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Treatment Strategies for Infant Colic

Infant and Children | February 6, 2015 | Author: The Super Pharmacist

infant

Treatment Strategies for Infant Colic

Colic is a common condition in infancy marked by prolonged episodes of intense crying, usually during the evening hours. The crying arises suddenly and for no apparent reason. The infant cannot be consoled, even by feeding, and typically exhibits clenched fists, tensing of the abdomen, flexing of the legs, and arching of the back. Bouts tend to come on suddenly and end suddenly. The baby may have a bowel movement or pass gas near the end of the colic episode. Parents may describe their baby’s cry as more piercing, painful or intense compared to his normal cry. Parents often think of colicky pain as abdominal pain, but the precise cause of colic is unclear.

Infant colic poses a serious problem for family quality of life as it can lead to parental exhaustion, loss of patience and frustration. Colicky babies may be at an increased risk of abuse at the hands of exhausted and frustrated parents. Additionally, the parent may not properly bond with the child because of feelings of inadequacy and anger, leading to developing behavioral problems as the child grows. 

Despite its intensity, colic resolves on its own with no interventions. By three months of age, colic has resolved in 60% of infants. By four months, it is resolved in 90% of infants. It sounds harmless and short-lived, but colic’s ability to induce stress in parents cannot be overstated. Parents may be angry, frustrated, depressed, exhausted, or just feel guilty, ascribing their baby’s cries to some parenting fault. 

Defining colic

In 1954, Dr. Morris Wessel first defined an infant with colic as "one who, otherwise healthy and well-fed, had paroxysms of irritability, fussing, or crying lasting for a total of three hours a day and occurring on more than three days in any one week for a period of three weeks." Paediatricians have since defined colic by the “rule of three:” crying for more than three hours per day, for more than three days per week, and for longer than three weeks in an infant who is well-fed and otherwise healthy.

The incidence of colic in breastfed and bottle-fed infants is similar with no difference. Colic is one of the most common reasons that parents seek medical advice for their baby in his first 3 to 4 months of life.

How Is Colic Diagnosed?

Organic causes, although rare (accounting for less than 5% of cases) must always be considered and excluded. Organic conditions to consider can be classified as cardiac, gastrointestinal, infectious, or traumatic. The following physical findings would alert the physician to any of these organic causes:

  • Respiratory distress
  • Bruising and abrasions
  • Extreme irritability
  • Fever and inconsolability
  • Fever in an infant ≤ 8 wk of age

Could it be Gastroesophageal reflux?

Gastroesophageal reflux, also known as acid reflux, is one organic condition, in particular, that can masquerade as colic and present with excessive crying. In his book "Colic Solved," paediatrician, Bryan Vartabedian, postulates that reflux is a common cause of colic. While all babies will reflux from the stomach into the esophagus, only some babies will experience discomfort or other symptoms related to their reflux. Reflux/spitting up tends to peak at age 4 months while colic symptoms seem to start to ease at the four month mark. However, in many cases, parents and doctors may feel that reflux is related to a baby’s fussiness. Thus, particular care must be taken in distinguishing the two conditions. No investigations are required if the history is typical of colic and no abnormalities are found on physical examination.

What Causes Colic?

Several medical and behavioural hypotheses have been proposed as explanations for colic. These medical hypotheses include:

  • food hypersensitivity or allergy
  • immaturity of gut function and dysmotility (abnormal intestinal contractions, such as spasms and intestinal paralysis)
  • alterations in the gut microflora
  • lactose intolerance

Behavioural hypotheses include:

  • inadequate maternal–infant interaction
  • anxiety in the mother
  • difficult infant temperament

The Medical Hypotheses of Colic

Food hypersensitivity or allergy

Substantial evidence supports the hypothesis that infantile colic may be related to food allergy. In these cases, colic may be associated with gas, bloating and even diarrhea.

Trace amounts of blood or stringy mucus may be found in the nappy of an infant with this condition. Approximately 25% of infants with moderate or severe symptoms of colic are allergic to cow’s milk. 

This model of colic focuses on the infant’s immunological response to allergens, such as cow milk proteins found in breast milk or in infant formula as the cause of the colic. 

Several studies including a systematic review demonstrated the efficacy of excluding cow’s milk in nursed infants by excluding cow’s milk protein from the diet of breast-feeding mothers, by using hypoallergenic formulas, and by using casein-hydrolyzed formulas.

Gut motility disorder

Early scientific literature refers to colic as ‘hypertonia of infancy,’ which was thought to be due to hyperexcitability of the parasympathetic nervous system that supplies the gastrointestinal tract and which increases gastrointestinal motility. This concept is supported by the documented beneficial effects of drugs with antispasmodic effects, such as dicyclomine hydrochloride in cases of colic. Also, in keeping with the theory of a gut motility disorder, infants with colic have been shown to have elevated levels of the peptide hormone, motilin, which is secreted by the intestines and acts to stimulate bowel contractions. Motilin is thought to cause hyperperistalsis, leading to abdominal pain and colic.

