Prevalence of infant colic

The effect of behavioral therapy based counseling with anxious mothers on their infants' colic: a randomized controlled clinical trial

Background

Given the possible effect of maternal anxiety on the severity of colic pain in infants, this study aimed to investigate the effects of behavioral therapy counseling on infantile colic (primary outcome), maternal anxiety, and mother-infant attachment (secondary outcomes) in anxious mothers with colicky infants.

Method

This randomized controlled clinical trial was conducted on 46 anxious mothers of 2–6-weeks-old exclusively breastfed colicky infants who had a score of 112 and above according to the Postpartum Specific Anxiety Scale (PSAS), reffered to the pediatric clinics of Al-Zahra, Taleghani and Children Hospitals of Tabriz, Iran. The participants were randomly assigned to the intervention (n = 23) and control (n = 23) groups using randomized block design. Mothers in the intervention group attended 8 systematic desensitization counseling sessions (2–3 sessions per week). Those in the control group received routine care. The researcher completed the Postpartum Specific Anxiety Scale (PSAS), Mother-Infant Attachment Questionnaire (MIAQ), and Infant Colic Scale (ICS) by interviewing the participants before and two weeks after the intervention.

Results

There was no significant difference between the intervention and control groups in the socio-demographic profile of participants. After the intervention, the mean postpartum anxiety score of women in the intervention group was significantly lower than that of those in the control group (Mean Difference (MD) = 22.5, 95% Confidence Interval (CI) = 2.3 to 42.7; p = 0.029). The mean infant colic score of the infants of mothers in the intervention group was insignificantly lower than that of those in the control group (MD = -2.9, 95% CI = -8.3 to 2.4; p = 0.271). In addition, no significant difference was observed between the two groups in terms of their mean mother-infant attachment scores (MD = -0.04, 95% CI = -3.1 to 0.3; p = 0.976).

Conclusion

Behavioral therapy counseling effectively reduced postpartum anxiety in women with colicky infants; however, this reduction did not lead to a significant decrease in the infants’ colic pain. Therefore, health care providers are recommended to use this counseling method in combination with other effective counseling approaches to promote mental health of these mothers.

Trial Registration

IRCT Registration Number: IRCT20111219008459N14, registered on 08/10/2020. https://irct.ir/user/trial/45949/view

Efficacy of probiotics for managing infantile colic due to their anti-inflammatory properties: a meta-analysis and systematic review

BACKGROUND

Infantile colic (IC) is excessive crying in otherwise healthy children. Despite vast research efforts, its etiology remains unknown.

PURPOSE

Most treatments for IC carry various side effects. The collection of evidence may inform researchers of new strategies for the management and treatment of IC as well as new clues for understanding its pathogenesis. This review and meta-analysis aimed to evaluate the efficacy and possible mechanisms of probiotics for mananaging IC.

METHODS

Ten papers met the study inclusion and exclusion criteria, and the meta-analysis was conducted using Review Manager (RevMan) software and a random-effects model.

RESULTS

This meta-analysis revealed that probiotics are effective for treating infantile colic, while the review showed that this efficacy may be due to their anti-inflammatory effects.

CONCLUSION

Probiotics may be an important treatment option for managing infantile colic due to their anti-inflammatory properties.

Vestibular stimulation with Indian hammock versus music intervention in the prevention of infantile colic in term infants: An open-labelled, randomized controlled trial

BACKGROUND AND OBJECTIVES

To determine whether vestibular stimulation offered by Indian hammock and music intervention are useful in reducing the occurrence of infantile colic in term infants.

METHODS

This open-labelled randomized clinical trial was conducted among 465 term neonates who were randomly assigned to one of three groups: music group, hammock group and control group. The music intervention was given for a cumulative duration of at least 4 h a day with one stretch of at least 1 h. In the hammock group, babies were put to sleep inside the Indian hammock and were swung gently until they sleep, and were allowed to sleep in it, until they wake up. For the control group, routine pre-discharge counselling was given. All parents were provided a cry log and were instructed to record the log of cry events and duration. The primary outcome measure was occurrence of infantile colic episode as defined by ROME IV criteria. The infants were followed up from birth until the age of 3.5 months, and the cry log was collected during each follow-up visit.

RESULTS

Of the 435 term neonates who completed follow-up, 59 infants developed infantile colic (13.6%). The prevalence of infantile colic in the control group, music group and the Indian hammock group was 25.6%, 5.4% and 9.6% respectively; there was a significant reduction in the prevalence of infantile colic in the intervention groups as compared to the control group.

