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Indian Pediatr 2018;55:979-987 |
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Infantile
Colic: An Update
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J Murugu Sarasu, Manish Narang and Dheeraj Shah
From Division of Pediatric Gastroenterology,
Hepatology and Nutrition; Department of Pediatrics, University College
of Medical Sciences and Guru Teg Bahadur Hospital, University of Delhi,
Delhi, India.
Correspondence to: Prof Manish Narang,
Department of Pediatrics, University College of Medical Sciences and
Guru Teg Bahadur Hospital, University of Delhi, Delhi, India.
Email: [email protected]
Published online: June 13, 2018.
PII:S097475591600124
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Context: Infantile colic is
self-limiting condition but it can be a cause of anxiety for parents and
challenge for doctors. The challenge for the doctors lies in correct
identification of the condition and appropriate management. The
objective of this review article is to summarize the pathophysiology,
treatment options and outcome in infantile colic so that clinicians can
have a fair idea about the condition, recent updates and future
prospects.
Evidence: A search of the
Cochrane Library, PubMed, and Google Scholar was made using the key
words "Infant colic", Infantile colic", "excessive crying in infants".
All the materials were analyzed and summarized.
Results: At present, infantile
colic is an area of clinical research both in terms of etiology and
treatment. Various etiological theories have been proposed but none of
them are strong enough to completely describe the condition. Various
treatment agents are being tried for colic like counseling and
behavioral modification, dietary modification, lactase and probiotic
supplementation, pain relieving agents, and chiropathy. Proper
counseling of the parents is the first line of management at present.
Simethicone has no role in decreasing the symptoms of colic and
Dicyclomine is not recommended in children younger than six months. No
specific recommendations have been made on the use of pain relieving
agents and manipulative therapies in colic. At present strong evidence
is lacking regarding the use of probiotics, lactase supplementation and
dietary modification.
Conclusion: Counseling of
parents about the benign nature of the condition is considered first
line for now until an effective treatment is established. Other
treatment options are prescribed on a case-based manner, and based on
the parental perception of the condition.
Keywords: Counseling, Crying, Lactase,
Management, Probiotics.
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C rying is an essential behavior to communicate the
demands of the baby so that it can be fulfilled by the caregiver. Crying
is a good signal that child is in need but a poor signal of what the
child needs. Prolonged crying or fussing, particularly unsoothable
crying is a source of anxiety and distress for the parents, and
challenge for the doctor. Infant colic is a diagnosis of exclusion for
prolonged cry in early infancy. It is described as compulsive and
paroxysmal crying or fussing with multi-factorial etiology. It is
considered as a behavioral syndrome of early infancy and a normal
variant of crying curve in infancy [1].
Definition
The classic definition of infant colic was given in
1954 by Wessel [2], who described colic as a condition occurring in an
otherwise healthy, well-fed infant with crying or fussing for more than
three hours a day, for more than three days a week and for more than
three weeks. The need for modification of Wessel’s criteria was realized
later because it was not practical to ask parents to wait for three
weeks to arrive at a diagnosis. Hence modified Wessel’s criteria was
given in which the duration of symptom was reduced from three weeks to
one week. But this definition failed to address the benign nature of the
condition and babies were referred to experts in view of excessive
crying. To avoid unnecessary diagnostic and therapeutic misadventures
the need for recognition of colic as a functional disorder was felt and
thus infant colic was classified as a functional gastrointestinal
disorder (FGID) under Rome diagnostic criteria (ROME) III criteria. FGID
comprise of chronic/ recurrent symptoms that occur in the absence of any
anatomic abnormality/ inflammation or tissue damage. The ROME III
criteria for infant colic is for infants from birth to four months and
must include paroxysms of irritability, fussing/crying that starts and
stops without any obvious cause, episodes lasting three or more hours a
day, occurring three days a week for at least one week and no failure to
thrive [3]. But soon the flaws in ROME III criteria were recognized. The
three-hour cut-off for crying or fussing was arbitrary and an infant who
