1. Continuity Clinic COLIC Every Parent’s Nightmare Michael Martin, MD

2. Continuity Clinic Objectives Be able to define colic AND know it when you see it Be familiar with the other diagnoses that might resemble colic Know both medical and behavioral treatments that are available

3. Continuity Clinic Is this Colic?

4. Continuity Clinic

5. Why Cry? Crying –normal primitive protective reflex –serves as an alarm to alert parents to problem and get their attention  Crying tends to assure “parental investment” in the infant –“attachment behavior” Other potential reasons: –Ward off predators –Nutrition (frequent feeding)

6. Continuity Clinic Why Cry? Colic – when cry is excessive without an identifiable need

7. Continuity Clinic Background Other Animals –Infant chimpanzees Crying peaks in 2nd month of life only manifest in nonhuman infants if separated from parent Other Cultures –!Kung San hunter gatherers of Botswana –Constant skin-to-skin contact, frequent moving with the infant in a sling (or kaross), “continuous” feeding (every 15 min for 1 to 2 min per feed), upright posture, and caregiver responds to every fret and whimper within 10 seconds –Frequency of crying is the same as in Western infants, but the duration is reduced about 50% –90% of the time, !Kung parents can calm their crying baby within 30 seconds

8. Continuity Clinic Working Definition Infant cries more than 3 hours per day, and more than 3 days per week, and for more than 3 weeks (Wessel Criteria) –Also known as the rule of 3’s

9. Continuity Clinic Why should you care? Associated Risks Increased risks of breastfeeding failure Postpartum Depression Martial Conflict Higher rates of child abuse

10. Continuity Clinic Background Between 16% and 26% of all infants experience colic No predilection for race, ethnic groups, sex, socioeconomic grouping Temporal Pattern: –Excessive crying begins at 2 weeks of age –Peaks at 6 weeks –Decreases by 8 weeks –Resolves completely by 16 weeks Premature infants experience colic 2 weeks past due date

11. Continuity Clinic Presentation Episodic crying spells UNRELATED to feeding Pattern is diurnal, with increased crying in the evening and night –Note: All infants experience crying episodes in the evening that peaks at 6 weeks of age Physical signs (usually described by parents) –Infants draw up their legs while they cry –Tense abdomens –Arch their backs (parents describe them as “gassy”)

12. Continuity Clinic Etiology Theories Anyone? Maternal Anxiety Difficult infant temperament Brain Immaturity GI disorders –Gas and cramps –Aerophagia –Food intolerance –GERD

13. Continuity Clinic Diagnosis Physical Examination – NORMAL! –Must rely on history taking Gastroesophageal reflux (GER), which can present with increased crying, often is suggested as causing colic –only 2% to 4% of infants who have symptoms of colic have been shown to have GER Formula intolerance such as cow milk allergy often implicated but is associated with additional symptoms: –emesis, diarrhea,blood in the stool, severe eczema, or urticaria THIS IS A DIAGNOSIS OF EXCLUSION!

14. Continuity Clinic Management

15. Continuity Clinic Management Common books for parents that admit that for really fussy babies they have little to offer: –“Very often, you may not be able to quiet the screaming.” What to Expect the First Year –“It’s completely all right to set the baby in the bassinet while trying to drown out the noise with the running water of a hot shower.” The Girlfriend’s Guide to Surviving the First Year of Motherhood –“The whole episode goes on at least an hour and perhaps for three or four hours.” Your Baby and Child

16. Continuity Clinic Management -Traditional Medical Approaches- Simethicone (Mylicon) – RCT does not show superiority to placebo Dicyclomine (Bentyl) and Hyoscyamine (Levsin) –Anticholinergic (antispasmodic) –Has demonstrated reduced time of crying –AE: Sedation, apnea, seizures, and coma (contraindicated in those under 6 months old) Dietary changes for a breastfeeding mother or multiple formula changes have not been shown to have benefit

17. Continuity Clinic Management Behavioral: Tight swaddling, rapid swinging or jiggling motion, nonnutritive sucking, and steady loud white noise such as “hushing.” –Combining these techniques may calm both caregiver and infant –Holding the infant for more than 3 hours daily has been shown to decrease the intensity of the cry but not the duration

18. Continuity Clinic Management Behavioral: The Happiest Baby on the Block –Swaddling –Side/Stomach –Shushing (white noise) –Swinging –Sucking

19. Continuity Clinic Management -Complementary Medicine Herbal tea mixture: chamomile, vervain, licorice, fennel, and balm mint in a dose of 120 mL given TID –improved colic in one RCT –Risks: large volume of tea potentially could cause poor caloric intake and hyponatremia Fennel Seed Oil –1 RCT study (125 infants) showed benefit –may cause allergic reactions of the skin (rashes) and respiratory tract (asthma and breathing difficulties), seizures Probiotics –trial of Lactobacillus reuteri compared with simethicone in the treatment of infantile colic –95% of the probiotic treatment group were considered “responders” (ie, no longer met Wessel criteria) compared with only 7% of the simethicone group –Bacteremia/septicemia, pneumonia, and meningitis have been documented in immunocompromised and severely debilitated patients in other studies

20. Continuity Clinic Time heals all……..