by Dr Julia Thomson, Paediatrician
Archive for the ‘Uncategorized’ Category.
We were Highly Commended in the interprofessional award category of the London Deanery’s 2011 Elisabeth Paice awards for educational excellence. This is a rare glimpse of the Paediatric Pearls unassuming webmaster with our certificate!
In Waltham Forest children under 5 who are thought to possibly have a social and communication disorder should be referred to the Community Paediatric Services at Wood Street health centre. The care pathway is available here. Older children need to be referred to the Child and Mental Health Service at Thorpe Coombe please.
One of our current SHOs has put together this very comprehensive article on infantile colic:
Infantile Colic (with thanks to Dr Katie Knight):
Among all the feeding related problems of early infancy, colic is the one that often causes parents the most anxiety and stress. Around 1 in 6 families consult a healthcare professional about colic – the prevalence of the disorder is around 9-16% in the UK. [1,2] Usually beginning from two weeks old, colic symptoms peak at 2 months and resolve by 3-4 months. It is not well understood and given its unclear aetiology can be difficult to manage.
The triad of symptoms is paroxysmal, prolonged crying (commonly related to feeds, and often worse at night); pain (the baby may draw its legs up and grimace) difficulty comforting an otherwise thriving infant. It is important to stress this caveat – if the infant is losing weight, has faltering growth or other unexplained symptoms, more serious potential diagnoses must be ruled out. Colic is therefore essentially a diagnosis of exclusion, in an otherwise healthy child.
This article explains some of the current theories about colic, and looks at the evidence regarding interventions and management.
What causes colic?
Breast vs formula? The confounding factors would make an association with either type of feed extremely difficult to prove. [12,13] Interestingly, one study of breast and bottle fed infants found that excessive infant crying peaked at different ages depending on method of feeding – breast fed infants cried most at 6 weeks, formula fed infants cried most at 2 weeks. [14]
Protein intolerance? A small number of infants with colic symptoms end up being diagnosed with cow’s milk protein intolerance. This is a transient phenomenon in infancy, and is probably related to the relative immaturity of the gut immune system, as antigens are allowed to cross the mucosa.
Bowel hypersensitivity? Excess gas (swallowed at feeding if there is poor sucking/interrupted feeds, or produced by intestinal bacteria) builds up in the bowels, causing pain
Intestinal microflora? The newborn intestine is gradually colonised with bacteria after birth. Different patterns of colonisation have been found in colicky and non-colicky infants [6], and a high numbers of gas-forming coliforms have been demonstrated in some babies suffering from colic [7]
Poor breastfeeding technique?
The first mouthfuls of milk from the breast are high volume but low in calories; the last bit of milk from the breast is high calorie and high fat. If the mother swaps the baby to the other breast before all milk from the first breast has been taken, the baby only gets low calorie, unsatisfying feeds. The fast gastric emptying encouraged by low fat milk means that the intestine may not have enough lactase to break the milk down. This can lead to fermentation of lactose, gas formation and the irritability associated with colic. [11]
Socio-economic risk factors? Colic is more often reported by very young mothers, and mothers above 35. [8]
It is more common in babies with a highly anxious mother, and when the father does not cohabit; good support networks seem to reduce the risk for colic. [9] There are also differences between social classes; colic is much more often reported by parents who are professionals (23%) than by parents who are unskilled workers (7%). [10] These patterns are complex and there are lots of confounding factors, but there is a suggestion that what one parent believes is normal behaviour for a baby, another may find extremely worrying and interpret as colic – and this could be affected by their experiences with previous children, support at home (or lack of), and emotional state.
Management
The general recommendation is a stepwise approach to management, beginning with behavioural and environmental adjustments. What works for one child may not work for another, so managing colic takes time and patience while different strategies are tried.
Support and general reassurance are of great benefit – giving an explanation, normalising the parents expectations of infant behaviour, supporting breastfeeding and exploring anxiety issues, and tackling any guilt that the parents might feel about their baby’s distress [15]. Many parents still use the old fashioned ‘gripe water’ – a solution of alcohol, sodium bicarbonate, herbs and sugar, available over the counter – although it is now thought that the soothing effect is due to the sugar (which has an analgesic effect in infants), or the sedative effect of the alcohol, and nothing to do with the ‘active’ ingredients!
Dicycloverine, a smooth muscle relaxant, has been used in the past but is NOT RECOMMENDED for infants due to its side effects which include respiratory depression and coma [16].
For formula fed babies who do not respond to conservative measures, a trial of hypoallergenic formula may be indicated. This should always be overseen by a doctor. For these difficult cases, some studies have shown improvement in symptoms with partially hydrolysed formula when compared with standard formula [17,18,19] However, because so few infants with colic do have a genuine food intolerance, trials of hypoallergenic formula are not recommended as first line management. Probiotic drops (intended to ‘rebalance’ the intestinal microflora) are only available in some health food shops and not on prescription, but have become popular with parents recently. A recent small randomised controlled trial found they had some benefit in colic [20]
Long term effects?
