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Causes of infantile colic and simple support measures

Key learning points:

- Infantile colic is common and often causes both infants and their carers considerable distress

- The cause or causes remain largely unexplained and there is little evidence to support therapeutic interventions. For most infants the key management approach is to advise simple measures and to ensure there is appropriate support in place for families

- In a small subset of infants, the cause will be cows' milk allergy (CMA) and it is important to recognise which infants need this diagnosis to be properly explored

Colic is characterised by inconsolable excessive crying in the early weeks of life in an otherwise healthy infant. It is a common problem, estimated to affect between 5-19% of infants.1 Although the exact causative mechanism of colic remains unclear, it has been hypothesised that in some cases dietary allergens may be implicated in its cause and treatment.2  This article will provide an overview of colic and explore the possibility of a link between colic and cows' milk allergy (CMA).

Diagnosis of colic

Although different definitions of colic exist, the most commonly accepted definition was first published in 1954 by Wessel et al.3 and follows a 'rule of threes': “unexplained crying lasting > three hours a day, for > three days a week for > three weeks of duration”. During the episodes of crying, infants may also draw up their legs, arch their back, have a flushed face, pass wind and have a rigid abdomen. Infants presenting with these symptoms should be assessed by a qualified medical practitioner to rule out other diagnoses.4 In some cases, excessive crying may mean an infant is presenting in pain, needing urgent investigation (see “warning signals” in Table 1). Box 1 lists factors that should be considered before making a diagnosis of infantile colic.

Natural history and consequences of colic

Colic is thought to be largely a benign and transient condition that presents in the first six weeks of life and resolves spontaneously by approximately four months of age. Despite its short-lived nature, understandably the repeated bouts of crying can cause considerable parental distress. Perhaps unsurprisingly, unexplained crying is the most common presentation to paediatricians in the first 16 weeks of life.5 In general, colic is not thought to have any long term health consequences, however it has been suggested that infants with colic may be more likely to have feeding difficulties6 and that infants with severe cases of colic may be more likely to experience recurrent abdominal pain and allergic disorders at the age of 10 years old.7

Causes of colic

Despite several decades of research, the precise cause or causes of colic remain unknown. Numerous mechanisms have been proposed; including food hypersensitivity, gut dysmotility or immaturity, behavioural factors, maternal smoking and altered gut microflora, however it is possible that the cause is multifactorial, with inconsolable crying as the final common outcome.8 Breastfeeding does not appear to be protective against colic, as colic affects both breast and formula-fed infants equally.1

Colic as a presentation of Cows' Milk Allergy

In the UK, it is estimated that approximately 3% of infants experience CMA.9 Infants are exposed to cows' milk protein via the maternal diet if breastfed, via standard infant formula, or when solids are introduced. It is therefore not surprising that cows' milk is often identified as a possible cause for gut and skin problems, particularly in early infancy. It is known that parents may incorrectly perceive their child to have a food allergy10 and that cows' milk free diets are sometimes initiated unnecessarily.11,12

Infantile colic is listed by the National Institute of Health and Clinical Excellence (NICE) food allergy guideline as one of the symptoms of food allergy (see Table 1).13 However, infants with CMA don't often present with colic as an isolated symptom. Typically, there may be some other skin and/or respiratory symptoms in addition to gastrointestinal symptoms.

The NICE guideline13 emphasises that food allergy should be particularly considered:           

- In infants where there is a family history of allergic disease (but the absence of a family history of allergy does not exclude the possibility of an infant becoming allergic)

- In infants where symptoms are persistent and affecting different organ systems

- In infants who have been treated for moderate to severe atopic eczema, Gastro Oeosphageal Reflux Disease (GORD) or other persisting gastrointestinal symptoms (including 'colic', loose stools, constipation), but have not responded to the usual initial therapeutic interventions.

Colic and exclusion diets

Studies of exclusion diets, both maternal and infant, have yielded conflicting results, perhaps because many of the studies have small sample sizes and are prone to bias.14 In one study, maternal consumption of cruciferous vegetable (e.g. broccoli, cabbage, cauliflower) and onions was associated with increased colic, with no affect of chocolate or garlic.15 A systematic review concluded that changing the maternal diet to reduce the burden of allergy-associated foods can provide some benefit in reducing infantile colic in breast-fed infants.14 However, this must be weighed against the difficulties and practicalities of ensuring a balanced and adequate maternal diet to meet the demands of breastfeeding when excluding major food groups. In addition, it has been acknowledged that a placebo effect is often seen, with improvements in colic symptoms also reported in the control group of infants.16

The evidence from the systematic review also suggests that the use of hydrolysed infant formula can be effective in reducing the symptoms of infant colic in formula-fed infants, however consideration should be given to the resource and cost implications of such a measure. The NHS guidelines on routine postnatal care of women and their babies4 state that “use of hypoallergenic formula in bottle fed babies should be considered, but only under medical guidance”. Unsupervised dietary exclusions can put infants at risk of nutritional deficiencies17 or at risk of a more serious allergic reaction when cow's milk is reintroduced,18 hence they should only be initiated under the advice and guidance of an experienced dietician.

