2. دکترمحمد حسين بهزاد مقدم متخصص كودكان و نوزادان آذر 93 Infantile Colic-Treatment And Role of Probiotics

3.         

4. The classic Wessel definition defines infantile colic as: When an otherwise healthy infant cries for: - > 3 hours a day - on > 3 days a week - for > 3 weeks 1 (or alternative definition: for >1 week 2 ) Infantile colic is particularly difficult to soothe and is often accompanied by additional symptoms e.g. flatulence Definition When an otherwise healthy infant is crying for an excessively long time 1. Wessel MA, Cobb JC, Jackson EB et al. Pediatrics 1954; 14:421-34. 2. Hyman et al. Gastroenterology; 2006;130(5):1519-26.

5. Arching back Flushing Constipation Abdominal Distention Flexed legClinched fits Abdominal cramp Regurgitation Painful facial expression Flatulence Accompanied symptoms

6. A very common condition Can occur in up to 40% of babies 1 Common in both breastfed and bottle-fed babies 1,2,3 Usually starts in the first few weeks of life A driver for up to 25% of pediatric consultations 1 1. Lucassen PLBJ, Assendelft WJJ, van Eijk JThM et al. Arch Dis Child 2001; 84:398-403. 2. Brazelton TB. Pediatrics 1962;29:579-88. 3. Iacono G, Merollar et al. Dig Liv. Dis. 2005; 37: 432-438.

7. Peaks at 5 -6 weeks of age

8. Mean crying time: average 2 - 2.5 hours/ day at 6 weeks of age

9. Crying time: Peaks 6:00 pm - 12:00 pm

10. Management and treatment Up to now, there is no consensus concerning management and treatment. Literature reports growing evidence about the effectiveness of dietary, pharmacological, complementary and behavioral therapies as options for the management of infantile colic

11. Nutrition Some nutritional studies reported favorable results for the use of Casein hydrolysed formulas in bottle-fed infants or low-allergen maternal diets in breastfed infants such as avoidance of cow's milk proteins were favorable but not for the use of additional fiber or lactase. Looking for new treatments of Infantile Colic Ital J Pediatr. 2014 Jun 5;40:53.

12. Stimulation Behavioral studies on the use of increased stimulation gave unfavorable results, whereas results from the use of decreased stimulation and contingent music were favorable.

13. Pharmacological Tx Pharmacological studies on Simethicone gave conflicting results and with Dicyclomine hydrochloride and Cimetropium bromide results were favorable but side effects were noted. Some of them can cause potentially serious adverse reactions (dicyclomine). J Paediatr Child Health. 2012 Feb;48(2):128-37

14. Effectiveness is likely for a probiotics (Lactobacillus reuteri) and for herbal mixtures containing fennel extracts. Presse Med. 2012 Jul;41(7-8):e404-10

15. Probiotics: definitions World Health Organization: – “live microorganisms which when administered in adequate amounts confer a health benefit on the host” A bacterial strain that: – Survives the stomach acid and bile – Adheres to intestinal lining – Grows and establishes temporary residence in the intestines – Imparts health benefits R Fuller. Probiotics: The Scientific Basis. London: Chapman and Halls. 1992

16. Probiotics Lactobacillus sp. – reuteri – casei – ramnosus – acidophilus Streptococcus sp. Bifidobacterium sp. – infantis – lactis – longum – breve – bifidum Sacharomyces boulardii (non- human) VSL no.3

17. Probiotics: Proposed uses Infectious diarrhea Antibiotic-associated diarrhea IBD, IBS, and pouchitis Necrotizing Enterocolitis Bacterial vaginosis Recurrent UTI’s Atopic diseases Immune system enhancement H pylori infections Dental caries Radiation induced diarrhea Cardiovascular risk reduction Constipation Rheumatoid arthritis

18. Probiotics: prescribing Which organism to use? Which product? For what conditions? What dose? For How long? Any side effects to be aware of? How much does it cost?

19. Probiotics: prescribing – Lactobacillus GG best studied to date – Combination products not well studied, but may work as well – 10 billion organisms/d – Keep in fridge – Give in cool food/drink – 2% risk bloating/gas

21. Preterm Infant GI Flora The microbial flora of the intestines of preterm neonates in NICU differs from that of normal term neonates. VLBW preterm neonates usually acquire microbial flora mainly from intensive care environment rather than from their own mother. Few studies have demonstrated that there is delay in appearance of Bifidobacteria species in VLBW neonates until third week of life, even in those receiving only breast milk.

22. VLBW preterm neonates are at risk of gut colonization with pathogens which can alter the permeability of intestines and promotes inflammatory cascade which facilitates NEC.