CONCLUSIONS

Vestibular stimulation by Indian hammock and music intervention individually reduced the occurrence of infantile colic.

Assessment of Evidence About Common Infant Symptoms and Cow's Milk Allergy

IMPORTANCE

Sales of specialized formula for managing cow's milk allergy (CMA) have increased, triggering concern that attribution of common infant symptoms, such as crying, vomiting, and rashes, to CMA may be leading to overdiagnosis, which could undermine breastfeeding.

OBJECTIVE

To understand whether CMA guideline recommendations might promote CMA overdiagnosis or undermine breastfeeding.

EVIDENCE REVIEW

We reviewed recommendations made in CMA guidelines and critically appraised 2 key recommendations. First, we reviewed relevant literature summarizing whether maternal or infant dietary exclusion of cow's milk is effective for managing common infant symptoms. Second, we reviewed published data on breastmilk composition and thresholds of reactivity in CMA to estimate the probability that cow's milk protein in human breastmilk can trigger symptoms in infants with CMA. We also documented the level of commercial involvement in CMA guidelines.

FINDINGS

We reviewed 9 CMA guidelines published from 2012 to 2019. Seven suggest considering CMA as a cause of common infant symptoms. Seven recommend strict maternal cow's milk exclusion for managing common symptoms in breastfed infants. We found CMA proven by food challenge affects approximately 1% of infants, while troublesome crying, vomiting, or rashes are each reported in 15% to 20% of infants. We found clinical trials do not provide consistent support for using maternal or infant cow's milk exclusion to manage common symptoms in infants without proven CMA. We estimated that for more than 99% infants with proven CMA, the breastmilk of a cow's milk-consuming woman contains insufficient milk allergen to trigger an allergic reaction. Three CMA guidelines were directly supported by formula manufacturers or marketing consultants, and 81% of all guideline authors reported a conflict of interest with formula manufacturers.

CONCLUSIONS AND RELEVANCE

Recommendations to manage common infant symptoms as CMA are not evidence based, especially in breastfed infants who are not directly consuming cow's milk. Such recommendations may cause harm by undermining confidence in breastfeeding.

Continuous wavelet analysis of postprandial EGGs suggests sustained gastric slow waves may be slow to develop in infants with colic

BACKGROUND

Electrogastrography in conjunction with Fast Fourier transform has limited success in detecting low grade abnormalities in gastric electrophysiological activity owing to the non-stationarity of the signal. Analysis by continuous wavelet transform is suitable for non-stationary signals and was used to analyse EGG activity in babies with and without colic.

METHODS

Thirty minute postprandial EGG recordings were obtained from 23 sleeping breast-fed infants with clinically validated recurrent colic and 26 breast-fed non-colicky infants. Continuous wavelet transform analysis (CWT) identified three principal frequency components. The mean, standard deviation, and the number of frequency maxima that fell below one standard deviation from the mean were determined for each infant and each frequency.

KEY RESULTS

Three component frequencies in the ranges 1.4-2.5 cpm, 2.5-4.0 cpm, and 4.0-15 cpm were found in all EGGs. Pairwise comparisons of the characteristics of each of the frequency ranges by univariate analyses showed significant differences between colicky and non-colicky subjects only in the number of maxima in the mid range of frequencies that lay below one standard deviation from the mean. However, CWT based on all frequencies allowed discrimination of the EGGS of colicky from non-colicky babies on a basis of number of frequency maxima below one standard deviation from the mean in the midrange of frequencies and in the mean and standard deviation in the low range of frequencies that was likely a harmonic of the midrange.

CONCLUSIONS & INFERENCES

CWT allowed distinction of EGG signals from colicky and healthy babies. The results indicate that colic may result from tardiness in the establishment of coherent propagation of the gastric slow wave in colicky babies.

Prevalence and Health Outcomes of Functional Gastrointestinal Symptoms in Infants From Birth to 12 Months of Age

OBJECTIVES

The aim of the study was to review published evidence and the opinion of practising clinicians on the prevalence and long-term health consequences of functional gastrointestinal symptoms in infants younger than 12 months.

METHODS

PubMed was searched from inception to November 2014 to find articles reporting the prevalence and long-term health outcomes of infantile colic, regurgitation, functional constipation, functional diarrhoea, and dyschezia in infants younger than <12 months. A questionnaire was sent to practising clinicians worldwide, and a group of 15 international experts met to discuss the likely frequency and longer-term consequences of these symptoms.