Alterations in gut microflora

An imbalance of intestinal microflora has also been proposed as an aetiology of infantile colic. ‘Microflora’ are the microorganisms that naturally line the inner surface of the human gastrointestinal system. Lower counts of intestinal lactobacilli have been found in colicky infants compared to healthy ones. An inadequate balance of lactobacilli in colicky infants may be related to immaturity of the gut barrier. In a prospective study, a cohort of 90 breastfed colicky infants was randomly assigned to treatment with the probiotic Lactobacillus reuteri (L. reuteri) or simethicone. Infants in the L. reuteri-treated-group showed significantly reduced crying compared to the simethicone group, supporting the hypothesis that probiotic supplementation may benefit infants with colic.

Lactose intolerance

Lactose intolerance due to a relative deficiency of the lactase enzyme which normally metabolises lactose, a sugar found in milk, has been identified as a possible cause of some cases of infant colic.

Excess lactose in the gut becomes a substrate for the lactobacilli bacteria which are part of the normal gut microflora. Fermentation of lactose by these bacteria leads to production of lactic acid and hydrogen. Rapid production of hydrogen in the lower bowel causes bowel distension which can cause pain.

A recent study found a significant decrease in both crying and breath hydrogen in those infants who were fed with lactase-treated formula, supporting the concept that symptoms could be relieved by reducing the lactose content of a lactose-intolerant infant’s nutritional intake. If a transient lactase deficiency is suspected, treatment usually involves switching to a lactose-reduced or lactose-free formula (for bottle fed babies) or liquid lactase enzyme supplementation (for breastfed babies). 

The Behavioural Hypotheses of Colic

Infant temperament

Colic has also been suggested to be a personality disorder in the child. Colicky infants are often considered irritable and hypersensitive, with a different temperament. However, crying as an individual characteristic lacks stability, which is generally agreed to be a defining feature of temperament. Most studies have found that there is little overlap between the infants who cry a lot during the first 4 months of life and those who cry later in the first year.

Maternal anxiety and psychosocial factors

It is a frequently held view that maternal anxiety may play a role in the development of colic. Some of the older scientific literature attributes colic to handling of the infant by a nervous or anxious person. Some research has demonstrated higher emotional turmoil and tension in the families of children with colic, and implicated maternal depression or emotional tension during pregnancy as factors that increase the risk of infant colic. According to one observational study, colic was associated with maternal anxiety and emotional lability. It has also been reported that the parents of colicky babies have significant psychosocial risk factors, prenatal emotional distress, maternal psychopathology, and postnatal parental conflicts.

Neurodevelopmental immaturity

The neurodevelopmental theory of colic is supported by several observations. The first is that all babies with colic outgrow it, usually by 4 months of age. The second is that soothing strategies which involve a good deal of stimulation (such as rocking, singing, talking, feeding, changing diapers, etc.) usually are counter-productive for colicky babies. In contrast, strategies which involve reduction in stimulation (swaddling, placing in a dark room, “white noise”) tend to be more successful. 

The neurodevelopmental hypothesis has been supported by several studies. In one randomized, controlled trial where the experimental group of mothers were asked to increase the amount of time that they carried their infants by 50%, there was no difference in the duration or frequency of crying or fussing when compared with the control group. This is in direct contrast to the substantial 43% reduction in crying and fussing in response to supplemental carrying found in healthy infants. 

These studies suggest that infants with colic lack the emotional regulatory capacity to self-soothe. This diminished regulatory capacity is attributed to central nervous system immaturity. 

An individualized intervention program, referred to as the “REST Routine for Infant Irritability”(REST Routine), was developed. The program elements evolved out of previous research spanning a 15 year period. The program had two components: the first component consisted of activities directed toward the infant, and the second component was developed for the parents. The four principles guiding the REST routine for infants were: Regulation, Entrainment, Structure and Touch.

The following is a brief explanation of these four concepts, which the intervention nurse uses to form specific recommendations and care plans for the infant at each of the home visits:

  • Regulation refers to the support required to assist these infants in regulating their state behavior and to protect them from becoming overstimulated and exhausted during the first few months of life.
  • Entrainment is the process whereby the infant’s basic sleep-wake cycles was synchronised with relevant aspects of the environment.
  • Structure and repetition were also key concepts of the REST program. The goal was to create a predictable and recurrent pattern of events for these infants who were not intrinsically well-organized.
  • Touch covers various infant holds and positions that were incorporated into the program.

