Infantile colic

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Welcome to Australian Prescriber podcast. I'm Dr Ashlea Broomfield, your host for this episode and it's a pleasure to be speaking to Valerie Sung, consultant paediatrician and postdoctoral research fellow. Today we're talking about infant colic. Hi Valerie.

Hi. How are you?

Good thank you. Infant crying is something that's really common in the community and it's a really common reason for presenting to GPs or clinics at the paediatric hospitals. What are some red flags on history or examination that would highlight to GPs the serious pathology rather than normal infant sleep and crying.

If a baby is unwell then the baby doesn't have colic. So the first thing to do really is to make sure that the history is consistent with colic, it's not an acute history of crying. Let's say if the baby is well then the approach is really still the same except that you have in mind the common causes of crying from birth, so the ones to exclude I guess are cow's milk protein or soy allergy. Number one. And the symptoms that suggest that are poor feeding, frequent vomiting, mucus or blood in the stools, eczema, a found history of allergies and failure to thrive. And you don't have to have all these symptoms but certainly, if any of these occur in the context of a crying baby, then you do need to think about that as a top cause to exclude, and you also need to look at the crying curve in terms of knowing that the peak of crying is about six to eight weeks, and if the baby is getting increasingly irritable beyond the peak period then you also will probably need to consider cow’s milk protein allergy as an alternative course rather than just colic. Then the other things to consider are if the baby has clinically any lactose overload or secondary lactose intolerance. I say this because primary lactose intolerance is extremely rare and the most common cause of this is actually secondary to the feeding practices. For example, if the baby is snacking on breast feeds, just taking the fore milk rather than getting to the hind milk, in which case changing the feeding pattern would be able to solve this problem. But the other reason is if you have a primary cow’s milk protein allergy then you can get a secondary lactose overload or, let's say the baby had a viral gastroenteritis or had immunisations with a rotaviral vaccine, then you can also get a secondary lactose intolerance picture and that would get better with time. So these are probably the main things to exclude and, of course, the question comes in terms of reflux and parents will always ask that because that's a problem that people perceive to cause crying but we know now there is really no evidence to support reflux as a cause of crying in babies less than one year of age, and there's no evidence to support use of proton pump inhibitors in this age group either for crying

And so it was quite a common practice to be using PPIs in the past, and it was quite normal for parents to come along to the doctor after having multiple contacts with the child health or family nurses and say I think that my baby has reflux and I've been told to come and get a script. Can you outline what the problems are with PPIs in young infants?

Yeah. The main issue is that there's more evidence that there can be adverse effects of prolonged PPI use in infants, in particular there have been studies showing increased risk of infection in these babies. In addition there's been good randomised trials as well as systematic reviews that have looked at the effectiveness of PPIs in crying and there is no effectiveness. So it's not an absence of evidence, it’s an abundance of evidence that they do not work.

And getting back to the cow's milk protein allergy, you spoke about an increase in the frequency of vomiting as a potential trigger. Can you describe how that would be different from a normal regurgitation of a normal baby.

Yeah. Most babies with this kind of cow’s milk protein allergy will have difficulties feeding, and you need to really get into the history and the details of the feeding, and really get an understanding of whether there're any behavioural components to the feeding as well, or whether the feeding is too frequent. But these babies typically would be very eager to feed and then they get more and more distressed during the feed and afterwards. And vomiting more than five times a day is one of the red flags of allergy and of course mucus or blood in the bowel actions is also quite indicative.

And can these babies continue to put on weight just by having a cow's milk protein allergy?

They actually can so not all of them will fail to thrive as I alluded to before. In particular, if they're getting progressively difficulties with feeding beyond the six-to-eight weeks mark when you are expecting the irritability to settle, then this really needs to be considered, and of course if they're breastfeeding and mum had a lot of dairy and it definitely produces increased symptoms, then that's another kind of clue.

Is there anything on physical examination that you might see apart from eczema in a child with cow's milk protein allergy?

No. Really eczema is really probably the only examination finding you might see and unfortunately the diagnosis is not straightforward because there's no test for it. The only way to diagnose it is to exclude the culprit from the diet, so in the breastfeeding mum to exclude dairy. And I usually say soy as well because there's a 50% chance that the baby can also react to soy. And we’d do that strictly for two weeks and then rechallenge with the dairy to see whether it reproduces the symptoms. And of course in a formula-fed baby then you have to use elementary formula or hypoallergenic formula.

