COLIC Every Parent’s Nightmare

1. COLICEvery Parent’s Nightmare Michael Martin, MD

2. Objectives • Be able to define colic AND know it when you see it • Be familiar with the other diagnoses that might resemble colic • Know both medical and behavioral treatments that are available

3. Is this Colic?

5. Why Cry? • Crying • normal primitive protective reflex • serves as an alarm to alert parents to problem and get their attention  Crying tends to assure “parental investment” in the infant • “attachment behavior” • Other potential reasons: • Ward off predators • Nutrition (frequent feeding)

6. Why Cry? • Colic – when cry is excessive without an identifiable need

7. Background • Other Animals • Infant chimpanzees • Crying peaks in 2nd month of life • only manifest in nonhuman infants if separated from parent • Other Cultures • !Kung San hunter gatherers of Botswana • Constant skin-to-skin contact, frequent moving with the infant in a sling (or kaross), “continuous” feeding (every 15 min for 1 to 2 min per feed), upright posture, and caregiver responds to every fret and whimper within 10 seconds • Frequency of crying is the same as in Western infants, but the duration is reduced about 50% • 90% of the time, !Kung parents can calm their crying baby within 30 seconds

8. Working Definition • Infant cries more than 3 hours per day, and more than 3 days per week, and for more than 3 weeks (Wessel Criteria) • Also known as the rule of 3’s

9. Why should you care?Associated Risks • Increased risks of breastfeeding failure • Postpartum Depression • Martial Conflict • Higher rates of child abuse

10. Background • Between 16% and 26% of all infants experience colic • No predilection for race, ethnic groups, sex, socioeconomic grouping • Temporal Pattern: • Excessive crying begins at 2 weeks of age • Peaks at 6 weeks • Decreases by 8 weeks • Resolves completely by 16 weeks • Premature infants experience colic 2 weeks past due date

11. Presentation • Episodic crying spells UNRELATED to feeding • Pattern is diurnal, with increased crying in the evening and night • Note: All infants experience crying episodes in the evening that peaks at 6 weeks of age • Physical signs (usually described by parents) • Infants draw up their legs while they cry • Tense abdomens • Arch their backs (parents describe them as “gassy”)

12. EtiologyTheories Anyone? • Maternal Anxiety • Difficult infant temperament • Brain Immaturity • GI disorders • Gas and cramps • Aerophagia • Food intolerance • GERD

13. Diagnosis • Physical Examination – NORMAL! • Must rely on history taking • Gastroesophageal reflux (GER), which can present with increased crying, often is suggested as causing colic • only 2% to 4% of infants who have symptoms of colic have been shown to have GER • Formula intolerance such as cow milk allergy often implicated but is associated with additional symptoms: • emesis, diarrhea,blood in the stool, severe eczema, or urticaria • THIS IS A DIAGNOSIS OF EXCLUSION!

14. Management

15. Management • Common books for parents that admit that for really fussy babies they have little to offer: • “Very often, you may not be able to quiet the screaming.”What to Expect the First Year • “It’s completely all right to set the baby in the bassinet while trying to drown out the noise with the running water of a hot shower.” The Girlfriend’s Guide to Surviving the First Year of Motherhood • “The whole episode goes on at least an hour and perhaps for three or four hours.”Your Baby and Child

16. Management-Traditional Medical Approaches- • Simethicone (Mylicon) – RCT does not show superiority to placebo • Dicyclomine (Bentyl) and Hyoscyamine (Levsin) • Anticholinergic (antispasmodic) • Has demonstrated reduced time of crying • AE: Sedation, apnea, seizures, and coma (contraindicated in those under 6 months old) • Dietary changes for a breastfeeding mother or multiple formula changes have not been shown to have benefit

17. Management • Behavioral: Tight swaddling, rapid swinging or jiggling motion, nonnutritive sucking, and steady loud white noise such as “hushing.” • Combining these techniques may calm both caregiver and infant • Holding the infant for more than 3 hours daily has been shown to decrease the intensity of the cry but not the duration

18. Management • Behavioral: The Happiest Baby on the Block • Swaddling • Side/Stomach • Shushing (white noise) • Swinging • Sucking

19. Management-Complementary Medicine • Herbal tea mixture: chamomile, vervain, licorice, fennel, and balm mint in a dose of 120 mL given TID • improved colic in one RCT • Risks: large volume of tea potentially could cause poor caloric intake and hyponatremia • Fennel Seed Oil • 1 RCT study (125 infants) showed benefit • may cause allergic reactions of the skin (rashes) and respiratory tract (asthma and breathing difficulties), seizures • Probiotics • trial of Lactobacillus reuteri compared with simethicone in the treatment of infantile colic • 95% of the probiotic treatment group were considered “responders” (ie, no longer met Wessel criteria) compared with only 7% of the simethicone group • Bacteremia/septicemia, pneumonia, and meningitis have been documented in immunocompromised and severely debilitated patients in other studies

20. Time heals all……..