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MANAGEMENT OF
INFANTILE COLIC
Jeanette I. Ch. Manoppo
UKK Gastrohepatologi 2013
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Definition
Common problem (1 in six families) consulting healthcare professionals
Gastroenterology 2006;130: 1519
Infantile colic
Paroxysms of irritability, fussing or crying
that start and stop without obvious cause,
lasting > 3 hours per day and occurring > 3
days each week.
Without a failure to thrive
Rome III criteria
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Incidence
Affects 10-30% of infants worldwide
Occurs in =
Commonly observed in neonates and infants aged 2 weeks to4 months
The incidence of colic in breastfed and bottle-fed infants is
similar with no difference
Arch Pediatr Adolesc Med. 2002;156:1123-8
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Etiology
The cause of infantile colic remains unclear
Organic causes account
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Organic causes of infant
with excessive crying
Pediatrics. 1998;102(5 suppl E):1283
Pediatrics. 1991;88:452
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Pathogenesis
Poorly understood
Abnormal gastrointestinal motility and pain signals from
sensitised pathways in gut viscera Inadequate amount of lactobacilli and increased amount of
coliform bacteria in the intestinal microbiota influences gut
motor function and gas production
Curr Opin Pediatr. 2010;22:791-7
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Common Etiopathogenesis
Lactose intolerance
Dysmotility
Gastro-esophageal reflux
Gut hormones (motilin, ghrelin)
Gut microflora (Lactobacillus spp.)
Feeding disorders
Food hypersensitivity (cows milk
allergy)
Psychological factors (infantparent
interaction)
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Diagnosis
Exclusion of other causes especially organic causes
No abnormalities in history and examination, therefore noneed for biochemical and radiological examination
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Differential diagnosis
BMJ. 2013;347,f4102:1-5
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Differential diagnosis
BMJ. 2013;347,f4102:1-5
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Sri Lanka Journal of Child Health. 2012; 41:192-8
UTI (Urinary Tract Infection)
AOM (Acute Otitis Media)
Flow Chart
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Management
Reassurance of parents regarding the benign and self-limiting
nature of the illness as most of the babies improve by the age
of 3 to 4 month
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Management options
Diet modification
Based on theory that infantile colic results from excessive gas
production from poor gut digestion of cows milk proteins Hypoallergenic formula preparations for bottlefed infants
High fibre formula
Soy based formula
Hypoallergenic maternal diet for breastfed infants
Lactase therapy
Matern Child Health J. 2012;16:1319-31
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Diet modification
Hypoallergenic formula preparations for bottlefed infants
Where a suspicion of cows milk protein allergy exists there is some
evidence that the use of an empirical time limited trial of a completely
hydrolysed formula is a reasonable option
Partially hydrolysed formula would not be recommended because are
not hypoallergenic and therefore will not address colic symptoms caused
by protein allergy
Matern Child Health J. 2012;16:1319-31
Paediatr Child Health. 2011;16:47-9
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Diet modification
High fibre formula
No significant difference in symptoms vs standard formula
Soy based formula Not recommended because concerns about the level of phytoestrogens
and that soy protein may be an allergen in infancy
J Paediatr Child H. 2012;48:128-37
Matern Child Health J. 2012;16:1319-31
Soya based infant formula. 2003. www.sacn.gov.uk/pdfs/smcn_03_10.pdf
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Diet modification
Hypoallergenic maternal diet for breastfed infants
One systematic review suggest exclusion of milk product and other
possible trigger foods(peanuts, soy, fish) on the mother correlate
with >25 % reduction in cry/fuss vs baseline but did not separatedthe results for breastfed infants from hypoallergenic formula fed
infants
Limited evidence to suggest that hypoallergenic diets in mothers
may be helpful
They should also be advised not to discontinue breast feeding while
switching to the hypoallergenic maternal diet
J Paediatr Child H 2012;48:128-37
Matern Child Health J 2012;16:1319-31
Soya based infant formula. 2003. www.sacn.gov.uk/pdfs/smcn_03_10.pdf
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Diet modification
Lactase therapy
Lactase drops mixed with breast or bottle milk feeds up to 24
horus before feeding
May benefit but lack of evidence
J Paediatr Child H. 2012;48:128-37
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Pharmacological management
Anticholinergic Dicyclomine hydrochloride, cimetopium bromide
may benefit but adverse reaction noted to infant
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Complementary therapies
Herbal supplements
Fennel extract and mixed herbal tea
showed reduction in symptoms Adverse effect like vomiting, sleepines,
constpation and loss of appetite
Lack of standardisation of dosage and
formulations have also limited their use
Pediatrics. 2011;127:720-33
Curr Opin Pediatr. 2010;22:791-7
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Complementary therapies
Sucrose solutions
May be benefit but lack of evidence
There are concerns about potential nutritional effects and
formulation standardisation
Pediatrics 2011;127:720-33Curr Opin Pediatr 2010;22:791-7
J Clin Nurs.2008;17:1754-61
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Probiotics
Based upon the hypothesis that aberrant intestinal microflora affecting
gut function and gas production may contribute to symptoms, the use
of probiotics in infantile colic has become more common
One randomised double blind placebo controlled trial involving 46
infants used a suspension of freeze dried Lactobacillus reuteri. 50%
reduction in crying time from baseline and show good weight gain and
gastrointestinal tolerance
Complementary therapies
Pediatrics 2010;126:e526-33
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Massage
One study noted a positive effect in massage using aromatherapy
oils, however, the results were not separated between massage and
aromatherapy
While several other studies identified in a systematic review showed
some improvement on symptoms of colic, overall the quality of
these studies is poor
Complementary therapies
Int J Nurs Prac. 2012;18:164-9
Pediatrics. 2011;127:720-33
J Clin Nurs. 2008;17:1754-61
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Swaddling
Reduced crying symptoms but associated
with development hip dyslplasia,overheating, and sudden infant death
syndrome if placed in the prone position
Therefore not recommended
Complementary therapies
Pediatrics. 2007;120:1097-106
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Chiropractic
More controversial
Positive effects noted but bias with parents coping ability rather
that true effectiveness of chriopractic
Limited evidence to support this practice
Complementary therapies
FACT. 2012;17:22-6
N Z Med J. 2011;124:55-71J Explore. 2011;7:168-74
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Acupuncture
Two trials noted a shorter duration and intensity of infantile colic
symptoms
Another double blinded randomised controlled trial comparing
acupuncture with a sham needle insertion noted no major effect on
symptoms including feeding, bowel movement frequency, and sleep
Complementary therapies
Acupunct Med. 2010;28:174-9
Acupunct Med. 2008;26:171-82
BMC Complement Altern Med. 2011;11:93
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Behaviour modification
Family involvement using an integrated care model led to the
relief of infantile colic symptoms more than standard care
The use of contingent music was noted to decrease symptomsin another study
Infant Mental Health J. 2012;33:110-22
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Conclusion
Majority of cases only need simple reassurance
Many intervention only have poor evidence support
There are no effective and safe pharmacological management
options available over the counter or by prescriptions
Infantile colic is self limiting and benign but can cause distress
to parents. Therefore, parental support is important.
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Thank you,
for your attention