And how can we determine the difference between a functional lactose overload and a true lactose intolerance?

By the feeding history and also by making sure that one breast empties completely before you go to the next and making sure the feeds are spaced out more than three hourly. If that makes a difference to the bowel actions and if the symptoms of lactose overload or intolerance is frothy, watery diarrhoea together with a very excoriated bottom. With these babies they often have ulcerations around the perianal area because of the acidity of the stools.

So this is a really complex issue that can take a long time to figure out what's happening with the baby and what's happening with the parents, and we know that this is a really stressful time for a lot of families. Are there any complications around having a baby that has excessive crying?

Well, if it is true colic then no. So we've actually just finished a follow-up study looking at behavioural and other outcomes of toddlers who had colic before, and we have been able to conclude quite confidently that there are no negative adverse effects at least in the median term. So I think we are safe to reassure families that this phase does pass and there are no long-lasting effects.

There is that association between infant sleep and crying and risk of postnatal depression that can be really important to have a look into.

Definitely. It's mainly listening to the family, spending time with them, observing the baby, because mothers really do appreciate that. And I think with postnatal depression using an instrument to help with that, so in our clinic we use the Edinburgh Postnatal Depression Scale, and that's quite useful because we basically get mum to just fill it out while we examine the baby and then you just score it there and then, and you can use that to show the mum that they are struggling and to talk about the depression and open up that conversation that way.

And it is a really stressful time for parents and, with the advent of Facebook groups for parents, there's often old wives’ tales and remedies that families learn about how to deal with infant crying and sleep. Are there any specific ones that are quite harmful that we should specifically ask for?

Well, all of them basically don't work. One of the very commonly recommended therapies is chiropractor treatment for crying. There is actually no evidence that that works and I would caution families to spend lots of money on that. Obviously we don't have definite evidence that it's harmful either, but in the conversation with the parents I think this needs to be explored. I think the harm comes in really purchasing things that don't help. And also that becomes a medicalisation of the whole presentation, so I think harm really comes through parents believing that there's something wrong with their child and needing something to stop the crying, where the main thing is actually to help them come to terms with the crying and help them cope with the crying rather than trying to stop the crying as such.

And what strategies do you utilise to engage parents and support them to do this?

As I said before it's mainly listening and getting across to them that you are considering all their concerns. So for me I feel that going through with them what you have thought about rather than just saying that the baby is well and will be fine, I feel that you really need to talk through ‘I've considered this, I've considered reflux. The reasons for not being reflux are these. I've considered cow’s milk protein allergy. These are the reasons why your baby doesn't have it. Your baby is growing well and look at the chart.’ And also reassuring the mother that she's doing really well and giving her that positive feedback really, and also giving them a review appointment as well to follow up even though you know that it's going to get better, and also showing them that the crying curve is also quite useful to visually see that, and point to the family where the baby is at.

And where would you get that?

The Royal Children's clinical practice guidelines has got a link to that.

And it can be really tempting to give the family something to make them feel like they're doing something, and that often was the case in the past with PPIs. Are there any other old medical treatments that are no longer recommended?

Certainly the most commonly used is Infacol or simethicone and has been shown to be ineffective, and the rest like herbal medicines – some have been actually shown to be effective but the issue is if the baby drinks a lot of herbal teas then they're not going to be having enough nutrition through proper feeding. The newer evidence now is probiotics I guess, so there's been one particular probiotic that has been shown in countries excluding Australia to be effective in breastfed infants only, and that probiotic is called Lactobacillus reuteri and it's the only probiotic that's been shown to be perhaps effective. My recommendation is that if parents are really asking for something and they're exclusively breastfed then it's probably okay to recommend that for a short period of time. And by that I mean three weeks which is where all the trials have looked into, and these are also for babies less than three months old.

Are there any online resources that you can direct parents or families to to get further information?

Yes, so the Raising Children website is really great for parents. There are specific information sheets on colic and crying and how to deal with that.

Yeah, it's a great website. I really like that one. It's got lots of information, even help with toddlers and behaviour as well.

That's right.

That's unfortunately all the time we've got this episode. Thanks for joining us today.

The infant colic full article is available online at nps.org.au/australian-prescriber. The views of the hosts and guests on this podcast are their own and may not represent Australian Prescriber or NPS MedicineWise. I'm Dr Ashlea Broomfield and thanks for joining us on Australian Prescriber podcast.