INFANTILE COLIC

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DEFINITION: repeated episodes of excessive and inconsolable crying in an infant that otherwise appears to be healthy and thriving.

PREVALENCE: 2-30% infants.

Not the same as Reflux!

What is Colic?

What causes colic?

• The underlying cause is UNKNOWN.

• Suggested underlying causes include:– Transient intolerance to the protein in cow's milk or to

lactose.– Gastrointestinal causes.– Parenting factors.– Others have suggested that colic is just the extreme end of

normal crying, or that it is due to the baby's temperament.

Diagnosis

Diagnose infantile colic when the history and examination and consideration of the differential diagnosis reveal no abnormality other than inconsolable crying.

Typically:

• Colic starts in the first weeks of life and resolves by around 4 months of age.

• Crying most often occurs in the late afternoon or evening.

• The baby draws its knees up to its abdomen, or arches its back when crying.

If symptoms started suddenly and recently, consider:

• Intussusception

• volvulus

• strangulated hernia

• Torsion of the testis

• Corneal abrasion

• Non-accidental injury

Differential Diagnosis

Rare, serious causes such as:Seizures; infantile spasms.Cerebral palsy.Chromosomal abnormalities.

Constipation

GORD

Transient cow’s milk intolerance

Parental depression or anxiety, or inability to interact normally with the baby

Discomfort.

- Hunger or thirst (assess feeding technique: is the baby feeding often enough?).

- Too hot or too cold (assess suitability of clothing, keep room temperature at around 18 ｰ C if possible).

- Too itchy (e.g. eczema, or itchy clothes or clothes labels).

- Nappy rash.

- Wind

- Woman's diet if breastfeeding (e.g. too much coffee, tea, or soft drinks that contain caffeine, or too much alcohol or spicy food).

Management of Colic

GOALS

1. To provide strategies to help soothe a crying baby

2. To reduce parental anxiety and stress

1st line: advice and reassurance

• What advice should I give to the parents?

Reassure the parents that their baby is well, they are not doing

something wrong, the baby is not rejecting them, and that colic is common and is a phase

that will pass within a few months.

1st line: advice and reassurance

• What advice should I give to the parents?

• Holding the baby through the crying episode may be helpful. However, if there are times when the crying feels intolerable, it is best to put the baby down somewhere safe (e.g. their cot) and take a few minutes' 'time out'.

• Other strategies that may help to soothe a crying infant include:– Gentle motion (e.g. pushing the pram, rocking the crib)– 'White noise' (e.g. vacuum cleaner, hairdryer, running

water).– Bathing in a warm bath.

1st line: advice and reassurance

• What advice should I give to the parents?

• Encourage parents to look after their own well-being:– Ask family and friends for support — parents need to

be able to take a break.– Rest when the baby is asleep.– Meet other parents with babies of the same age.

• Support Groupswww.cry-sis.org.uk

• Health Visitor

• Only consider trying medical treatments if parents feel unable to cope despite advice and reassurance. The options for medical treatments are:– A 1-week trial of simeticone drops – A 1-week trial of diet modification to exclude cow's milk

protein:– A 1-week trial of lactase drops

• Only continue treatment if there is a response.• If there is no response to one medical treatment, consider

trying another.• Breastfeeding mothers should take a calcium supplement if

they are going to remain on a dairy-free diet long term.

2nd line: Medical Treatment

THERE IS NO CONCLUSIVE

EVIDENCE FOR ANY OF

THE TREATMENT OPTIONS FOR COLIC!

Simeticone Drops• Although studies of simeticone have not provided evidence of benefit

in infantile colic, PRODIGY suggests that a 1-week trial as a placebo may still be worth a try because simeticone is easily available, licensed for this indication, and cheap. It has no reported adverse effects, and the simple act of being able to give their baby something may help parents cope better with the crying.

• Antiflatulent

Breastfed or bottle fed: Simeticone 40mg/ml oral suspension sugar freeGive one drop (0.5ml) before each feed. Increase to two drops (1ml) if required. Supply 50 ml.Age: under 6 monthsNHS cost: 2.14OTC cost: 3.77 Licensed use: yes

Hypoallergenic diet• There is limited evidence that switching to a hypoallergenic formula for

bottle-fed babies, or to a hypoallergenic diet for breastfeeding mothers (free of milk, eggs, wheat, and nuts) may help ease the symptoms of colic. [Evans et al, 1981; Hill et al, 1995; Lucassen et al, 2000].

Bottle-fed: Aptamil Pepti formula (whey based)

Use as baby milk. Age: under 6 monthsNHS cost: 8.62OTC cost: 13.00Licensed use: no - misc item available on the NHS

Bottle-fed: Nutramigen 1 LIPIL formula (casein based) Use as baby milk. Age: under 6 monthsNHS cost: 7.81OTC cost: 11.51Licensed use: no - misc item available on the NHS

Lactase drops• The available evidence suggests that lactase drops may help ease

symptoms for some babies, providing that the lactase is given some time to incubate in the feed before it is given.

• Low-lactose formula not recommended

Breastfed: Colief 50,000units/g infant drops

Express about a tablespoon of foremilk into a sterile container and add four drops of lactase. Breastfeed as usual, and then give the foremilk with the lactase at the end of the feed using a sterilized plastic teaspoon.

Bottle-fed: Colief 50,000units/g infant dropsWarm the feed and add four drops of lactase, wait for half an hour, and occasionally shake gently before feeding the baby.

Patient information: Colic is not a 'true' allergy, and after the colic has settled the baby will be able to digest lactose again. If there is no improvement after one week, there is no point in continuing with Colief drops, and you should resume normal feeds.

Homeopathic remedies

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• When should I consider stopping treatment?If there is no response to the trial of treatment stop it.

If there is a response to treatment: after the age of 3 months (and by 6 months of age at the latest), wean off treatment over a period of about 1 week.

• When should I refer a baby with infantile colic?Seek advice from a paediatrician if:

– The parents are not coping despite advice, reassurance, and primary care interventions.

– There is diagnostic doubt (e.g. the baby is not thriving; crying is not starting to get better or is getting worse after 4 months of age; significant gastro-oesophageal reflux is suspected).

– Unable to wean off treatment by the age of 6 months.

Complications

• Infantile colic can cause significant distress and suffering to the parents.

• Stress on the parents may affect their relationships with the child.• Breastfeeding might be stopped earlier, or weaning on to solid

foods begun sooner, than would otherwise have happened.

• Prognosis– Babies usually 'grow out' of infantile colic by 3–4 months of

age, and by 6 monthsat the latest.– conflicting evidence on whether or not infantile colic is

associated with later development of allergies (e.g. eczema, asthma, allergic rhinitis)