Baby cues and interactions

  • Babies are born ready to connect, engage and learn. 

    Babies thrive on engaging with their families who support them to gradually learn about the world around them. This section contains tips on how to recognise when your baby is ready to engage, how to get the most out of your shared interactions, and how to tell when your baby is tired or disinterested and just needs to be settled again.

    What are baby cues?

    Babies “talk” to their families all the time. Before they develop words, they use their voice, and face, arm and leg movements to communicate. These sounds and movements are called baby cues. Baby cues are the way your baby shows you how they feel and how to work out what they want. These signals are designed to draw attention, convey messages, and provide information. Cues tell you what your baby likes and what your baby doesn’t like; whether your baby is happy to continue in an activity or needs a break. Cues signal whether your baby is coping with the environment or whether there is too much going on.  

    Engagement cues are signals or body language the baby uses to show that they like what is going on around them. They are called approach or coping signals.

    Disengagement cues are signals or body language the baby uses to show that they do not like what is going on around them. They let you know when your baby is stressed and needs a break from what is happening.They are called defensive or avoidance signals. 

    Engagement cues

    Engagement cues

    • Eyes become wide open and bright as the baby focuses on you
    • Turning eyes, head or body toward you or the person who is talking
    • Alert face
    • Healthy pink colour
    • Steady breathing
    • Hand-to-mouth activity, often accompanied by sucking movements
    • Hands clasped together
    • Grasping on to your finger or an object
    • Smooth hand, arm, and leg movement 
    • Softly flexed posture (looks relaxed)
    Disngagement cues

    Disengagement cues

    • Crying or fussing
    • Gagging, spitting out
    • Red eyebrows
    • Frowning, grimacing
    • Hiccoughing, yawning, sneezing
    • Becoming red, pale or mottled
    • Irregular breathing
    • Jittery or jerky movements
    • Agitated or thrashing movements
    • Falling asleep
    • Turning eyes, head or body away from you or the person who is talking
    • Salute, finger splay
    • Limp or stiff posture
    • Back arching

    What causes babies to communicate engagement and disengagement cues?

    Babies communicate engagement cues when they become stable and organised (settled). This tells us they are able to continue with what is happening around them because it is not affecting their stability. Babies communicate disengagement cues when they become unstable and disorganised. This tells us they need a break or a change in what is happening around them to achieve stability again. Factors that affect stability and organisation (when the baby is settling) trigger baby cues.

    There are four main factors that impact or signal stability and organisation:

    1. Environment
    2. Infant behavioural state
    3. Motor function
    4. Physiological state

    1. Environment: Changes in the environment often cause baby cues. Babies like calm predictable environments. Loud, unexpected noises, or too much persistent noise which happens when a lot of people are talking, can cause your baby to become      disorganised. Similarly, bright light, strong smells like perfume, changes in temperature and increased handling or moving, can cause your baby to become disorganised. When this happens, your baby will communicate disengagement cues. 

    2. Infant behavioural state: How alert your baby looks describes their “state”. It is the term used to describe levels of consciousness or alertness. States are either asleep or awake.

    Becoming familiar with how your baby awakens and sleeps and how they maintain an alert state when awake will assist you to decide if they are stable, organised and coping. If your baby maintains state for short periods only or transitions state rapidly, this can be a sign that they are not coping with what is happening around them. Rapid transition from awake to asleep is their way of getting a break from what was causing them to feel unstable and disorganised. Likewise, maintaining a state indicates that your baby is coping with what is happening around them. You are more likely to see engagement cues that signal your baby is stable and organised.

    Learning about your baby’s behavioural states will give you clues about:

    • what they need
    • when to do daily routines
    • when they learn best
    • when they need a break from what is happening around them

    Sleep is important for babies on Butterfly. Sleep helps brain development, and allows babies to preserve their energy and catch up on their growth. Sleep means your baby is relaxed. It is important to know your baby’s sleep/wake cycle. In that way, you can assist staff in organising your baby’s daily care routine so that sleep times are protected and cares can be clustered when your baby is awake and alert. Don't forget about Safe Sleeping Guidelines!

