The challenge of infantile colic lies both in its obscure pathogenesis, and therefore treatment, as well as its seemingly spontaneous evolution and subsequent resolution. It is a clinical entity characterised by paroxysms of inconsolable crying in an otherwise healthy infant, typically beginning in the first weeks of life and by the ‘rule of three’. The symptoms last approximately three hours per day, occur more than three days per week for a period of at least three weeks.1,2 In the majority of cases, infantile colic is self-limiting and subsides by the age of four months.3 Despite its benign nature, it can result in considerable frustration and distress for infants, and parents often seek medical advice in desperation.4
A thorough history, combined with a meticulous physical examination, usually suffices in establishing the correct diagnosis and guiding the formation of an appropriate plan of action. Not only is this critical to limiting inappropriate and unnecessary investigation and treatments, but it is of significant importance to prevent potential unfavourable sequelae, which include parental distress and exhaustion, disturbances in the parent-child bonding, premature termination of breastfeeding along with earlier than recommended weaning to solid foods.5
Standard current treatment
The main aim of treatment is to decrease the frequency, duration and intensity of the infant’s fussiness, and strengthen the relationship and interaction between baby and parents.6,7 Management strategies for infantile colic have been the focus of both NICE guidance and drug and therapeutics bulletins in the last two years.5,8
First-line interventions include the following:5,8
• Reassurance to the family that their child is healthy and well
It is imperative that you adequately explain to the parents that colic is a common and benign condition of infancy that lasts only for a short period of time. It is also essential that you highlight that symptoms do not indicate that the parents are following an inappropriate approach, nor that their baby is rejecting them.
• Implementation of strategies to soothe the baby
Examples include holding the baby during the crying episode, use of a pacifier, gentle motion of the baby in its buggy or cradle, and providing a warm bath.
• Provision of robust and easily accessible parental support
This is one of the pillars of the management of infantile colic. The parents should be advised not to ignore their own needs and well-being. Receiving help from other members of the family, relatives, family and friends or health visitors is crucial for the parents to be able to take a break. Such approaches with parental guidance and support have proven to be very beneficial in the overall management of colicky babies.9-12 Meeting other families with babies of a similar age and exchanging experiences with their parents could also prove of invaluable help.13 A national telephone helpline (CRY-SIS, available daily from 9am to 10pm) is also available and dedicated to supporting families with children displaying excessive crying, sleeplessness and demanding behaviour.
• Modifications in the feeding technique Alteration to the feeding technique of bottle-fed babies may be considered.14 For example, bottles with collapsible bags can decrease the amount of swallowed air. A consultation with a lactation specialist to support and further guide the mother of a breastfed colicky baby may also be warranted.
Second-line approaches should be considered only in more challenging cases, where parents report inability to cope with their babies’ symptoms despite receiving sufficient guidance, support and reassurance together with frequent follow-up.5 Such interventions include the following:5,8
• A trial for one week of simeticone drops for both breastfed and bottle-fed infants.
• A trial for one week of lactase drops for both breastfed and bottle-fed infants.
• A trial for one week of dietary modification, consisting of a dairy-free diet for the mothers who breastfeed, or starting a hypoallergenic (extensively hydrolysed) formula for babies who are bottle fed.
The aforementioned treatments should only be continued if there is a clear improvement in the infant’s symptoms. Gradual discontinuation, over approximately one week, of a successful treatment can be attempted after the age of three months and should be complete by the age of six months at the latest.
Although there are many studies of interventions for infantile colic, most are of poor methodological quality, making it difficult to evaluate the effectiveness of any of the above treatments.
Lactase preparations for the treatment of infantile colic
Liquid, lactase 50,000 units/g (dropper bottle).
For dosage and administration details consult product literature and manufacturer’s recommendations
NICE’s clinical knowledge summary for infantile colic suggests a one-week trial of lactase for infants of parents who find it difficult to cope despite adequate advice and reassurance. Provided that the diagnosis of infantile colic is secure, NICE CKS does not recommend any additional work-up prior to initiation of this treatment
Source: BNF for Children, 2014
What’s newly available
A number of new agents and interventions remain under investigation for their potential therapeutic effect. Probiotics, nepadutant, baby massage, manipulative/chiropractic techniques and acupuncture may offer additional therapeutic options in the future. However, the paucity of robust published data, along with conflicting results and methodological limitations of the relevant studies, preclude a recommendation for generalised application in everyday clinical practice.15-27
What has fallen out of fashion and why?
Soy protein-based formulas are not recommended given the possibility of allergic reactions, and also concerns regarding their content of phytoestrogens.8 Herbal and homeopathic preparations are also not recommended, including gripe water,
as their efficacy is disputed and there is a lack of standardisation and control in their preparation (for example, to stop contamination with toxins and unlabelled substances).28-33
Anticholinergic agents, such as dicyclomine hydrochloride, cimetropium bromide, have been studied in infantile colic, but demonstrated severe adverse effects and are not licensed in the UK.8
Swaddling has also fallen out of fashion as it can lead to hip dysplasia, overheating and sudden infant death syndrome if the baby is positioned to lie prone.8
The use of sucrose solutions for symptomatic relief should also be avoided for reasons similar to those described for herbal remedies.8
Special consideration is required for infants treated for congenital hypothyroidism, as simeticone can interact with thyroxine and lead to potential under-treatment.
Caution is required if using ‘white-noise’ generators for auditory soothing, as they can be louder than those safely recommended.34
Referral to a specialist should be considered in the following cases:5
• The parents cannot cope despite appropriate interventions.
• If there are red flags such as poor weight gain, excessive regurgitation or vomiting, constipation.
• The treatment for infantile colic cannot be stopped after the age of six months.
Two simeticone preparations for the treatment of infantile colic
Colic drops (= emulsion), simeticone 21mg/2.5ml solution.
Dose (by mouth):
• Neonate – 2.5ml with or after each feed (maximum of six doses in 24 hours). May be added to bottle feed.
• Child aged one month to two years – 2.5ml with or after each feed (maximum of six doses in 24 hours). May be added to bottle feed.
Note: The brand name Dentinox is also used for other preparations including teething gel.
Liquid, sugar-free, simeticone 40mg/ml (low Na+). Counselling, use of dropper.
Dose (by mouth):
• Neonate – 0.5-1ml before feeds.
• Child one month to two years – 0.5-1ml before feeds.
Source: BNF for Children, 2014
As outlined, the mainstay of treatment is advice, support and reassurance, along with simple techniques to alleviate infants’ discomfort during episodes of irritability. Pharmacological intervention is considered as a second-line treatment and is reserved for cases that do not respond to first-line approaches, or where parents experience significant difficulties in coping.
Dr Nikhil Thapar is an honorary consultant and senior lecturer in paediatric gastroenterology at Great Ormond Street Hospital, London
Dr Efstratios Saliakellis is a senior clinical fellow in paediatric gastroenterology at Great Ormond Street Hospital, London
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