.
…so we went to the GP and then their advice was really helpful.And they tried everything that I think could be tried, to help ease the reflux, but unfortunately nothing that we tried did help… they explored the avenues so, so we saw a few different doctors… and each of them was, was really nice, and took it se- As their foundation to help-seeking, they also commonly sought advice, information or support and validation of experiences from social networks or online.
The concerns about underlying causes influencing help-seeking is in line with recent online discussion forum research about excessive infant crying; parental suggestions/thoughts about various diagnoses and underlying causes influence parents to search for a diagnosis (Ghio et al., 2022).This highlights the need to inform parents about when symptoms are a normal part of baby behaviour and when a label/diagnosis or medical intervention is required.
Whilst there were mentions of non-pharmacological recommendations in this study, the findings about diagnoses/labelling of reflux or allergy and prescriptions (for specialist formula or reflux medication) are similar to findings from other research about labelling and prescribing (Chalmers et al., 2020;Mehta et al., 2022;Scherer et al., 2013;Schoemaker et al., 2015;Vincent et al., 2022).Although it is important to diagnose and treat these conditions when they occur, research suggesting over-labelling (Chalmers et al., 2020;Schoemaker et al., 2015;Vincent et al., 2022) and inappropriate prescribing (Mehta et al., 2022;Scherer et al., 2013) further highlights the need to distinguish between when diagnoses and prescriptions are necessary.The search for a diagnostic label or underlying cause also aligns with core assumptions in Leventhal's (2012) Common Sense Model of self-regulation (Leventhal & Brisette, 2012), which finds identity and cause to be core domains of illness representations.
Parents in this study sought validation, empathy and understanding in their help-seeking.They often felt this was missing from health professionals, feeling 'fobbed off' or dismissed, resulting in negative perceptions of their support or reassurance of 'normal' baby behaviour.This is echoed in recent survey research of parents with unsettled babies in the Netherlands (van der Veek & van Rosmalen, 2023) and similar to other paediatric conditions in primary care/community health such as eczema and sleep (Cook et al., 2020;Santer et al., 2012).It is therefore important to ensure that parents feel understood and that reassurance about normal behaviour (or a lack of label/diagnosis) does not mean that patients will not be supported.
The current study highlights that often parents perceive limited access to health professionals and a varied health professional/patient relationship, which impacts their perceptions and management of their babies' behaviours.Parent frustration surrounding access to health professionals is understandable; however, this study was conducted at a time of increasing strain and scarcity of health visitors (UK community child health nurses) and GP workforce, which possibly contributed to frustrations with access.For example, for health visitors, the primary contact of babies in this age range in the UK (Public Health England.Health visiting and school nursing service delivery model, 2021), the recommended caseload is 250 children.
However, only 6% have this recommended amount or less and 28% currently manage over 3 times more.It is estimated that the UK is short of 5000 health visitors currently with a reduction of 40% since 2015 (Institute of Health Visiting, 2023).This study was also conducted whilst COVID-19 was still active and remote consultations were more frequent with GPs.Therefore, whilst it is important to improve on ways to help patients, which ease the pressure on the NHS, the way that new support is accessed, communicated and tailored will be an important factor for ensuring parents accept and trust the support.
The role of online help-seeking and social support (online and in person) is also important.These findings are similar to studies of online help-seeking whereby parents/patients value the use of finding convenient and credible information online but acknowledge risks such as finding overwhelming, inaccurate or distressing information (Treadgold et al., 2020;Ziebland & Wyke, 2012).The current study also echoes research, which highlights the use of sharing experiences online whereby people can develop a feeling of connectedness and being understood from accounts of shared experiences (Treadgold et al., 2020;Ziebland & Wyke, 2012).
Indeed, the current study findings are in line with previous excessive baby crying research whereby parents shared experiences in online discussion forums, which influenced their perceived credibility (Ghio et al., 2022) and whereby parents emphasize the importance of social support (Brown, 2018).Parents in this study also had positive perceptions of parent groups both online and in person, suggesting that increasing access to remote or face-toface parent groups may also provide an alternative to individual consultations.
It would therefore be beneficial to provide families with a tool such as an online support guide that provides the evidence-based information and tailored advice, which would reduce their uncertainties and facilitate self-management.This tool could be accessed prior to consulting with health professionals and include patient stories, which may ease parental anxieties and reduce the number of consultations needed.Similarly, a tool could be used to facilitate consultations whereby health professionals can effectively signpost for further information.