    As your baby matures, they will be more able to maintain sleep and awake states. They will also be able to transition more smoothly between states, moving gradually from asleep to alert and vice versa. When your baby is younger, smaller, or more unwell, they may not be able to do this. Preterm babies spend less time in states (iv) and (v) (see below).

    When your baby is disorganised you will also see this in their state. Their changes in state may be frequent and abrupt. When your baby is organised and coping, you are more likely to see them maintaining their state, or changing their state gradually and smoothly. 

    Behavioural states

    There are six behavioural states. Three are sleep states and three are awake states.

    Behavioral state deep sleep COCOON - The Royal Children's Hospital

    (i) Deep sleep

    Quiet sleep, regular breathing, your baby moves very little.

    Deep sleep needs to be protected. Babies are least likely to be disturbed by outside noises in deep sleep.

    Behavioral state active sleep COCOON - The Royal Children's Hospital

    (ii) Active sleep

    Light sleep, rapid eye movements, breathing is faster and more irregular, more activity is seen with twitchy mouthing movements, smiling and whimpers.

    Babies spend a lot more time in this state compared to deep sleep. It is an important part of their sleep cycle. It is the time when brain cells are making lots of connections.

    Behavioral state drowsy COCOON - The Royal Children's Hospital

    (iii) Drowsy

    Half-awake, eyes are closed but intermittently open and flickering, glazed expression, limp and quiet with some fussing. Babies can go one of two ways: either wake up or go to sleep. Drowsiness is part of their sleep cycle and you may need to help your baby go back to sleep.

    Behavioral state quiet awake COCOON - The Royal Children's Hospital

    (iv) Quiet awake

    Awake, quiet and paying attention, little movement and eyes bright and shiny, relaxed facial expression, sometimes frowning with effort.

    This is a great time to interact with your baby, it is when they are most sociable. This is their best "learning" state.

    Behavioral state active awake COCOON - The Royal Children's Hospital

    (v) Active awake

    More movement and fussing in this state, making sounds.

    Babies are more physically active in this state and may even fuss. Fussing can signal that your baby needs something to change or stop.

    Behavioral state crying COCOON - The Royal Children's Hospital

    (iv) Crying

    Loud fussing, rhythmical crying.

    Babies cry for different reasons. As they get older they will cry more and you will be able to understand the different cry signals, such as hunger or tiredness.

    3. Motor function

    This describes your baby’s muscle tone, posture and movement patterns. Motor stability tells you whether your baby is coping, organised and stable or whether they are stressed, disorganised and unstable. Motor movements form part of the baby cues your baby uses to tell you what they need. 

    When your baby is orientated to the midline, this is called a flexed posture. Active flexion is when arms and legs are moved toward the body. This flexed posture and movement pattern communicate your baby is coping, organised and stable. Smooth, controlled movements indicate the same thing. These are engagement cues and signal your baby is happy to continue with what is happening around them. Limp, floppy or tense muscle tone communicates instability, as do jerky movements and repetitive cycles of movement. Movements where the arms and legs are moving away from the body or posture where the arms and legs are resting outward from the body are called extension or extensor movements. These movements signal your baby is stressed, unstable or disorganised. These are disengagement cues and signal your baby needs a break from what is happening around them. 

    4. Physiological state

    This describes your baby’s heart rate, breathing rate, their colour and how comfortable they are. It relates to how their breathing, circulation and digestion is working. You can find a description of these “vital signs” in the “My Room” section of the Butterfly tab in the My RCH app. 