cried for 2 hours and 50 minutes was no different from an infant who
cried for three hours a day. Moreover crying peaks by five to six weeks
of age and a three hour cut off for a four month baby for whom the peak
has already occurred was not correct. Also maintaining a Cry-record for
seven days was practically not possible for most parents. Thus the ROME
IV criteria was given in 2016, in which diagnostic criteria was given
for clinical purpose and additional criteria was given which had to be
satisfied for research proposes [4]. The ROME IV criteria are "An infant
who is less than five months of age when symptoms start and stop;
recurrent and prolonged periods of infant crying, fussing or
irritability reported by caregivers that occur without any obvious cause
and cannot be prevented or resolved by caregivers; no evidence of infant
failure to thrive, fever or illness" [4]. Here "fussing" refers to
intermittent distressed vocalization and has been defined as "
(behavior) that is not quite crying but not awake and content either"
[4]. Infants often fluctuate between crying and fussing, so that the two
symptoms are difficult to distinguish in practice. For
clinical research purposes, a diagnosis of infant colic must meet the
preceding diagnostic criteria and also include: Caregiver reports infant
has cried or fussed for three or more hours per day during three or more
days in seven days in a telephone or face-to-face screening interview
with a researcher or clinician, and total 24-hour crying plus fussing in
the selected group of infants is confirmed to be three hours or more
when measured by at least one prospectively kept, 24-hour behavior diary
[4]. Thus colic is a disease of well thriving infant with
no underlying disease.
Salient features of ROME IV criteria are that instead
of using the duration of crying for diagnosis, it considers the crying
behavior which causes distress to parents, and provides separate
criteria for clinical use and research (Table I). Even
though the classical three-hour cut-off is considered arbitrary and not
used for clinical criteria, this has been retained for research purpose.
TABLE I Major Differences Between ROME III and ROME IV Criteria For Infantile Colic
Criteria |
Rome III [3] |
Rome IV [4] |
Age limit range for diagnosis |
Birth to 4 mo |
5 mo |
Main focus for diagnosis |
Relied mainly on duration of crying (atleast
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Crying/fussing which cause distress to parents
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3 h/d for atleast 3 d/wk for atleast 1 wk). |
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Additional criteria for research |
Separate criteria not given. |
Includes subjective parental reporting of crying
|
|
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more than 3 h/d for atleast 3 d/wk and objective
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|
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record by a 24 h cry-record diary. |
Epidemiology
The prevalence of infant colic varies greatly
depending on the criteria used in the study, type of study conducted,
method of data collection (community-based/ hospital record-based), and
the population studied (Table II). Global prevalence of
infantile colic is estimated to be around 20%, but most of the research
has been done in Western population [5]. A systematic review of 39
randomized control trials on infantile colic reported that 20 different
definitions of infantile colic were used and the outcome criteria were
also not uniform [6]. A systematic review of literature done in 2001
(before publication of ROME III criteria) revealed that occurrence rate
of infantile colic in prospective studies varied from 3% to 28% and in
retrospective studies between 8% to 40% [7]. In this review, two
prospective studies of high quality which used Wessel’s criteria for
definition had a prevalence of 5% and 19%, respectively [8,9]. Canivet,
et al. [8] conducted a retrospective as well as prospective study
on colic and found that retrospective studies had higher prevalence even
though the definition of colic was similar. Van Tilburg, et al.
[10] determined the prevalence of Functional gastrointestinal disorders
(FGID) in US population as reported by parents, and reported it to be
5.9%. Similarly in a cross-sectional study, Liu, et al. [11] used
ROME III criteria and found a prevalence of 1.4% in China. With the
publication of ROME III it became the new standard and prevalence
studies were based on it. Community-based studies are expected to yield
better results than hospital-based studies because only a fraction of
the parents approach the health care facilities and the child rearing
practices differ among communities. Thus a well-structured study
involving population representative of different parts of the world and
using uniform criteria is needed to know the exact prevalence of the
condition.
