MANAGEMENT OF INFANTILE COLIC

Jeanette I. Ch. Manoppo

UKK Gastrohepatologi 2013

Definition
Infantile colic
Rome III criteria

Paroxysms of irritability, fussing or crying that start and stop without obvious cause, lasting > 3 hours per day and occurring > 3 days each week. Without a failure to thrive
Common problem (1 in six families) consulting healthcare professionals
Gastroenterology 2006;130: 1519

Incidence
Affects 10-30% of infants worldwide Occurs in = Commonly observed in neonates and infants aged 2 weeks to

4 months
The incidence of colic in breastfed and bottle-fed infants is

similar with no difference

Arch Pediatr Adolesc Med. 2002;156:1123-8

Etiology

The cause of infantile colic remains unclear Organic causes account <5% of infants presenting with excessive crying

Organic causes of infant with excessive crying

Pediatrics. 1998;102(5 suppl E):1283 Pediatrics. 1991;88:452

Pathogenesis
Poorly understood Abnormal gastrointestinal motility and pain signals from

sensitised pathways in gut viscera

Inadequate amount of lactobacilli and increased amount of

coliform bacteria in the intestinal microbiota influences gut motor function and gas production

Curr Opin Pediatr. 2010;22:791-7

Common Etiopathogenesis

Lactose intolerance Dysmotility Gastro-esophageal reflux Gut hormones (motilin, ghrelin) Gut microflora (Lactobacillus spp.) Feeding disorders Food hypersensitivity (cows milk allergy) Psychological factors (infantparent interaction)

Diagnosis

Exclusion of other causes especially organic causes

No abnormalities in history and examination, therefore no

need for biochemical and radiological examination

Differential diagnosis

BMJ. 2013;347,f4102:1-5

Differential diagnosis

BMJ. 2013;347,f4102:1-5

Flow Chart

UTI (Urinary Tract Infection) AOM (Acute Otitis Media)

Sri Lanka Journal of Child Health. 2012; 41:192-8

Management
Reassurance of parents regarding the benign and self-limiting

nature of the illness as most of the babies improve by the age of 3 to 4 month

Management options
Diet modification
Based on theory that infantile colic results from excessive gas

production from poor gut digestion of cows milk proteins

Hypoallergenic formula preparations for bottlefed infants

High fibre formula

Soy based formula Hypoallergenic maternal diet for breastfed infants Lactase therapy

Matern Child Health J. 2012;16:1319-31

Diet modification
Hypoallergenic formula preparations for bottlefed infants
Where a suspicion of cows milk protein allergy exists there is some

evidence that the use of an empirical time limited trial of a completely hydrolysed formula is a reasonable option
Partially hydrolysed formula would not be recommended because are

not hypoallergenic and therefore will not address colic symptoms caused by protein allergy
Matern Child Health J. 2012;16:1319-31 Paediatr Child Health. 2011;16:47-9

Diet modification
High fibre formula
No significant difference in symptoms vs standard formula

Soy based formula

Not recommended because concerns about the level of phytoestrogens

and that soy protein may be an allergen in infancy

J Paediatr Child H. 2012;48:128-37 Matern Child Health J. 2012;16:1319-31 Soya based infant formula. 2003. www.sacn.gov.uk/pdfs/smcn_03_10.pdf

Diet modification
Hypoallergenic maternal diet for breastfed infants
One systematic review suggest exclusion of milk product and other

possible trigger foods (peanuts, soy, fish) on the mother correlate with >25 % reduction in cry/fuss vs baseline but did not separated the results for breastfed infants from hypoallergenic formula fed infants
Limited evidence to suggest that hypoallergenic diets in mothers

may be helpful
They should also be advised not to discontinue breast feeding while

switching to the hypoallergenic maternal diet

J Paediatr Child H 2012;48:128-37 Matern Child Health J 2012;16:1319-31 Soya based infant formula. 2003. www.sacn.gov.uk/pdfs/smcn_03_10.pdf

Diet modification
Lactase therapy
Lactase drops mixed with breast or bottle milk feeds up to 24

horus before feeding

May benefit but lack of evidence

J Paediatr Child H. 2012;48:128-37

Pharmacological management
Anticholinergic
Dicyclomine hydrochloride, cimetopium bromide

may benefit but adverse reaction noted to infant <6 months (respiratory distress and seizures)

Simethicone

reduce intraluminal gas

not useful

Am Fam Physician. 2004;70:735-40

Complementary therapies
Herbal supplements
Fennel extract and mixed herbal tea

showed reduction in symptoms

Adverse effect like vomiting, sleepines,

constpation and loss of appetite

Lack of standardisation of dosage and

formulations have also limited their use

Pediatrics. 2011;127:720-33 Curr Opin Pediatr. 2010;22:791-7

Complementary therapies
Sucrose solutions
May be benefit but lack of evidence There are concerns about potential nutritional effects and

formulation standardisation
Pediatrics 2011;127:720-33 Curr Opin Pediatr 2010;22:791-7 J Clin Nurs.2008;17:1754-61

Complementary therapies
Probiotics
Based upon the hypothesis that aberrant intestinal microflora affecting

gut function and gas production may contribute to symptoms, the use

of probiotics in infantile colic has become more common

One randomised double blind placebo controlled trial involving 46

infants used a suspension of freeze dried Lactobacillus reuteri. 50% reduction in crying time from baseline and show good weight gain and gastrointestinal tolerance
Pediatrics 2010;126:e526-33

Complementary therapies
Massage
One study noted a positive effect in massage using aromatherapy

oils, however, the results were not separated between massage and aromatherapy
While several other studies identified in a systematic review showed

some improvement on symptoms of colic, overall the quality of these studies is poor
Int J Nurs Prac. 2012;18:164-9 Pediatrics. 2011;127:720-33 J Clin Nurs. 2008;17:1754-61

Complementary therapies
Swaddling
Reduced crying symptoms but associated

with development hip dyslplasia, overheating, and sudden infant death syndrome if placed in the prone position
Therefore not recommended

Pediatrics. 2007;120:1097-106

Complementary therapies
Chiropractic

More controversial Positive effects noted but bias with parents coping ability rather that true effectiveness of chriopractic Limited evidence to support this practice
FACT. 2012;17:22-6 N Z Med J. 2011;124:55-71 J Explore. 2011;7:168-74

Complementary therapies
Acupuncture
Two trials noted a shorter duration and intensity of infantile colic

symptoms
Another double blinded randomised controlled trial comparing

acupuncture with a sham needle insertion noted no major effect on symptoms including feeding, bowel movement frequency, and sleep

Acupunct Med. 2010;28:174-9 Acupunct Med. 2008;26:171-82 BMC Complement Altern Med. 2011;11:93

Behaviour modification
Family involvement using an integrated care model led to the

relief of infantile colic symptoms more than standard care

The use of contingent music was noted to decrease symptoms

in another study

Infant Mental Health J. 2012;33:110-22

Conclusion
Majority of cases only need simple reassurance Many intervention only have poor evidence support There are no effective and safe pharmacological management

options available over the counter or by prescriptions

Infantile colic is self limiting and benign but can cause distress to parents. Therefore, parental support is important.

Thank you, for your attention