Special Considerations 4Infant colic is a common condition characterized by excessive crying without any obvious cause in an otherwise healthy child. Colic usually presents within the first 3 months of life and, in severe cases, can disrupt feeding and prevent an infant from gaining weight.1 The underlying cause of colic is not well established. In particular, a prospective cohort study has demonstrated that breastfeeding has no influence on whether an infant develops colic,2 but there is some evidence suggesting that changes to the intestinal microbiota and pre-existing maternal anxiety may be involved in the pathogenesis of colic.2-4

Defining infant colic

Infant colic is defined by Wessel’s criteria, or the “Rule of Three”, as crying that lasts for ≥3 hours per day for ≥3 days per week for a minimum duration of 3 weeks.5 However, as caregivers are usually unable to wait 3 weeks before consulting a physician, modified Wessel’s criteria are often used to clinically define infant colic as crying that lasts for ≥3 hours per day for ≥3 days per week for at least 1 week.

The Rome III criteria expanded on Wessel’s criteria for infant colic by further adding the additional criteria of age <5 months and no evidence of a failure to thrive. However, the updated Rome IV criteria have redefined and simplified the assessment of crying in infant colic to “recurrent and prolonged periods of infant crying, fussing, or irritability reported by caregivers that occur without obvious cause and cannot be prevented or resolved by caregivers.”6

Behavioural and developmental impact of infant colic

There is some evidence that infant colic may be associated with future behavioural and developmental problems, such as gastrointestinal disorders, migraine, sleeping problems, impulsivity and allergies.7−12 There is also preliminary data to suggest that infants with colic may have a higher risk of developing pain-associated functional gastrointestinal disorders during adolescence.11,13 However, much of this evidence is inconclusive and still needs to be validated with well-designed prospective studies.7

Infant colic also disrupts the family dynamic by provoking feelings of anger, frustration and incompetence in caregivers.14,15 Collectively, this can significantly increase the risk of non-accidental injury to the infant and impose significant economic burden due to healthcare costs.16 Accordingly, effective management strategies are pivotal for reducing caregiver stress.

Management of infant colic

As the cause of colic is unknown, there is no cure. General strategies for managing infant colic aim to calm the infant, allowing caregivers to get adequate rest, including1:

  • Dimming the lights in a quiet room
  • Skin-to-skin nursing
  • Placing a warm water bottle on the stomach of a crying baby
  • Warm baths
  • Rubbing/massage

While studies have been conducted looking at the impact of dietary modification, lactase therapy or pharmacotherapies for colic, there is insufficient evidence available to support their efficacy.

Altered faecal microflora in infants with colic

While the underlying cause of colic is traditionally believed to be non-organic, there is some data available to suggest that the pathophysiology of infant colic may be related to changes in the colonic microflora including3:

  • A reduction in butyrate-producing species
  • An increase in proteobacteria, including species that produce gas and inflammation
  • A reduction in Lactobacillus and Bifidobacteria species
  • Lower diversity and stability

Additionally, another study has found that faecal calprotectin levels were twice as high in infants with colic compared with infants without colic.4

Probiotics in the management of infant colic

As infants with colic have a considerably different microflora compared with infants without colic, probiotic supplementation may be advantageous in enhancing the mucosal barrier and promoting microbial diversity. A number of studies have demonstrated that probiotic supplementation with Lactobacillus reuteri significantly reduces daily median crying times compared with simethicone16 or placebo.17,18 The beneficial effects observed with Lactobacillus reuteri are thought to be due to the significant increase in faecal Lactobacilli and reduction in Escherichia coli following treatment.17

However, a larger randomized controlled trial that looked at the same endpoints found no difference in the daily duration of crying or fussing in infants given a probiotic versus infants given a placebo, nor did Lactobacillus reuteri supplementation improve infant sleep, maternal mental health or quality of life.19 Laboratory analyses of faecal samples also failed to identify a difference in faecal microflora or calprotectin levels between the groups.19

Consequently, the differing outcomes across studies mean that probiotics cannot be routinely recommended for children at this stage of development to help manage colic.

Summary

The mainstay in the management of infant colic is supporting caregivers and helping them cope with periods of excessive crying. While there is evidence that probiotic supplementation can reduce crying time,16-18 there is significant variability between trials and these putative effects must be further validated with high quality clinical studies.7

References

  1. Kerzner B. Clinical investigation of feeding difficulties in young children: A practical approach. Clin Pediatr, 2009. 48(9): p. 960-5.
  2. Clifford, T.J. et al. Infant colic: empirical evidence of the absence of an association with source of early infant nutrition. Arch Pediatr Adolesc Med, 2002. 156(11): p. 1123-
  3. De Weerdth, C. et al. Crying in infants: On the possible role of intestinal microbiota in the development of colic. Gut Microbes, 2013. 4(5); p. 416-21.
  4. Rhoads, J.M. et al. Altered fecal microflora and increased fecal calprotectin in infants with colic. J Pediatr, 2009. 155(6): p.823-
  5. Wessel, M.A. et al. Paroxysmal fussing in infancy, sometimes called colic. Pediatrics, 1954. 14(5): p. 412-5.
  6. Benninga, M.A. et al. Childhood functional gastrointestinal disorders: Neonate/toddler. Gastroenterology, 2016. 150(6): p. 1443-55.
  7. Vandenplas, Y. et al. Gut health in early life: Implications and management of gastrointestinal disorders. p. 112. Available at: http://www.essentialknowledgebriefings.com/downloads/gut-health-in-early-life-implications-and-management-of-gastrointestinal-disorders/. Accessed 23 January 2017.
  8. Romanello, S. et al. Association between childhood migraine and history of infantile colic. JAMA, 2013. 309(15): p. 1607-12.
  9. Neu M. and J. Robinson. Infants with colic: their childhood characteristics. J Pediatr Nursing, 2003. 18(1): p. 12-20.
  10. Savino, F. et al. A prospective 10-year study on children who had severe infantile colic. Acta Paediatr Suppl, 2005. 94: p. 129-32.
  11. Kalliomaki, M. et al. Extent of fussing and colic type crying preceding atopic disease. Arch Dis Child, 2001. 84: p. 349-50.
  12. Partty, A. et al. Infant distress and development of functional gastrointestinal disorders in childhood: is there a connection? JAMA Pediatr, 2013. 167(10): p. 977-8.
  13. Long, T. and M. Johnson. Living and coping with excessive infantile crying. J Adv Nursing, 2001. 34: p. 155-62.
  14. Iacovou, M. et al. Dietary management of infantile colic: a systematic review. Matern Child Health J, 2012. 16(6): p. 1319-31.
  15. Morris, S. et al. Economic evaluation of strategies for managing crying and sleeping problems. Arch Dis Child, 2001. 84(1): p. 15-9.
  16. Savino, F. et al. Lactobacillus reuteri (American Type Culture Collection Strain 55730) versus simethicone in the treatment of infantile colic: a prospective randomized study. Pediatrics, 2007. 119: p. e124-30.
  17. Savino, F. et al. Lactobacillus reuteri DSM 17938 in infantile colic: a randomized, double-blind, placebo-controlled trial. Pediatrics, 2010. 126(3): p. e526−
  18. Szajewska, H. et al. Lactobacillus reuteri DSM 17938 for the management of infantile colic in breastfed infants: a randomized, double-blind, placebo-controlled trial. J Pediatr, 2013. 162(2): p. 257-
  19. Sung, V. et al. Treating infant colic with the probiotic Lactobacillus reuteri: double blind, placebo controlled randomised trial. BMJ, 2014. 348: p. g2107.