Archive | September 2013

Infantile Colic

Infantile Colic
Guest post by Betula Lenta, MD

 

       All infants cry. It is a baby’s major means of communication with her caregivers in the first few months of life. Crying can mean, “I’m hungry,” “My diaper is dirty,” or simply “I’m tired and over-stimulated and don’t know what to do about it!” An average infant cries for almost 2 hours a day during the first two months of life. So when is crying too much? When does normal crying cross the line and become colic?

 

In 1954 Dr Wessel defined colic as crying for more than 3 hours per day, 3 days per week for at least 3 weeks. (1) In practice, colic can be used to describe an infant who cries inconsolably for no apparent reason. Most caregivers feel that crying associated with colic is different from “normal” crying, often being more high-pitched and frantic. The baby frequently stiffens, drawing the legs and arms in to the body. The episodes also cluster in the evening and nighttime hours. Colic is a diagnosis of exclusion, meaning that other causes of inconsolable crying need to be ruled out before saying that a baby has colic. Some such causes are a broken bone, infection, hair tourniquet (rare situation in which a hair becomes very tightly wrapped around a digit or the penis), foreign body in the eye, gastro-esophageal reflux, heart anomalies, metabolic disorders or intestinal structural anomalies. Any inconsolable crying associated with fever, green-tinged or forceful vomiting, bloody stools, markedly decreased urine output, a distinct change in feeding or difficulty breathing should be evaluated by a physician.

 

Infantile colic is extremely common, occurring in up to 19% of otherwise healthy babies. Symptoms usually start at 3 weeks of age, peak at 6 to 8 weeks, and resolve by 3 months. Colic occurs at the same rates in male and female infants and across all racial groups. It also occurs at approximately the same rates in both breast and formula fed babies. (2, 3) Colic does not seem to have any lasting negative effects on infants. Babies with prolonged colic, or symptoms lasting beyond 6 months, are more likely to be diagnosed with a food allergy, but this only occurs in a very small percentage of affected babies. (3) Colic can cause significant stress for already tired caregivers and can be associated with earlier weaning, increased rates of postpartum depression, and increased rates of child abuse.

 

Despite its prevalence, the cause of colic remains unknown. Caregivers generally feel that colicky babies are experiencing abdominal pain or excess intestinal gas. Many researchers have looked for a gastrointestinal cause of colic such as milk protein intolerance, food allergies, gastro-esophageal reflux, excess gas and intestinal dysmotility. (4) These studies have not shown a consistent cause. Other researchers examined family stress as a cause of infantile colic, but while colic can heighten family tension it is not necessarily caused by stress. More recent studies examined differences in types of bacteria colonizing the intestinal tracts of infants as a way to explain the symptoms of colic, but much more research is needed in this area. (5)

 

Since the cause of colic remains unknown, there is no simple universal treatment. Swaddling and rocking a baby are some of the simplest interventions and can be very effective. It is important to leave babies some freedom of movement at the hips when swaddling because excessively tight swaddling around a baby’s legs can put too much pressure on the hips. Also, it is not recommended to continue swaddling a baby after two months or when she starts attempting to roll over. Never lay a swaddled baby face down because it significantly increases the risk of suffocation. Sometimes taking a crying baby for a short car ride or walk can lull him to sleep. Other caregivers put on soothing music or white noise in the form of the vacuum or clothes dryer. Overfeeding a colicky baby can actually exacerbate the problem, so pacifiers can also be helpful and help some babies to self-soothe. Finally, abdominal massage, or gently rubbing a baby’s abdomen in a clockwise direction, can soothe a colicky baby.

 

Many caregivers alter a baby’s diet to decrease gas and symptoms of colic. Some gas-provoking compounds can pass through breast milk and affect the baby. A breastfeeding mother of a colicky baby can keep a food and symptom diary to determine which foods could potentially be making the baby uncomfortable. Another option is to eliminate some more common culprits. Foods in the Brassicaceae (Mustard family) such as cabbage and broccoli are often thought to increase colic symptoms. Caffeine and chocolate can also pass through breast milk and cause a baby to be fussier. Other potential triggers include dairy, soy, wheat, peanuts, and eggs. It is not necessary for a breastfeeding mother to eliminate all of these foods from her diet, but a trial elimination for a few days can help her identify problem foods.

 

For formula fed babies, a simple change in formula can alleviate symptoms. Several large trials have examined formula change and its effects on symptoms of colic. In general, changing from a cow milk formula to a soy formula can decrease the symptoms of colic, but there are concerns regarding the phytoestrogens in soy formula and future development. Switching to a hypoallergenic formula (formula in which the proteins have been extensively broken down) also seems to help the symptoms of severe colic. However, hypoallergenic formula is significantly more expensive than cow milk formula and it is not clear that it alleviates the symptoms of more mild colic. (6) Many formula brand names include such words as “soothe” or “gentle” because the proteins are slightly more broken down than in standard cow milk formula. Caregivers often feel that their babies do better on these formulas, but there is no evidence to support their routine use. Recently, researchers have begun to look at ways to alter a colicky infant’s intestinal flora to reduce the amount of gas-producing bacteria in the intestines. Many infant formulas now contain probiotics, or bacteria that promote intestinal health. Recent studies have also looked at Lactobacillus spp supplementation to improve colic symptoms in breastfed babies. These probiotics have been shown to be very safe and effective in otherwise healthy infants. (7)

 

The most commonly recommended pharmaceutical treatment for colic is simethicone (Mylicon), which is available without a prescription. Simethicone theoretically breaks up gas bubbles in the intestine, but several trials have demonstrated that it is no better than placebo in reducing symptoms of colic. (6) Some babies are also given medications to reduce gastric acid (ranitidine or omeprazole), but since colic is usually not due to gastro-esophageal reflux these medications are not generally effective. Even in the case of reflux, feeding a baby upright and burping her well after feeds is more effective with fewer potential side effects than using medication.