TABLE II Prevalance of Infantile Colic
Study, Country, Year
|
Study design |
Definition(s) used
|
Age |
Occurrence |
Canivet, et al., Sweden, 1996 [8] |
Prospective |
3h/3d/3 wk
|
0-3 mo |
5%
|
|
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3h/3d |
|
11% |
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1h/4d/1 wk |
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17%
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|
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Problem crying |
|
3% |
Canivet, et al., Sweden, 1996 [8] |
Retrospective |
3H/3D/3W |
0-3 mo |
12% |
|
|
1H/4D/1W |
|
15% |
|
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Problem crying |
|
12% |
Hogdal, et al., Denmark, 1991 [9] |
Prospective |
1.5H/6D/1W |
0-6 mo |
19% |
Van tilburg, et al., California, 2015 [10] |
Questionnare |
ROME III |
0-4 mo |
5.9% |
Hide, et al., Wales, 1982 [12]
|
Prospective |
Mothers interpretation as colic |
0-12 mo |
16% |
Vanderwall, et al., Netherland, 1998 [13] |
Retrospective |
>3H/1D |
2-3 mo |
7.6% |
|
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Crying a lot |
|
14% |
|
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Difficulty to comfort |
|
10.3% |
Talachian, et al., Iran, 2008 [14] |
Prospective |
3H/3D/3W |
0-3 mo |
20% |
Chogle, et al., Colombia, 2016 [15] |
Prospective |
ROME III |
1-4 mo |
27% |
Rubin, et al.,UK, 1984 [16] |
Prospective |
Unexplained crying |
0-3 mo |
26% |
Pathophysiology
Several theories have been proposed relating various
factors to infantile colic, but none of these theories have sufficient
evidence to establish causation. The word colic points towards the
gastrointestinal origin but even the classical Wessel definition does
not mention it as a discomfort originating from gut. There is no proof
that the source of discomfort in infants with colic is gut but for ease
these theories can be broadly classified as non-gastrointestinal or
gastrointestinal. The non-gastrointestinal causes of colic include
behavioral causes, altered parent-child interaction, immaturity of CNS,
and early form of migraine. The gastrointestinal causes of colic include
developmental lactose intolerance, altered gut microorganism, immaturity
of enteric nervous system, increased motilin receptors or cow milk
hypersensitivity. It has been shown that the early mode of enteral
nutrition does not affect the incidence of colic that is whether the
child is breast fed or bottle fed does not affect the incidence of
colic. The widely reviewed etiology now is relating to gastrointestinal
causes which includes lactase deficiency in early infancy and altered
gut microorganisms.
Non-Gastrointestinal Causes
The word colic imparts unwarranted emphasis on the
gastrointestinal etiology even though no such evidence exists. Various
non-gastrointestinal theories for colic have been proposed which can be
broadly classified as factors relating to mother, baby and environment.
Factors related to mother include maternal age, educational background,
smoking, alcohol consumption, antenatal maternal stress and anxiety, and
poor feeding techniques [17]. Maternal smoking in pregnancy has been
shown as a risk factor for colic. Poor feeding techniques lead to
a hungry unsatisfied infant. Factors related to baby include difficult
infant temperament, way to maintain normal homeostasis, immaturity of
central nervous system, or an early form of migraine. Factors related to
environment include lack of family support and family stress. The
behavioral cause states that altered parent-child interaction can be a
cause of colic. It has been proposed that misinterpretation of infant
cries lead to ineffective caregiver responses which lead to unsatisfied
infant. A new concept has come which states that colic is due to CNS
immaturity and colic can be a form of migraine [18].
