“Cracking the Colic Code: Insights into Infantile Colic and Effective Solutions”
Q-1-month-old baby comes to you for excessive crying. Her mother told that she was well and accepting feed, passing urine and stool till 2 weeks. Crying start usually in the late afternoon and in the evening. The duration of crying was usually 2 to 3 hours. The rest of all day baby was OK. The episode of crying is 3 to 4 days in a week. What is diagnosis and treatment?
Infantile Colic
• Infant colic usually begins by 2 to 3 weeks of age, peaks by 6 weeks, and resolves by 3 months.
• There is no sex predisposition
Five etiological theories of Infantile colic:
cow milk/ soy protein allergy/ intolerance;
immature gastrointestinal system,
immature central nervous system,
difficult infant temperament and
parent-infant interaction problem
CLINICAL PRESENTATION
The classical presentation is an over-anxious parent with an inconsolable infant Parents usually explain that the colicky cry is different from other cries and describe these cries seems to be more urgent, piercing, and making them feel that baby is in pain. These cries are usually associated with hypertonia, facial flushing, withdrawal of legs towards the abdomen, and flatulence. The crying starts and stops abruptly
Behavioral Modification and Parental Counseling
Behavioral modification is usually considered first-line therapy as it is not associated with any side effects and is cost-effective.
Proper counseling: explaining the normal crying pattern of infants, encouraging them and helping them to build confidence as parents, encouraging continuing breastfeeding, and infant calming techniques.
Techniques to calm a crying baby should be taught to parents. One such technique is the 5S technique which includes Swaddling, Side/ stomach, Shh-sound, Swinging the baby with tiny jiggly movements, and Suckling (letting the baby suckle on breast/ clean pacifier). Other techniques of infant calming include the use of white noise, minimal handling, and simulating car rides.
Dietary Modification
Lactase supplementation:
Lactase supplementation as a dietary intervention is undergoing tremendous research. some studies have shown the effectiveness of lactase supplementation, no strong evidence has been shown which would help in formulating guidelines.
Probiotic supplementation:
The supplementation of probiotics in infants with colic is based on the etiological theory that colic is due to altered gut flora.Role of probiotics in both the prevention and treatment of colic is under evaluation. Other strains of Lactobacillus and Bifidobacter have also been used but the scientific evidence is limited.
Hydrolyzed infant formula/infants with cow milk allergy (CMA):
sometimes Cowmilk allergy can manifest as colic. infants with cow milk allergy, dietary modification is recommended. In exclusively breastfed infants with CMA, breastfeeding should be continued but all forms of milk products should be restricted from the mother’s diet. In a mixed-fed infant with CMA, the baby should be given only breastfeeding and no restriction of maternal diet is required. In a formula-fed infant with CMA, the extensively hydrolyzed formula should be considered. Soy-based formulas are not recommended for infants less than 6 months.
Fermented formula with oligosaccharides:
Few studies support that the infantile colic was less in the group fed with fermented formula along with oligosaccharides (short-chain galactooligosaccharides and fructo oligo ) as compared to the group which was fed either with fermented milk or oligosaccharides alone. More study is needed on the use of fermented formula with oligosaccharides.
Pharmacological Intervention
It was found that Simethicone had no role in decreasing the symptoms of colic.
Herbal medications decreased the symptoms of colic but were associated with side effects.
Dicyclomine and cimetropium are used in colic based on the etiological theory that pain in the gut is due to immaturity of the enteric nervous system which leads to spasms in the intestine.
Dicyclomine and cimetropium are smooth muscle relaxants that act on the cholinergic and muscarinic receptors, respectively, and cause smooth muscle relaxation. The use of dicyclomine is associated with side effects like breathing difficulty. Therefore, it is not recommended in children less than 6 months.
Other agents like cimetropium, dicyclomine, and sucrose had very low-quality evidence for use in colic. Thus no recommendation could be made on the effectiveness of pain-relieving agents for the treatment of colic.
The use of gripe water is common in our country. the most common belief was that it helps in digestion and decreased abdominal pain. Present-day gripe water is alcohol-based. In infants, it is not recommended as there are no proven health benefits, and the use of pre-lacteal feed in infants is not recommended by WHO.
A presumptive diagnosis of GERD in excessively crying infants and the use of proton pump inhibitors are also not recommended. If a strong possibility of GERD is kept, then proper recommended investigations should be done before starting any acid suppression medication.