For the vast majority of babies with colic, the clinical symptoms resolve completely by 3-4 months of age. However, the psychological effects might be long lasting. While colic lasts, infant distress, poor feeding and poor sleeping can have a significant effect on the parent-child relationship. Excessive crying in infancy is associated with maternal depression, and mothers have been found to be more likely to be depressed even six months after the crying had resolved [3] These mothers are also more likely to stop breastfeeding earlier [4]. Caring for a ‘difficult’ baby makes parents lose confidence in their parenting ability, and the effect of the strained relationship at an early age can be considerable – one study found that infants who had suffered with colic were, at one year old, more likely to be described as ‘demanding’ and ‘bad tempered’ by their mothers [5]
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Colic: Taking a history (from NICE clinical guidance 37) Assessment of excessive and inconsolable crying should include: • general health of the baby • antenatal and perinatal history • onset and length of crying • nature of the stools • feeding assessment • woman’s diet if breastfeeding • family history of allergy • parent’s response to the baby’s crying • any factors which lessen or worsen the crying. NB: The medical definition of ‘excessive crying’ is crying that lasts at least 3 hours a day, for 3 days a week, for at least 3 weeks http://www.ncbi.nlm.nih.gov/pubmed/9596593 |
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In summary – important advice to give to parents Give the parents an explanation of colic – reassure them that it is a very common condition that gets better with time. If the baby is gaining weight and otherwise thriving, further investigations are rarely needed and the baby is extremely unlikely to have an underlying cause for its symptoms. Colic is not the parents fault – give them time to discuss their feelings and try and alleviate any guilt they might feel Encourage them to seek support from family and friends, many other parents have experience of colic and can help reassure them that it is a common problem, and normalise their experience Practical tips: a calm environment at bed time and when distressed can help – dim lights, calming music or sounds, swaddling. Repetitive motion comforts some babies – rocking, walking in a pushchair, going for a drive in the car Breastfeeding for 4-6 months is recommended for all babies, and may improve symptoms of colic. If they are having problems breastfeeding, refer to a breastfeeding counsellor |
1 http://bestpractice.bmj.com/best-practice/evidence/background/0309.html
2 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1627691/
3 http://www.ncbi.nlm.nih.gov/pubmed/19432839
4 http://www.ncbi.nlm.nih.gov/pubmed/17661591
5 http://www.ncbi.nlm.nih.gov/pubmed/6478547
6 http://www.ncbi.nlm.nih.gov/pubmed/15693915
7 http://www.ncbi.nlm.nih.gov/pubmed/19604166
8 http://www.bmj.com/content/314/7090/1325.full
9 http://www.ncbi.nlm.nih.gov/pubmed/15764238
10 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1627691/pdf/archdisch00756-0081.pdf.
11 http://www.ncbi.nlm.nih.gov/pubmed?term=Fisher%2BC%5Bauth%5D%20colic
12 http://www.ncbi.nlm.nih.gov/pubmed/14502331
13 http://www.bmj.com/content/314/7090/1325.long
14 http://www.ncbi.nlm.nih.gov/pubmed/10193923
15 http://pediatrics.aappublications.org/content/92/2/197.full.pdf+html.
16 http://www.nice.org.uk/nicemedia/pdf/CG37NICEguideline.pdf
17 http://www.ncbi.nlm.nih.gov/pubmed/16736065
18 http://www.ncbi.nlm.nih.gov/pubmed/14599049
19 http://www.ncbi.nlm.nih.gov/pubmed/18592627.
http://www.nhs.uk/Planners/birthtofive/pages/tipstosoothecrying.aspx has some tips for parents from the Birth to 5 publication on how to cope with your crying baby. I personally found the comments and diagrams in Dr Christopher Green\’s book, Babies! , very helpful for my own colicky baby. Comments welcome below.
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Last modification date : [17/08/2011]
Most babies who are still jaundiced at 2-3 weeks of age are well. It is important not to miss biliary atresia which presents as CONJUGATED hyperbilirubinaemia. The baby will usually, though unfortunately not always, have pale, putty-coloured stools and it is important to pick them up early as the treatment is surgical and has a better outcome if carried out around the age of 6 weeks. The community midwives in Waltham Forest do the first line investigations for prolonged jaundice. The following documents are downloadable here:
1) Prolonged jaundice guideline for midwives
2) Investigation sheet for prolonged jaundice
We try very hard to keep these babies out of the Emergency Department as they run the risk of coming in well and going out with something they’ve caught while waiting to see us. They also have to be put in a cubicle and then there is no room for A and E to see all the other children in the department.