    When your baby is stable, they will show a healthy rosy colour, have a stable heartbeat, steady gentle breathing, and look comfortable before, during and after feeding. If your baby becomes unstable, you may see their colour change to pale, dusky or mottled and their heart rate may become rapid, slow or erratic. Their breathing rate may change and look fast, irregular or laboured. You may see breathing pauses, nasal flaring, gasping or sighing. Your baby may also hiccough, tremor or twitch if their physiological state becomes unstable. Feeding may be less comfortable and more gagging and positing may occur, or you may notice straining, grunting and passing wind. Changes in physiological states often trigger baby cues as your baby tries to get back to, or maintain, stability. 

    How can you help your baby stay calm on Butterfly?

    how to keep your baby calm on Butterfly

    The ward can be a stressful environment for babies to develop and grow in. There are ways you can help your baby cope with the stress of the environment and the stresses associated with medical treatments and daily cares. The aim is to read your baby’s cues to understand what they might need to remain stable and cope with what is happening around them. Butterfly staff are available to teach you strategies to help your baby stay calm and better able to cope with the activities around them. These strategies include changing the environment, talking to and interacting with your baby, using music, skin-to-skin care, comfort touch, non-nutritive sucking, positioning, nesting, swaddling, and patting. You can find more information about many of these techniques by talking to the nursing and allied health therapists working with you and your baby. 

    Getting to know your baby using all five senses

    Babies are born to be social, and they try to interact as soon as they arrive. This section has been written by one of our Infant Mental Health specialists and it is structured around using senses, both your and your baby’s, to learn more about each other.

    1. Seeing 

    Looking at faces 

    Baby looking at faces image 1 - COCOON The Royal Children's Hospital

    A baby would prefer to look at a person than anything else. People are the best toys for newborn babies.

    Baby looking at faces image 2 - COCOON The Royal Children's Hospital

    Marked mirroring – your baby understands the world by looking to those around them. Babies who are sick still tune in to social cues, particularly facial expressions. It's important to try and match your facial expressions with those you may read from your baby, to show you understand them, but in ways that show your baby reassurance.

    Optimal distance for baby to see

    Optimal distance for baby to see image 1 - COCOON The Royal Children's Hospital

    Approximately 30 cm – the distance between your face and your baby's face if you were breastfeeding.

    Optimal distance for baby to see image 2 - COCOON The Royal Children's Hospital

    If you're too far away, your baby can't find you. If you're too close, your baby may not be able to focus well, and may disengage.

    Mutual meeting of gaze

    Mutual meeting of gaze - COCOON The Royal Children's Hospital

    Don't "chase" your baby if they look away. Turning away, or closing eyes is the baby's way of regulating themselves in social interactions. If you wait, your baby will find you again when they're ready.

    Looking and watching

    Looking and watching image 1 - COCOON The Royal Children's Hospital

    Your baby is interested in the world around them but they will get tired easily, and may be easily startled. Introduce things to look at slowly and with curiosity, at a safe distance. Hold the object still, and enable your baby to focus and look in their own time.

    Mobiles are good, particularly when there are faces on the underside of the mobile for the baby to look at.

    Looking and watching image 2 - COCOON The Royal Children's Hospital

    You can learn a lot of about your baby from watching and observing them, even when they are asleep – what they like, what they don't, and how their personality is beginning to develop.

    2. Hearing 

    Hearing image 1 - COCOON The Royal Children's Hospital

    Your baby has been listening to you and their surroundings since before they were born. Your baby will listen if you read to them, sing to them, and talk to them.

    Hearing image 2 - COCOON The Royal Children's Hospital

    Your baby will recognise the voices that are important to them.

    Your baby can tell the difference between your voice, and the voices of the Butterfly staff who are caring for them.

    Hearing image 3 - COCOON The Royal Children's Hospital

    Your baby is able to tune out noise and sounds as they get used to them. We call this habituation. They will learn how to sleep through the noise of the ward.

    Hearing image 4 - COCOON The Royal Children's Hospital

    Your baby will be curious about new noises but may startle if the noise is loud or unexpected.