The four concepts of the REST Routine that guided the nurse's intervention in working with the parents were: Reassurance, Empathy, Support, and Time-out. These concepts were individualized and applied in some of the followings ways:

  • Reassurance was focused in two areas; the infant’s health and the parent’s competence.
  • Empathy was provided through listening and acknowledging the challenge of parenting these high-need and high-maintenance infants.
  • Support involved serving as an advocate and resource for parents in obtaining assistance and creating a support network.
  • Time-out legitimised the primary caregiver's critical need to take care of themselves. A specific period of time-out from parenting (at least 1 hour) was scheduled into each day.

The results indicated a consistent pattern of reduction in irritability over time. Both groups showed a decrease in crying over the 8-week study period. However, infants in the REST Routine treatment group cried 1.7 hours less per day at study completion than the control group infants. Not only do the results of this study support the dysregulation theory of colic but the techniques used in the home interventions outline behavioural practices that can be used to treat colic.

How Is Colic Treated?

First and foremost, parents should be reassured that their infant is healthy and that his or her irritability is not due to poor parenting. Parents should be further reassured that the condition is benign and that it will resolve on its own. Physicians should express their understanding of how stressful a colicky infant can be for parents.

Behavioural interventions

Parents should be taught to give more appropriate responses to their infants, including less overstimulation and more effective soothing. At the same time, the parents should be advised not to exhaust themselves and, if possible, to leave their infants with others.

The 5 S's approach

Rhythmic calming techniques are effective in calming colicky babies which forms the core of the "5 S's approach."

1. Swaddling, safe swaddling carefully avoiding overheating, covering the head, using bulky or loose blankets, and allowing the hips to be flexed.

2. Side or stomach positioning (holding a baby on the back is the only safe position for sleep, but it is the worst position for calming a fussy baby);

3. Shhh sound (making a strong shush sound near the baby's ear).

4. Swinging the baby with tiny jiggly movements always supporting the head and neck.

5. Sucking (letting the baby suckle on the breast, a clean finger or a pacifier)

Dietary interventions

For breast-fed infants, a strict cow’s milk-free diet for the mother (with an extra supplement of calcium) may be suggested. According to one study, therapeutic benefit was demonstrated in eliminating dairy products, eggs, wheat and nuts from the diet of breast-feeding mothers.

For formula-fed infants, hypoallergenic formulas, mainly extensively hydrolysed formulas based on casein or whey, are effective in the treatment of infantile colic. 

The ESPGHAN Committee on Nutrition has recommended that soy protein formula not be used in infants with food allergy during the first 6 months of life, stressing that there is no evidence supporting their use in the management of infantile colic.

Herbal formulations

Herbal teas containing mixtures of vervain, camomile, fennel, liquorice and lemon balm have been shown to decrease crying in infants with colic through their antispasmodic activity.

Hypertonic glucose solution

Oral hypertonic glucose and sterile water were compared for treatment of colic in infants in a randomized trial. In the group receiving glucose, 30% had significantly less colic than the placebo group.

Gripe water

Gripe water is an age-old, home remedy for colic that used to be made with dill, baking soda, and alcohol. Modern versions do not include alcohol but may include herbs that settle the stomach or help relax cramping muscles, such as ginger, dill, and fennel. Each gripe water product will have different ingredients. Gripe water formulas often contain one or more of these ingredients: anise, angelica, caraway, chamomile, cinnamon, dill, fennel, ginger, and sodium bicarbonate (baking soda - an antacid). It is typically given to an infant with a dropper in liquid form.

Probiotics

ProbioticsLactobacillus reuteri endogenous to the human gastrointestinal tract was found to relieve colic symptoms in breastfed infants within one week of treatment. This was compared with simethicone, which suggests that probiotics may have a role in treatment of infantile colic. In a more recent study, 50 exclusively breastfed colicky infants were randomly assigned to receive either L. reuteri or placebo daily for 21 days. A 50% reduction in crying time from baseline was noted in the L reuteri group compared with the placebo group.

Pharmaceutical interventions

Simethicone (Mylicon), a safe, over-the-counter drug for decreasing intestinal gas, has been promoted as an agent to decrease colic. A randomized, placebo-controlled, multicenter trial concluded that treatment with this agent produces results similar to those of placebo. Dicyclomine hydrochloride (Bentyl) is an anticholinergic drug that has been proven in clinical trials to be effective in the treatment of colic. However, because of serious, although rare, adverse effects (eg, apnea, breathing difficulty, seizures, syncope), its use cannot be recommended. In Italy, cimetropium bromide is used extensively to treat infantile colic. According to one study, it was more effective than placebo in the treatment of infantile colic.

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