RESULTS

The literature search identified 30 studies reporting the prevalence of infantile colic (2%-73%), 13 that of regurgitation (3%-87%), 8 that of functional constipation (0.05%-39.3%), 2 that of functional diarrhoea (2%-4.1%), and 3 that of dyschezia (0.9%-5.6%). The studies varied in design, populations investigated, and definition of the symptoms. Questionnaires were received from 369 respondents. The experts agreed that the likely prevalences for colic, regurgitation, and functional constipation were 20%, 30%, and 15%, respectively. The limited data in the literature for functional diarrhoea and dyschezia suggest prevalences <10%. Infantile colic may be associated with future health problems in a subset of infants.

CONCLUSIONS

Functional gastrointestinal symptoms appear to occur in a significant proportion of infants younger than 12 months and may have an impact on future health outcomes. Prospective collection of data according to agreed criteria is needed to obtain more accurate estimates of the prevalence and consequences of these symptoms.

GI symptoms in infants are a potential target for fermented infant milk formulae: a review

Besides pre- and pro-biotic-containing infant formulae, fermented infant formulae are commonly used to relieve or prevent symptoms of gastrointestinal (GI) discomfort in young infants. During the fermentation process in cow's milk-based formulae, the beneficial bacteria modulate the product by forming several beneficial compounds, which contribute to the alleviation of the symptoms observed. This review summarizes the clinical evidence on the impact of fermented infant formulae on common pediatric GI-symptoms. The potential mechanisms involved are discussed: i.e., the lactose and protein (in-) digestibility, effects on gastric emptying and gut transit and modulation of the colonic microbiota. Although initial evidence indicates a beneficial effect of fermented formulae on GI discomfort in newborns, validation and confirmation of the clinical proof obtained so far is warranted, as well as further research to (more fully) understand the mode of action.

[Which treatments for infantile colics?]

BACKGROUND

Infantile colics or excessive crying represent a source of stress for parents and a frequent reason for encounter in primary care.

OBJECTIVE

To assess the effectiveness of treatments of this syndrome from a systematic review.

INFORMATION SOURCES

Medline, Cochrane and Embase databases.

SELECTION OF STUDIES

We used the following inclusion criteria: therapeutic assessment of infant colics or excessive crying, randomized controlled trials or meta-analyses, published in English or French language. Thirty-one randomized controlled trials and one meta-analysis have been included.

RESULTS

Allopathic drugs have not proved effectiveness (simethicone, lactase) and some of them can cause potentially serious adverse reactions (dicyclomine). Protein hydrolysate or soy formulas seem to be effective, but soy milk can induce allergies. Sucrose solutions provide some benefit in studies with low level of evidence. Effectiveness is likely for a probiotics (Lactobacillus reuteri) and for herbal mixtures containing fennel extracts. Evidence is lacking for manual (osteopathy, acupuncture) and behavioural therapies (decreased stimulations, reassurance of parents).

LIMITATIONS

The definition of infantile colics and the methods used for crying measurement changed across trials. The included trials were of variable quality, especially with no double-blind procedure in 17 trials.

CONCLUSION

The most validated treatments for infantile colics are the substitution of cows' milk by a hydrolysed formula, the use of L. reuteri and of fennel extracts.

The role of negative reinforcement in infant caregiving: an experimental simulation

We observed 11 undergraduates in an experiment designed to simulate infant caregiving. In negative reinforcement conditions experienced by all participants, a targeted caregiving response (e.g., rocking a baby doll) produced escape from, and avoidance of, a recorded infant cry. Nine participants' caregiving was shown to be controlled by this negative reinforcement contingency. Nine participants experienced an extinction condition that consisted of an inescapable cry, and the previously reinforced caregiving responses of 2 of these participants were resistant to extinction. For both of these participants, the previously reinforced response was eliminated when an alternative form of caregiving was reinforced. These results highlight the role of negative reinforcement in infant caregiving and suggest the need for additional research on the effects of crying on caregivers as well as the development of effective strategies for minimizing infant crying.

A retrospective study of chiropractic treatment of 276 danish infants with infantile colic

OBJECTIVES

The aim of this study was to investigate if the outcome of excessively crying infants treated with chiropractic manipulation (1) was associated with age and/or (2), at least partially, can be explained by age according to the natural decline in crying.