    Hearing image 5 - COCOON The Royal Children's Hospital

    Your baby particularly likes voices that have a melody. With new babies, we often find ourselves using "motherese", a singsong-like tone when talking to babies.

    Hearing image 6 - COCOON The Royal Children's Hospital

    Play is important, even for little babies. Being playful with your voice, and your facial expressions, will be interesting for your baby. Your baby will watch, and will even start to join in with the game with their own facial expressions and little sounds.

    3. Touch

    Touch image 1 - COCOON The Royal Children's Hospital

    There are many benefits of skin-to-skin sessions with babies for both mums and dads. See the "Comfort touch and skin-to-skin care" section for more information.

    Touch image 2 - COCOON The Royal Children's Hospital

    Newborn babies try to grab hold of things. They like to hold on to your fingers. In Butterfly, they also like to hold on to tubes! If a baby likes to do that, we can give them a baby ring or something similar to grasp or hold.

    Touch image 3 - COCOON The Royal Children's Hospital

    Butterfly babies have had lots of handling that is sometimes unpleasant. We can give them a different experience through gentle touch. We can use different types and textures of gentle fabrics such as silk, wool, and sheepskin.

    Touch image 4 - COCOON The Royal Children's Hospital

    Talking to your baby while touching them will help reassure and contain them.

    Babies like a firm but sensitive touch when they are well enough, but they're not very keen on tickling.

    4. Smell

    Smell image 1 - COCOON The Royal Children's Hospital

    A baby is able to recognise their mother's scent and smell. This is one of the ways that your baby knows you.

    Smell image 2 - COCOON The Royal Children's Hospital

    You can leave a piece of your clothing with your baby when you aren't on the ward with them, so they still have your scent close by.

    5. Taste

    Taste image 1 - COCOON The Royal Children's Hospital

    Your baby will be curious about taste, and can tell the difference between tastes that are nice, and tastes that are not.

    It is important to not push a baby into tasting or feeding until they are ready, and follow their lead by watching their cues. You can learn a lot more about this in the "Feeding" section.

    If you would like to talk to one of our Infant Mental Health specialists, please ask your bedside nurse or the ward clerk to make an appointment for you.

    Singing and listening - parents have the power

    This section has been written by our music therapist and contains lots of helpful hints on using the power of music to interact with your baby.

    As mentioned in the previous section, the sounds of your voices are the most meaningful and supportive sounds to your baby. Your baby particularly remembers your voices from before they were born and regardless of how they seem right now, they will be soothed by you talking or singing. Singing is good for you too. When you sing you breathe more deeply and you relax a little.  That’s good for you and for your baby. You can sing any time - maybe when you are standing or sitting at the bedside, holding or feeding your baby, or during cuddles.

    Given that hospital is not a very private space some parents don’t feel like they can sing in front of others. You need to know that we hear all sorts of sounds, and singing is one we love to hear because we know it’s good for babies. You might like to try humming first. That’s also really good, but not so revealing!

    If singing or humming is not for you then talking is also a great reassurance for your baby. Not only does the baby hear your voice, but when you are up close your baby can actually feel the warmth of your breath on their skin. This means that they can ‘feel’ you right there and benefit from your loving care.If you are not available during your baby’s wakeful times, the nurse might recommend that the music therapist provide some music for your baby. The music therapist will always try to speak to you before seeing your baby to explain the sorts of things that can be done.

    Recorded music

    Research shows that appropriate recorded music can assist in calming babies.  The music therapists can provide you with a CD or MP3 player and appropriate music. The music therapist first assesses that recorded music would benefit your baby. For some babies there is already too much happening and further stimulation might not be appropriate. For others, there is a real need to help them get organised, and music can help.

    The music therapist will come and discuss what music you like, what music we might play to your baby, how often and for how long.  They might then organise a time to come and assess your baby’s ability to cope with music. Music will then be selected or prepared for you and your baby to use. The music generally has a slow, steady speed and is not too loud. The music includes only a few instruments with no sudden changes. This type of music can help to provide a soothing and comforting support.