Gastrointestinal Causes
Lactose Intolerance: It has been observed that
patients with lactose intolerance have high hydrogen content in the
expired air after an oral lactose challenge [19]. Lactase is an enzyme
present in the small intestine which is responsible for digestion of
lactose. When lactase enzyme is deficient, lactose escapes digestion in
small intestine and reaches large intestine where the colonic
microorganisms act on it and lead to its fermentation and hydrogen
production. The hydrogen gas is absorbed in the blood stream, reaches
the lungs and is expired through the nose which is then measured by gas
chromatography technique. The hydrogen breath test is used as a
non-invasive tool for detection of carbohydrate intolerance (lactose,
fructose) and small intestinal bacteria overgrowth. In lactose breath
hydrogen test rise in breath hydrogen by 20 ppm above basal level after
lactose ingestion is considered positive [19]. The theory relating
infant colic to lactase deficiency suggests that lactase deficiency in
early infancy leads to lactose malabsorption and increased gas
production which in turn acts as a source of discomfort for infants
[20]. It is also supported by the observation by Illingworth [21] that
such cries are relieved by flatulence. It has been shown that infants
with colic have more hydrogen content in the breath as compared to
non-colicky infants after ingestion of milk [22]. However, this theory
fails to explain the fact that infants with colic cry more during
evening even though their main diet is lactose rich milk (either breast
milk/ formula feed). In some studies it has been proposed that infants,
including preterm, have sufficient amount of lactase to digest the milk
[23]. They found that the lactase activity of the newborn is equal to
the immediate demands of milk feeding, but after five days of age. It
has been proposed that even infants with primary lactase deficiency can
tolerate some milk without producing symptoms. In a study conducted by
Liebmann, et al. [24], babies with colic did not have reduced
stool pH and positive stool reducing substance test. Thus the
association between lactose intolerance and colic is yet to be
established.
Altered gut flora: Alteration in gut
microorganism or more correctly decrease in commensal bacteria like
Lactobacillus and Bifidobacter in gut of babies as a reason
for colic and as a treatment option is gaining momentum. It was known
earlier that there were differences in gut flora between colicky and
non-colicky infants [25]. Weerth, et al. [26] revealed that there
was significant difference in intestinal flora in infants with and
without colic even by the age of one week, i.e., even before the
onset of symptoms. Infants with colic had slower colonization, lower
diversity and stability of gut microorganism, increased concentration of
Proteobacter, and decreased concentration of Lactobacillus,
Bifidobacter and other butyrate producing bacteria [26]. In this
study, it was suggested that early detection of change in gut
microorganism can be used for preventive strategy i.e., probiotic
supplementation even before the onset of colic in infants or even
antenatal supplementation to mothers. More research is required to
accept this suggestion. The microorganism reported most recently to be
associated with infantile colic is H. pylori [27]. In a
study conducted in Egypt to determine the relation of H. pylori
with colic, it was found that H. pylori stool antigen test was
positive in 81.8% of infants with colic and 23.3% of infants without
colic [27]. It was suggested that H. pylori alters the host
immune response which in turn leads to non-commensal bacterial
colonization and altered gut micro flora [27].
The other gastrointestinal theories proposed for
infantile colic are: immaturity of enteric nervous system which leads to
intestinal contraction and colic, increased motilin receptors which
causes intestinal hyper-peristalsis, and cow milk hypersensitivity. Some
children, especially with family history of atopy, are sensitive to cow
milk protein. This entity must be differentiated from lactose
intolerance because lactose intolerance causes only a symptomatic
disease but cow milk protein allergy can cause damage to intestinal
epithelium. Evidence shows that 25% of infants with moderate to severe
symptoms have cow milk protein dependent colic.
Clinical Features
The classical presentation is an over-anxious parent
with an inconsolable infant. Parents usually say that the colicky cry is
different from other cries and describe these cries to be more urgent,
piercing and making them feel that baby is in pain [28]. These cries are
associated with hypertonia, facial flushing, withdrawal of legs towards
abdomen and flatulence. The crying starts and stops abruptly. Assessing
an infant during an episode of colic may indicate that the baby is in
moderate to severe pain as per FLACC score, a pain scoring system for
infants [29]. Infant colic begins by 2 to 3 weeks of age, peaks by 6
weeks and resolves by 3 months [1]. There is no sex predisposition
[17,30] but familial predisposition has been suggested [30]. In most of
the studies, the incidence of colic has not shown to be related to the
mode of enteral nutrition of baby or position of baby on the breast
[17,31,32], but some authors report that breastfeeding was a protective
factor [33]. In contrast, in a study conducted in Turkey on infants with
colic, 83.3% of infants were breast fed [34]. This difference might be
due to selection bias as most of the children in this study were
breastfed as compared to mixed-fed and top-fed infants. Even though the
benign nature of infant colic, it is important for the doctor to
identify the condition because prompt counselling of parents about the
benign course will avoid unwarranted diagnostic intervention in the baby
and anxiety and self-doubt in the parents.