METHODS

This was a retrospective evaluation of clinical records of 749 infants from a private Danish chiropractic practice. All of the infants were healthy, thriving infants born to term within the age of 0 to 3 months who fulfilled the diagnostic criteria for excessively crying infants (infantile colic), whose parents sought chiropractic treatment. The infants were treated using chiropractic management as decided by the treating doctor of chiropractic, and changes in crying based upon the parents' report were noted as improved, uncertain, or nonrecovered. Age predictor groups were cross-tabulated against the outcome variables, and difference between classification groups was tested with χ(2) tables and confidence intervals.

RESULTS

Slightly older age was found to be linked to excessively crying infants who experienced clinical improvement. However, no apparent link between the clinical effect of chiropractic treatment and a natural decline in crying was found for this group of infants.

CONCLUSION

The findings of this study do not support the assumption that effect of chiropractic treatment of infantile colic is a reflection of the normal cessation of this disorder.

Why are they having infant colic? A nested case-control study

We aimed to analyse infant (birth characteristics, feeding type, faecal enzyme activities) and environmental (maternal smoking, nutrition and psychological status, mother-child bonding, family structure, support for the mother, familial atopy) risk factors for infant colic and to follow infants with respect to physical growth, sleeping status up to 8 months of age in a nested case-control study. 660 mothers who delivered at Dr Zekai Tahir Burak Maternity Hospital, were enrolled within 3-72 h post delivery. Each infant with inconsolable persistent crying and four matched infants with no crying episodes were invited by phone to Hacettepe University Ihsan Doğramacı Children's Hospital at 30-45 days post partum. At 40-55 days, we examined the infants and gave mothers a questionnaire, including crying characteristics of the infants; 47 infants were diagnosed with colic and 142 as non-colic. When the infants were 7-8 months old, another interview was done. The colic group had higher proportions of less-educated (≤ 8 years) and smoking mothers, extended family and families with domestic violence than the non-colic group. The colic group of mothers had significantly higher rates of 'impaired bonding' in the Postpartum Bonding Questionnaire, higher scores on the Edinburgh Postnatal Depression Scale, higher scores for hostility subscales of the Brief Symptom Inventory and a more irregular sleep pattern than the non-colic group. No differences were revealed for faecal enzyme activities. At 7-8 months, the colic group was shorter than the non-colic group. Colic was associated with various perinatal factors (maternal education, smoking habits, cheese consumption, hostility scores and domestic violence) and having colic in infancy negatively affected the sleeping pattern and the height of the infant.

Gastroesophageal reflux symptoms in infants in a rural population: longitudinal data over the first six months

BACKGROUND

Increasing numbers of infants are receiving prescription medications for symptoms associated with gastroesophageal reflux. Our aim was to prospectively measure reported gastroesophageal reflux symptoms in healthy term infants for the first six months of life.

METHODS

In a prospective cohort study in the rural Upper Peninsula of Michigan, 128 consecutive maternal-infant pairs were followed for six months and administered the Infant Gastroesophageal Reflux Questionnaire Revised (I-GERQ-R) at the one-month, two-month, four-month, and six-month well-child visits.

RESULTS

The I-GERQ-R scores decreased with age. Average scores were 11.74 (SE = 5.97) at one-month, 9.97(4.92) at two-months, 8.44(4.39) at four-months, and 6.97(4.05) at six months. Symptoms associated with colic were greatest at one month of age.

CONCLUSION

Symptoms of gastroesophageal reflux as measured by the I-GERQ-R decrease with age in the first six months of life in otherwise healthy infants; however the I-GERQ-R may have difficulty differentiating gastroesophageal reflux disease from colic in those under 3 months of age.

Characterization of activity epochs in actimetric registries for infantile colic diagnosis: Identification and feature extraction based on wavelets and symbolic dynamics

The diagnosis and therapy planning of high prevalence pathologies such as infantile colic can be substantially improved by statistical signal processing of activity/rest registries. Assuming that colic episodes are associated to activity episodes, diagnosis aid systems should be based on preprocessing techniques able to separate real activity from rest epochs, and feature extraction methods to identify meaningful indices with diagnostic capabilities. In this paper, we propose a two step diagnosis aid methodology for infantile colic in children below 3 months old. Identification of activity periods is performed by means of a wavelet based activity filter which does not depend on the acquisition device (as so far proposed methods do). In addition, symbolic dynamic analysis is used for extraction of discriminative indices from the activity time series. Results on real data yielded 100% sensitivity and 80% specificity in a study group composed of 46 cases and 10 control subjects.