| Strengths and limitations of the work
This study had a sample size of 25 mothers with sufficient informa- which may have been relevant to perceptions of unsettled behaviours.Furthermore, some of the babies had been born prematurely and this may have impacted the advice they sought and received.
Full analyses on these aspects were outside the scope of this study and need exploration in further research.
Most of the expressions of interest were from social media; eventual participants were from social media (n = 19) and via GP practices (n = 6).This may have led to bias whereby the sample included were more likely to search online for help.Parental experiences may have been different if more had been recruited via GP practices and health visiting teams.Due to participant self-selection by responding to adverts, some participants with more extreme experiences (e.g.highly negative) may have been more likely to take part.Parent accounts were also mostly retrospective, rather than about current experience.Nevertheless, parents often appeared to remember these difficulties clearly.
Parental labels for colic and reflux, and variations of these terms such as 'colicky' babies were often interchangeably used as symptoms and labels.Due to parental report, the exact diagnosis, label or advice given to parents by health professionals was not confirmed nor was it always certain which exact combination of behaviours parents were referring to.However, the interchangeable use of these terms by parents and in the advice that parents perceived or retained is interesting and supports previous research (Ghio et al., 2022).Future analysis on parental understanding and labelling of baby behaviours is required.

| Recommendations for further research
The perceived role of healthcare professionals in facilitating parents' understanding and management of baby behaviours suggests that it would be beneficial to conduct qualitative research with front-line healthcare professionals.It would be beneficial to interview health visitors and GPs because they are the first point of call for parents in the UK and they were often mentioned by participants in this study.
Future research to develop and better sign postresources such as self-help interventions, with evidence-based advice and explanation, would be useful.Currently, there are websites available with some information about a range of child health issues such as Wessex Healthier Together (Healthier Together, 2023).An intervention specific to unsettled babies would provide more detailed and individualized information specific to this issue, which may be more meaningful to parents.Parents could then access this for support, providing them reassurance whilst also easing pressure and resources needed from time-constrained and resource-limited consultations.

| Implications for policy and practice
It is important to address parental concerns and uncertainties, ensuring that they feel understood and that they will still be supported.An online tool could be used in conjunction with strong healthcare professional communication skills.This study suggests that for the tool to be effective, the consultation with a healthcare professional recommending it will need to be experienced as empathic and validating for the parent.Patient voices may also be useful for an online intervention increasing perceived credibility of information for parents; this technique has been used successfully in other digital self-management interventions (Sivyer et al., 2022).

| CON CLUS ION
Parents often feel uncertain and desperate about their baby's be-

ACK N OWLED G EM ENTS
We would like to thank the parents who participated in the study and the NIHR clinical research networks, GP practices and health visiting teams involved for their support in recruitment.

PEER R E V I E W
The peer review history for this article is available at https:// www.webof scien ce.com/ api/ gatew ay/ wos/ peer-review/ 10. 1111/ jan.
What does this paper contribute to the wider global clinical community?•Addressing parental uncertainties is important; about what is normal, nonpharmacological approaches and when pharmacological intervention is required.•A digital information/self-management intervention may be useful for parents/ clinicians.K E Y W O R D Sadvice, baby, crying, general practitioner, health visitor, help-seeking, parent, qualitative research, symptoms, unsettled, vomiting 13652648, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jan.16070by University Of Southampton, Wiley Online Library on [28/02/2024].See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions)on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License Research questions were as follows: 1.When and where do parents seek advice and support for their baby's behaviours? 2. What advice do they take away from these interactions?3. What are parents' views and experiences of obtaining advice from healthcare professionals working in primary care? 4 | ME THODS/ME THODOLOGY 4.1 | Design A qualitative semi-structured interview study with parents of babies with unsettled behaviours such as excessive crying and vomiting.

Facilitated
by the National Institute for Health and Care Research clinical research network, four GP practices (1 from the Wessex region and 3 from Thames Valley and South Midlands) completed a database search and invited up to 100 parents with babies aged up to 12 months, and opportunistically invited parents in consultation.Two health visiting teams within one NHS Trust opportunistically invited parents in each of their clinics and advertised with posters.Interested parents informed the research team directly by completing a reply form with their contact details (via Microsoft Forms online or in a freepost envelope) or by contacting the researcher.Social media advertising involved social media posts and targeted advertising, linking to the reply form online.
and how these related to the findings.The Standards for Reporting Qualitative Research(O'Brien et al., 2014) was used for the reporting of this study.

Figure 1
Figure 1 highlights the themes and subthemes.