Diagnostic Tools
There are various tools for analysis of crying in
infants but none have been proven useful for clinical purpose. Validity
of these tools is an area for clinical research. Tools such as Barr Baby
Day Diary, Ames Cry Score, Parental Diary of Infant Cry and Fuss
Behavior, Crying Pattern Questionnaire, Infant Colic Scale have been
used for research purposes and there are no recommendations for use of
these scales for clinical purpose [35]. Most of these tools are based on
"crying" as the main factor. Barr baby day diary is the most studied
tool. In this diary, each day was divided into four time rulers
representing night, morning, afternoon and evening. Each time ruler was
further divided into six divisions representing six hours. The smallest
time division which could be represented in this diary is five minutes.
These time rulers have to be shaded by the parents according to infant
behavior: sleeping, awake and feeding, awake and content, awake and
fussing, awake and crying, awake and sucking [36]. Ames cry score is a
simpler score which consists of three questions with four responses
which are scored from 0-3. A total score of more than three is
considered as colic [37]. A tool which was developed with a novel
insight was Infant Colic Scale by Ellet, et al. [38]. It was
based on the five etiological theory of colic namely: cow milk/ soy
protein allergy/ intolerance; immature gastrointestinal system, immature
central nervous system, difficult infant temperament and parent-infant
interaction problem. After publication of ROME III criteria for FGID, a
functional questionnaire was developed [3]. Under ROME IV, questionnaire
for pediatric research and epidemiological purpose of FGID has been
developed and is available online (R4PDQ – Toddler: parent report form
for infant and toddler) [4]. Questions of ROME IV criteria are based on
the definition of colic and include the age, crying behavior and weight
gain of the child, and presence or absence of fever.
Management
The main treatment of infant colic is first excluding
all causes of excessive crying in an infant, followed by counseling and
reassurance of the parents. The cause of excessive cry can be as simple
as diaper poking the baby to CNS infections leading to shrill cry. It is
emphasized that colic is a diagnosis of exclusion in a well thriving
infant and if a baby is visibly sick, diagnosis of colic is not
considered. A thorough history and physical examination must be
conducted to rule out any medical or surgical causes of infant cry.
Important negative history includes history of fall, fever, vomiting,
seizures, poor oral acceptance, crying associated with micturition, ear
discharge or vaccination. Detailed head to toe examination must be
conducted. Freedman [39], in an attempt to determine the role of
laboratory investigations in colic, conducted a study in which a series
of laboratory investigations were ordered based on history and
examination. Positive test results were obtained in 14.1% of cases but
diagnosis based on this positive result was made in only 1.4% of cases.
It was thus concluded that detailed history and examination are the
cornerstone in diagnosis of colic. Routine use of fluorescein stain to
rule out corneal abrasion and stool for occult blood is not recommended
in all cases but he recommended urine examination of all afebrile
infants with colic in first month of life.
There are no established guidelines for management of
colic. In general, treatment is individualized with special emphasis on
counseling the parents about the benign nature of the condition, and
addresses their sense of inadequency. The other treatment options
available but less commonly used are lactase supplementation, use of
probiotics, anti-spasmodics, and hypo-allergic formula feed. A brief
review of the treatment options available is discussed here. The
treatment is devised based on the etiological theory of colic, e.g.,
lactase supplementation for lactase deficiency, probiotics
supplementation in case of altered gut flora, antispasmodics for smooth
muscle relaxation, counseling of the mother to learn infant soothing
techniques, chiropathic techniques. Broadly these interventions are
classified as parental behavioral interventions, dietary
supplementation, pharmacological intervention and manipulative
therapies. A Cochrane review of the pharmacological treatment and
manipulative therapy is available separately [40,41]. Four more Cochrane
reviews are ongoing on parent training program, dietary modification and
probiotics in prevention on infantile colic and probiotics for treatment
of colic [42-45].