Management and treatment of colic

NHS guidelines recommend that colic is best managed by providing parental reassurance that colic is a phase that will resolve spontaneously.4 It emphasises the importance of peer support and suggests that such measures as gentle motion, 'white noise', baby massage and holding the infant may provide some comfort and relief during the crying episodes. There is insufficient evidence that medical treatments, such as lactase and simeticone drops are effective and they should only be tried if parents are unable to cope despite advice and reassurance, and discontinued if there is no improvement after one week. A systematic review of manipulative therapies (chiropractic, osteopathy and cranial manipulation), found some reduction in crying, however overall the studies had too few participants and were of insufficient quality to recommend manipulative therapies as a treatment for colic.8 The accompanying algorithm (Table 1) provides a summary of the diagnosis and management of infantile colic.

Conclusion

In the majority of cases, colic is a transient and self-resolving condition that is not related to food allergy. However, in infants with persisting symptoms of colic, particularly if there are other symptoms suggestive of CMA, a two to four week trial of a maternal milk-free diet or hypoallergenic formula is indicated.

This should be supervised by a healthcare professional with knowledge of food allergy. Unfortunately, despite extensive research, the exact cause of colic still remains unknown in most cases. The most practical treatment advice at present is to provide parental reassurance, advise simple measures of management and to ensure that there is appropriate support for the family. Therefore we have developed a combined diagnostic and management algorithm for infantile colic that attempts to set out such a
practical approach.

References

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2. Jakobsson I, Lothe L, Ley D, Borschel MW. Effectiveness of casein hydrolysate feedings in infants with colic. Acta Paediatr 2000, 89:18-21

3. Wessel MA, Cobb JC, Jackson EB et al. Paroxysmal fussing in infancy, sometimes called colic. Pediatrics 1954; 15: 421-435.

4. Dermott K, Bick D, Norman R, Ritchie G, Turnbull N. et al. Clinical Guidelines and Evidence Review for postnatal care: Routine Post Natal Care of Recently Delivered Women and their Babies. London: National Collaborating Centre for Primary Care and Royal College of General Practitioners; 2006

5. Miller J. Cry-babies: A framework for chiropractic care. Clin Chiropract 2007; 10:139-46.

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8. Dobson D, Lucassen PLBJ, Miller JJ, Vlieger AM, Prescott P & Lewith, G. Manipulative therapies for infantile colic. Cochrane Database Syst Rev 2012, Issue 12, Art. No.: CD004796.

9. Venter C, Pereira B, Voigt K, Grundy J, Clayton CB, Higgins B, et al. Prevalence and cumulative incidence of food hypersensitivity in the first 3 years of life. Allergy 2008; 63,354-9.

10. Venter C, Pereira B, Grundy J, Clayton CB, Roberts G, Higgins B, Dean T. Incidence of parentally reported and clinically diagnosed food hypersensitivity in the first year of life. J Allergy Clin Immunol 2006; 111:1118-24.

11. Eggesbo M, Botten G, Stigum H. Restricted diets in children with reactions to milk and egg perceived by their parents. J Paediatr 2001; 139:583-7.

12. Sinagra JL, Bordignon, V, Ferraro, C, Cristaudo A, Di Rocco M, Amorosi B, Capitanio B. Unnecessary milk elimination diets in children with atopic dermatitis. Paediatr Dermatol 2007; 241-6.

13. NICE. Diagnosis and assessment of food allergy in children and young people in primary care and community settings. Clinical guideline 116. 2011.

14. Iacovou M, Ralston RA, Muir J, Walker KZ, Truby H. Dietary Management of Infantile Colic: A systematic Review. Matern Child Health J 2012;16: 1319-1331.

15. Lust KD, Brown JE, Thomas W. Maternal intake of cruciferous vegetables and other foods and colic symptoms in exclusively breast fed infants. J Am Diet Assoc 1996; 96: 46-48.

16. Hill D, Roy N, Heine RG, Hosking CS, Francis D.E. et al. Effect of a low-allergen maternal diet on colic among breastfed infants: A Randomised Controlled Trial. Pediatrics 2005; 116, e709.

17. Noimark L, Cox HE. Nutritional problems related to food allergy in childhood. Pediatr Allergy Immunol. 2008; 19:188-95.

18. Al Dhaheri W, Diksic D, Ben-Shoshan M. IgE-mediated cow milk allergy and infantile colic: diagnostic and management challenges. BMJ Case Rep. 2013; Feb 6.

19. Reijneveld SA, Brugman E, Hirasing RA. Infantile colic: Maternal smoking as a potential risk factor. Arch Dis Child 2000; 83: 302-3.