Our new series provides an evidence-based lowdown on common presentations using PUNS and DENs. Dr Chris Barry kicks it off with a look at colic
The patient's unmet needs (PUNs)
A distressed young mother presents in the afternoon emergency surgery with her two-month-old child. The mother is very upset and says: ‘He just won't stop crying.' For the last two weeks, the baby has spent a large part of the afternoon and evening in apparent distress and, despite her best efforts, she's been unable to settle him.
Otherwise he seems well, with no vomiting or other symptoms, and examination is normal. You start to explain that you think the baby has colic, but she interrupts: ‘That's what the other doctor said, but you've got to give him something.'
The doctor's educational needs (DENs)
What is the prevalence and prognosis of infant colic? Are some babies at particular risk of this problem and if so, why?
Colic is common – it affects around one in five babies, equally in both sexes. Onset is usually within the first few weeks of life.
It typically lasts for three to four months and should certainly have resolved by six months of age. Crying is most common in the evenings, although it is by no means confined to that time of day. There is no generally recognised cause, but some authors say it is more common in bottle-fed babies and there is anecdotal evidence that avoidance of dairy products gives relief.
One American study of 48 infants suggested an association with family tension in 22 of the babies, allergy – presumably to cow's milk – in six, both together in nine, and no apparent cause in 11. But this study was published in 1954. Another study from 1983, referred to in NHS Choices, was a crossover trial of 66 babies whose mothers were given a cow's milk-free diet, followed by reintroduction of cow's milk protein. Of the 10 babies remaining at the end of the study, attacks of colic returned in nine babies when the cow's milk protein was reintroduced.
But since colic resolves spontaneously and often very quickly, it is probably not right to generalise too much.
How can GPs make a confident diagnosis? What other diagnoses should be excluded?
There is no test that confirms colic, so in most cases the diagnosis is by exclusion.
The NICE guideline on postnatal care1 advises urgent assessment of infants with colic. It is important to exclude other causes, such as intestinal obstruction due to Hirschsprung's disease or a hernia.
Take a history that includes onset and length of crying, nature of the stools, the mother's diet if she is breastfeeding and any family history of allergy. Perhaps most importantly, you should consider the parents' response to the crying – in this case, the mother is very upset by it.
Is the problem actually anything to do with bowel colic? If not, then what is thought to be the source of the distress?
The theory that colic is related to bowel spasm is – as far as I know – untested.
There is anecdotal evidence that excessive tea, coffee, alcohol or spicy foods in the mother's diet may have an effect. Rather than recommending a blanket exclusion on these foods and drinks, ask her to consider those possibilities and maybe to experiment by cutting down on them.
Many parents, grandparents and health visitors suggest a change of milk – is there any evidence that this helps? If so, what sort of milk should be advised, and why?
The NICE guideline does say that the use of hypoallergenic formula feeds should be considered, but used ‘only under medical guidance'. True lactose intolerance is rare in babies with colic, and they would need a paediatric assessment to confirm or exclude it. On a simpler level, if the mother hasn't already done so it may be worth using different teats on the bottles to alter the rate of flow. The health visitor will be key in advising on this. It has been suggested that babies could benefit from lactase drops – they are mentioned on the NHS Direct website, which is a useful and reliable resource.
Have any specific medical treatments been shown to be beneficial?
Good, old-fashioned simeticone seems to have little or no evidence behind it, but it is hard to see what harm it might do. NICE guidance doesn't mention simeticone, but it does say that dicycloverine (dicyclomine) should not be used because of side-effects including breathing difficulties and coma. In this patient's case, you have a distressed mother as well as a crying baby. Given the shortage of medical interventions on offer, it is important consider both individuals.
NICE guidelines say we should reassure parents that the baby is not rejecting them and that colic is usually a phase that will pass. They also suggest advising parents that holding the baby through the crying episode and accessing peer support may be helpful – although we all know that this may be easier said than done. Obviously, you will need to consider postnatal depression, but most commonly the mother will simply be exhausted and feeling inadequate because she is unable to comfort her baby.
My personal approach here is to remind her that holding and cuddling the baby will still be of comfort, whether or not the crying continues. If – as is likely – colic is a painful condition, the baby may well continue to cry until the pain has passed, which it will. So she should be reassured that she is still being a good mother, and while a cuddle may not stop the crying she is helping her baby. A warm bath might be of help, and will give parents something to do as the crying episode passes.
Key points
• Colic is common but harmless
• Parents should understand that it is a self-limiting condition, and that usually the best thing to do is comfort the child however they find works best
• The Department of Health's Birth to Five guidance2 and the NHS Direct website3 offer useful advice for parents
• Probably the most important role for the GP is to consider the family's support systems, and to direct them to local resources, such as health visitors, National Childbirth Trust groups or other postnatal groups locally
Dr Chris Barry is a GP in Wiltshire and was a member of the guideline development group for the 2006 NICE guideline on postnatal care
The patients' unmet needs (PUNs) and doctors' educational needs (DENs) system of personal learning was developed by Dr Richard Eve, a GP in Taunton
References
1 NICE. Postnatal care: routine postnatal care of women and their babies. Clinical guideline 37. July 2006
2 Department of Health. Birth to Five. October 2009
3 NHS Direct. 2011. www.nhsdirect.nhs.uk