Behavioral Modification and Parental Counseling
Even though much research work is done on lactase and
probiotic supplementation, one should always consider proper counseling
as the cornerstone of management. The behavioral cause states that
altered-parent child interaction can be a cause of colic. It has been
proposed that misinterpretation of infant cries lead to ineffective
caregiver response which in turn leads to unsatisfied infant. Behavioral
modification is usually considered as a first line intervention because
it is not associated with any side effect and is cost-effective [46].
Proper counseling includes explaining the normal crying pattern of
infants, encouraging them and helping them 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, Suckling
(letting the baby suckle on breast/ clean pacifier). Other techniques of
infant calming include use of white noise, minimal handling, and
simulating car ride. Parental counseling has been shown to be more
effective than dietary change (crying duration decreased from 3.2 h to
1.1 h per day in counseling group and from 3.2 to 2 h per day in dietary
intervention group). A recent concept is the period of ‘PURPLE Crying’
[48]. This concept was developed by Barr to help parents understand the
implication of colic and the dangers of child abuse associated with
excessive crying. The word PURPLE is an acronym which stands for "Peak
of crying, Unexpected, Resists soothing, Pain like faces, Long lasting,
Evening". The word "period" means crying has a beginning and an end. It
was suggested that explaining the pattern of crying to parents would
decrease the hospital visits for excessive crying and understanding that
excessive crying as a part of normal infant development would reduce
maternal anxiety and infant abuse. The counseling was done in the form
of a 10 page booklet and a 10 minutes DVD which was given to parents
after delivery. With the implementation of the concept of PURPLE Crying
the emergency room visits for excessive crying decreased by 30% over 3
years [48]. Thus counseling is the first line of therapy which can be
used while awaiting infant colic to run its natural history.
Dietary Modification
Lactase supplementation: Lactase supplementation
as a dietary intervention is undergoing tremendous research. But none of
the studies are of high quality and outcome measures are not uniform to
come at a conclusion. Kannabar, et al. [49] conducted a
double-blind placebo controlled randomized control trial with cross over
with a wash out period of five days to determine the efficacy of lactase
supplementation and found pre-incubation of feed with lactase reduced
the crying time and breath hydrogen content in the intervention group.
Similarly, in a crossover randomized control trial conducted by Kearney,
et al. [50], a reduction of mean crying duration by 1.14
hours/day in the intervention group was shown. But both these studies
have several limitations: small sample size, outcome measures were not
standardized, and cross-over period was different. Even though some
studies have shown the effectiveness of lactase supplementation, no
strong evidence has been shown which would help in formulating
guidelines. More trials in larger population groups are required which
will also be helpful in formulating the 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. The most researched bacteria is
Lactobacillus reuteri DSM 17938. A recent review article analyzing
three randomized control trials stated that probiotic supplementation
significantly reduced the crying duration in breast fed infants [51].
All infants were given L.reuteri 17938 orally in a dose of 1×10 8
cfu as five drops a day. But the limitation of
these studies was a small sample size and lack of cross over data and
duration of supplementation was not same and one study used L.reuteri
55730 strain [52–54]. Most of the studies conducted on the use of
probiotics have a favorable result but in a randomized control trial
conducted by Sung, et al. [55] involving 167 infants less than 13
weeks, L.reuteri did not reduce the crying time in infants with
colic. They also suggested that the improvement with the use of
probiotics can be actually a part of the natural course of the condition
than the actual effect [55]. Thus more randomized control trials are
required involving large sample size to produce evidence for use of
probiotics. As Wreeth [26] had suggested the possible role of probiotics
supplemen-tation in infants even before the onset may prevent the
development of colic; a Cochrane review on the role of probiotics to
prevent infantile colic is under process [44]. Another Cochrane review
on the role of probiotics as a treatment option is also ongoing [45].
Thus role of probiotics in both 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): Cow milk allergy can manifest as colic rarely. In
infants shown to have cow milk allergy, dietary modification is
recommended [56]. In exclusively breast fed infants with CMA, breast
feeding 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 breast feed and no restriction of maternal
diet is required. In a formula fed infant with CMA, extensively
hydrolysed formula should be considered. Soy based formulas are not
recommended for infants less than 6 months [56].