I
wanted answers.Because when I didn't know it was silent reflux it was, what is happening to my baby?Am I doing something wrong?Is it something I'm doing?Is there something wrong with her digestive system?… I just always felt in my gut, something isn't right.So, when I went to the GP I just wanted to know what the heck was going on, really.P15 I was really worried that he was, he did have an allergy or intolerance…but then when we ruled out an intolerance or an allergy, I felt better and I just thought, this is just the way he is.P13 F I G U R E 1 Final thematic map.13652648, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jan.16070by University Of Southampton, Wiley Online Library on [28/02/2024].See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions)on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License TA B L E 1 Participant characteristics.

13652648, 0 ,
Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jan.16070by University Of Southampton, Wiley Online Library on [28/02/2024].See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions)on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License Theme 4: Foundations to help-seeking Regardless of whether participants described seeking and receiving support from health professionals, it seemed their initial or main source of help-seeking were often social support and/or online helpseeking.These provided a sense of shared experience, a source of information (assessment of symptoms and management strategies), practical support/advice and emotional support.Participants discussed social support being a lifeline, providing reassurance, practical support and advice.Various forms of social support were discussed by parents, ranging from online parenting forums to family and friends.Parenting support groups were important (online or in person): thank God for this-for the [parent group] in [city], because I just go onto [messaging app] and I'm like, 'Hey, my child has got this funny rash on her face.Is it normal?Has, has anyone else experienced this?' P23 Although it was clear that social support was important to participants, there were mixed positive and negative perceptions about the social support received.For example, many were positive: I've always had a brilliant support network around me, so really lucky with that.P13 Some were negative or discussed limited support.For example, the following parent discussed limitations of social support in relation to their cultural norms: culturally, it's a little bit different.You don't really ask for help.People just, or advice, people just offer advice…having a baby in the kind of family dynamic that I live in…there's so much advice given to you about formula, breastfeeding, all of that, often in a very critical way, um, I just ignored most of it, to be honest, just filtered through, for my own sanity, for making sure that I could, I could manage.I think too much advice sometimes is a bad thing, you know.It's contradictory… what I've learned is that every child is different.What might work for one child will not work for another child.P12 Online information seeking also played a large role for parents in seeking support and managing their babies' symptoms.Various 13652648, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jan.16070by University Of Southampton, Wiley Online Library on [28/02/2024].See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions)on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License about what range of behaviours to interpret as normal and concern about potential underlying causes.They sought empathy, explanations and solutions from healthcare professionals but had mixed experiences and perceptions of health professional support.Experiences included limited access to support, assessment and labelling of reflux or allergy, reassurance of 'normal' baby behaviour, and both pharmacological and non-pharmacological management.
Distinguishing between when diagnoses and prescriptions are necessary could be facilitated by educating parents and professionals.Increasing detailed information about non-pharmacological strategies could help with this.This could ultimately reduce unnecessary NHS costs and side effects of medication.Any interventions developed may be signposted by current websites such as Healthier Together (Healthier Together, 2023), or by health professionals in consultations.Health professionals may also be able to use similar interventions in clinical practice as a guide for evidence-based advice and to reduce over-medicalization and over-prescribing.
haviours, with questions surrounding normality and suspected underlying causes.Consulting in healthcare is important to validate the parent experience and provide them with the support they need.Parental perceptions of limited accessibility, communication and mixed perceptions of advice given in consultation impact their perceptions/management of behaviours, and their parental mental health.Parents value shared experiences from other parents for their experiences to feel valid and for them to trust information.There is need for more support and improved access to support for parents.Due to increasing constraints on NHS resources and funds, it would be beneficial to develop a digital self-help intervention as a step between symptom onset and seeking advice in healthcare.This could target parental education around normality and when/where to seek help within the NHS, and it could incorporate patient stories from other parents.Digital interventions for health professionals could similarly be developed to help them advise about symptoms in consultation, with the target of reducing over-labelling of colic/reflux and inappropriate prescribing whilst still supporting families who are struggling with these symptoms.Ultimately, interventions such as this could help to alleviate parental distress and reduce harm through over-medicalization.Further research with primary care professionals (such as health visitors who are often the first point of access for parents) is necessary to inform the development of these interventions.

13652648, 0 ,
Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jan.16070by University Of Southampton, Wiley Online Library on [28/02/2024].See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions)on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License FU N D I N G I N FO R M ATI O N This study/project was funded by the National Institute for Health and Care Research (NIHR) School for Primary Care Research (project reference 536).The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care.For the purpose of open access, the author has applied a CC BY public copyright licence to any Author Accepted Manuscript version arising from this submission.