    If you would prefer to use music from home, check with the music therapist first to ensure it is appropriate for your baby.

    Why no radios?

    Please do not use the radio on the CD players or other equipment. The sound that comes from a radio changes every few minutes, with big changes in volume and quality. For baby’s ears, it is just more noise in an already noisy environment, and we know that noise can be harmful for some babies.  For that reason, we don’t have the radio on at all.

    If you would like to read more about how music therapy can help you and your baby, here is a list of links to some articles you might like to read:

    • Shoemark, H. & Dearn, T. Music therapy in the medical care of infants. Oxford Handbook of Music Therapy. London: Oxford University Press. In press.
    • Shoemark, H. (2013). Working with full-term hospitalized infants. J. Bradt (Ed.) Guidelines for Music Therapy Practice: Pediatric Care. (pp.116-151). Philadelphia: Barcelona Publishers. 
    • Shoemark, H. (2012). Frameworks for using music as a therapeutic agent for hospitalised newborn infants. In N. Rickard & K. McFerran (Eds.). Lifelong engagement in music: Benefits for mental health and well-being. Pp.1-20. New York: Nova Science Press.

    If you would like to talk to our Music Therapist, please ask your bedside nurse or the ward clerk to make an appointment for you. Belinda Tucquet is the music therapist who runs the Neonate & Infant Program at RCH.  She is available on Mondays, Tuesdays, and Wednesday mornings. 

    Talking about my baby

    In other sections you learned about how to talk to your baby. This section will teach you how to talk about your baby. We believe that you know your baby better than anybody else. You will be spending more time with your baby learning about their personality and their likes and dislikes than anyone else. You are the best advocate for your baby and you know your baby’s story best. This makes you the best person to talk about your baby. You never know, you might just teach us something we don’t know yet!

    As part of the COCOON model of care, we strongly encourage families to be present at the bedside during ward rounds, and to contribute to the discussions of their babies Care Plan for the day and into the future. Please see the “My Ward” section in the Butterfly tab of the My RCH app for more details about ward rounds.

    You don’t have to talk to the team about your baby during the ward round. In fact, some people find this too daunting, but if you would like to introduce your baby and tell us how they are doing, here are some suggestions on key points to communicate:

    Introduce yourself and your baby

    I’m Kylie and this is my baby Harrison.”

    Tell us how old your baby is

    “Harrison was born two weeks ago. He was born early at 32 weeks. He is now 34 weeks old.”

    If you can, tell the team what your baby’s main problems are

    “Harrison was born with a blockage in the upper part of his gut called Duodenal Atresia. He needed surgery the day he was born to fix that.”
    “He also had some problems with breathing early on and needed to stay on the ventilator for a bit longer than expected but he’s good now.”

    Tell us how you think your baby is today

    “Harrison was a bit grizzly overnight. I think he’s hungry because he’s only just working up on feeds now.”

    If you happen to know how much food or what medications your baby is receiving, you could tell us that too

    “Harrison is only getting about 15mls of EBM every two hours because he wasn’t tolerating it at first. He’s only on one medicine now, for reflux.” 

    Think about your plans for the day, what would you like to do with your baby

    “I’ve been getting to have skin-to-skin cuddles with him every day and now he’s starting to get interested in my milk. I’d really like to give him a bath soon.”

    If you are worried about anything or have any questions, you can use the ward round to speak up about these things

    “I really want to breastfeed him but I’m worried he won’t be able to learn how to do it because he’s being fed down the tube. Is there someone who can help me with that please?”

    When you first arrive on the ward, you are unlikely to be able to talk about your baby in this much detail; but as time goes by and you listen to the doctors and nurses talking about your baby, you’ll soon learn how to do it.

    Again, there is no pressure on you to do this. The care team can do most of the talking if you would prefer and they will always try to give you a chance to ask questions or make comments before they move on to seeing the next baby.