Fermented formula with oligosaccharides: With the
hypothesis that fermented formula along with oligosaccharides decrease
the incidence of colic in infants, Vandenplas, et al. [57]
conducted a double blind randomized control trial and found that the
overall incidence of infantile colic was less in the group fed with
fermented formula along with oligosaccharides (short chain
galacto-oligosaccharides and long chain fructo-oligosaccharides) as
compared to the group which were fed either with fermented milk or
oligosaccharides alone. More research is needed on the use of fermented
formula with oligosaccharides.
Pharmacological Intervention
The various drugs that have been used are dicyclomine
hydrochloride, cimetropium bromide, simethicone, sucrose and herbal
medications. These are mainly used as pain relieving agents. The studies
selected for the Cochrane review compared these pharmacological agents
with placebo with respect to reduction in cry duration as primary
outcome [40]. 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. The drugs dicyclomine and
cimetropium are used in colic based on the etiological theory that pain
in gut is due to immaturity of the enteric nervous system which leads to
spasm in intestine. Dicyclomine and cimetropium are smooth muscle
relaxants which act on the cholinergic and muscarinic receptors,
respectively and cause smooth muscle relaxation. Use of dicyclomine is
associated with side effects like breathing difficulty. Therefore, it is
not routinely used in children less than 6 months. Other agents like
cimetropium, dicyclomine, sucrose had very low quality evidence for use
in colic. Thus it was concluded that no recommendation could be made on
the effectiveness of pain relieving agents for treatment of colic [40].
Use of gripe water is common in this part of the world. A study
conducted in Puducherry, India, on 335 mothers of infant aged 1-6 months
showed that 64.3% of mothers used gripe water and their most common
belief was that it aided in digestion and decreased abdominal pain [58].
Present day gripe water are alcohol free but its use in infants is not
recommended as there are no proven health benefits and use of any pre
lacteal feed in infants is not recommended by WHO. Presumptive diagnosis
of GERD in excessively crying infants and use of proton pump inhibitor
is not recommended by NASPGHAN (North American Society for Pediatric
Gastroenterology, Hepatology and Nutrition) and ESPGHN (European Society
for Pediatric Gastroenterology, Hepatology and Nutrition) [59]. If a
strong possibility of GERD is kept, then proper referral and
investigations should be done before starting any acid suppression
medication.
The other less commonly used techniques are
chiropractic manipulation. In a Cochrane review on manipulative therapy,
no definite recommendations were made on its use even though RCTs have
shown its effect [41]. This was because of the poor study design and
risk of bias in those studies.
Consequences
Infantile colic is a benign condition which improves
with time. There are usually no associated abnormality and long term
sequelae in both baby and mother [25]. Despite its benign nature it can
act as a significant stressor for parents which leads to self-doubt,
premature termination of breast feeding or even child abuse. Long-term
associations, though few, have been documented in literature include
recurrent abdominal pain, behavioral problem, eating problem and
migraine.
Conclusion
Infantile colic is a condition of multi-factorial
etiology with wide variety of treatment options. The diagnosis of
infantile colic is entirely clinical and laboratory investigations are
not recommended. Even after the diagnosis of colic, the child should be
properly followed-up. At a time when most of the research is being
focused on infant feed supplementation, it should not be forgotten that
counseling is the cornerstone of management till high-level evidence
regarding other treatment options is available. Even though there is
insufficient evidence regarding the effective treatment options for
infantile colic, few commonly used options have been rejected based on
current evidence like Simethicone, Dicyclomine, Proton-pump inhibitors,
and Gripe water. Dietary modifications like lactase and probiotic
supplementation have shown benefits but more randomized control trials
will be required. More research is needed in this field with uniformity
in definition, large sample size, different population, and uniform
outcome measures.
Contributors: MSJ: manuscript writing,
literature search; MN: Study conception, and manuscript editing; DS:
manuscript editing, and critical review of manuscript for intellectual
content. All authors approved the final version of the manuscript.
Funding: None; Competing Interest: MN and
DS are investigators of an ongoing clinical trial on efficacy of Lactase
drops for treatment of infantile colic, which is supported by Walter
Bushnell Pharma Private Ltd. However, the firm had no role in
conception, literature search and interpretation, or funding of this
review article.
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