 

Many herbs have been used traditionally for infantile colic. In general herbs for colic have carminative or calming effects. A carminative is an herb that removes gas from the intestines thereby relieving discomfort. The simplest way to give herbs to a baby is by a standard infusion or tea. Pour one cup of hot water over one teaspoon of dried herb and steep for ten minutes. Strain and give directly to the baby when it cools to an appropriate temperature. Babies can drink tea from a dropper, medicine cup, or bottle. It is not necessary to sweeten the tea, and it is important not to give honey to infants under 12 months. A starting dose of tea is one ounce of standard infusion three times a day. This amount can be increased, but excessive intake of tea could potentially affect a baby’s appetite and milk intake. Another option is for a breastfeeding mother to drink one cup of the tea three times a day so that the active constituents pass through the breast milk to the baby. Finally, many herb extracts in glycerin are available commercially and can be given directly to the baby.

 

One of the most commonly used herbs for colic is fennel (Foeniculum vulgare, Apiaceae). The seed has carminative properties and can reduce intestinal spasms while aiding digestion. (8) Nursing mothers can also find it helpful to drink fennel seed tea because it stimulates milk production. An extract of the seed is used in many commercial “gripe water” preparations, often in combination with other herbal extracts. Several clinical trails of fennel seed extract or tea blends have consistently shown a decreased duration of crying in colicky infants. (9)

 

Other popular herbs for colic are chamomile flower heads (Matricaria recutita, Asteraceae) and lemon balm leaves (Melissa officinalis, Lamiaceae). Both herbs are carminatives and decrease intestinal spasms. They are both relaxing to the nervous system and can help ease tension and anxiety. Lemon balm additionally has some anti-depressant effects, and can also aid a potentially stressed mother of a colicky infant. Aviva Romm recommends “tummy ease” tea for colic consisting of a standard infusion of equal parts fennel, lemon balm and chamomile. (10) David Hoffman additionally suggests catnip (Nepeta cataria, Lamiaceae) and linden flowers (Tilia spp., Malvaceae). Both help ease tension and relax the nervous system. Linden also helps ease intestinal spasms and is generally calming. (8) Other useful herbs are ginger root (Zingiber officinale, Zingiberaceae) and peppermint (Mentha piperita, Lamiaceae). They are both classic herbs for indigestion, safe in children, and readily available.

 

Many other botanical blends are available for colic. A popular European tea blend includes fennel, chamomile, lemon balm, licorice (Glycyrrhiza glabra, Fabaceae), and vervain (Verbena officinalis, Verbenaceae). Several herbal extracts of fennel, chamomile, and ginger are widely available in the United States. My preference is to use simple manipulation of maternal diet combined with infusions of fennel, chamomile, and lemon balm or whichever herbs the family has on hand. The mother can also drink the teas for their calming and soothing effects. These interventions along with swaddling and gentle rocking can be extremely effective.

 

Colic is not the same for every baby, and caregivers should use what works best for them and their infant. Above all it is important for caregivers to maintain a sense of calm. Infants can sense tension, and this can increase their crying and distress. If the caregiver is feeling overwhelmed by the crying, it is okay to put the baby safely in her crib, walk away, and take a deep breath. Emotional support from a grandparent, family member or trusted friend can also be immensely helpful. Colic is extremely stressful. Relax, drink a cup of lemon balm, give an ounce to the screaming baby, and remember that it will get better.

 

References

  1. Wessel MA, Cobb JC, Jackson EB, Harris GS, Detwiler AC. Paroxysmal fussing in infancy, sometimes called colic. Pediatrics 1954;14:421-434.

  2. Lucassen PL, Assendelft WJ, van Eijk JT, Gubbles JW, Douwes AC, van Geldrop WJ. Systematic review of the occurrence of infantile colic in the community. Arch Dis Child. 2001;84(5):398-403.

  3. Hide DW, Guyer BM. Prevalence of infant colic. Arch Dis Child. 1982;57(7):559-560.

  4. Barr RG, Rotman A, Yaremko J, Leduc D, Francoeu TE. The crying of infants with colic: a controlled empirical description. Pediatrics. 1992;90:14-21.

  5. de Weerth C, Fuentes S, Puylaert P, de Vos WM. Intestinal microbiota of infants with colic: development and specific signatures. Pediatrics. 2013;131:e550-e558.

  6. Garrison MM, Christakis DA. A systematic review of treatments for infant colic. Pediatrics. 2000;106:184-190.

  7. Savino F, Cardisco L, Tarsco V, Palumeri E, Calabrese R, Oggero R, Roos S, Matteuzzi D. Lactobacillus reuteri DSM 17938 in infantile colic: a randominzed, double-blind, placebo-controlled trial. Pediatrics. 2010;126:e526-e533.

  8. Hoffman D. Medical Herbalism. Rochester: Healing Arts Press. 2003.

  9. Rosen LD, Bukutu C, Le C, Shamseer L, Vohra S. Complementary, Holistic, and Integrative Medicine: Colic. Pediatrics in Review. 2007;28:381-385.

  10. Romm A. Herbs for Kids. www.avivaromm.com. 2012.

Advertisements