Reprint of: a preliminary assessment of the impact of cranial osteopathy for the relief of infantile colic

In this open, controlled, prospective study, 28 infants with colic were randomized to either cranial osteopathic manipulation or no treatment; all were seen once weekly for 4 weeks. Treatment was according to individual findings, and administered by the same practitioner. Parents recorded time spent crying, sleeping and being held/rocked on a 24-h diary. A progressive, highly significant reduction between weeks 1 and 4 in crying (hours/24h) was detected (P<0.001) in treated infants; similarly, there was a significant improvement in time spent sleeping (P<0.002). By contrast, no significant differences were detected in these variables for the control group. Overall decline in crying was 63% and 23%, respectively, for treated and controls; improvement in sleeping was 11% and 2%. Treated infants also required less parental attention than the untreated group. In conclusion, this preliminary study suggests that cranial osteopathic treatment can benefit infants with colic; a larger, double-blind study is warranted.

Soothing methods used to calm a baby in an Arab country

This study was undertaken to determine how mothers soothed their crying infants. A total of 1137 mothers of different cultural backgrounds were approached, 998 agreed to participate in the study, but only 716 completed the questionnaire through a telephone interview. Analysis was restricted to 702 mothers from the UAE nationality, other Arabs, other Muslims, Indians and Philippinos. The questionnaire contained 23 questions on different soothing methods. The most common soothing method was breast-feeding (99.1%), followed by holding and carrying the infant (96.9%), letting infant suck on his thumb or finger (87.3%), herbal tea (65%), night bottle (42.1%) and swaddling infant (19.5%). Over 90% of mothers of all nationalities, preferred not to use pacifiers. Soothing herbs were often used, with the commonest being anise (165 mothers used anise). Fennel tea was also used by a substantial number of mothers (75), with gripe water (64), cumin (33), chamomile (32), mint (22) and fenugreek (16) making up most of the rest.

CONCLUSION

Mothers' ethnicity and nationality strongly impacted on the soothing methods used, with Arabs more often using herbal tea, prone positioning and swaddling to calm infants and illustrate the importance of culture in the upbringing of children from a very early age.

Incidence and risk factors for infantile colic in Iranian infants

AIM: To assess the incidence of infantile colic and its association with variable predictors in infants born in a community maternity hospital, Tehran, Iran.

METHODS: In this prospective cohort study, mothers who gave birth to live newborns between February 21 and March 20, 2003 at the hospital were invited to join to the study. For every infant-mother dyad data were collected on infant gender, type of delivery, gestational age at birth, birth weight, birth order, and mother’s reproductive history. Then mothers were given a diary to document the duration of crying/fussiness behaviors of their infants for the next 12 wk. We scheduled home visits at the time the infants were 3 mo of age to collect the completed diaries and obtain additional information on infants’ nutritional sources and identify if medications were used for colic relief. Cases of colic were identified by applying Wessel criteria to recorded data. Chi-square and Mann-whitney U tests were used to compare proportions for non-parametric and parametric variables, respectively.

RESULTS: From 413 infants, follow-up was completed for 321 infants. In total, 65 infants (20.24%) satisfied the Wessel criteria for infantile colic. No statistical significance was found between colicky and non-colicky infants according to gender, gestational age at birth, birth weight, type of delivery, and, infant’s feeding pattern. However, firstborn infants had higher rate for developing colic (P = 0.03).

CONCLUSION: Colic incidence was 20% in this population of Iranian infants. Except for birth order status, no other variable was significantly associated with infantile colic.

Use of soy protein-based formulas in infant feeding

Soy protein-based formulas have been available for almost 100 years. Since the first use of soy formula as a milk substitute for an infant unable to tolerate a cow milk protein-based formula, the formulation has changed to the current soy protein isolate. Despite very limited indications for its use, soy protein-based formulas in the United States may account for nearly 25% of the formula market. This report reviews the limited indications and contraindications of soy formulas. It will also review the potential harmful effects of soy protein-based formulas and the phytoestrogens contained in these formulas.

Familiarity of pediatricians with different commercially available neonatal and infant formulas

To assess the familiarity of pediatricians with commercially available formulas and their use for cow's milk protein allergy and colic, a list of formulas was generated by visiting several grocery stores. Pediatricians were ask to indicate their familiarity with these and other "specialized" formulas with regard to protein and carbohydrate sources, energy content, hypoallergenicity, and indication for infant colic. The participants answered an average of 46% of the questions correctly. Respondents were very familiar with 27% of the formulas, and unfamiliar with 35%. The highest score was 70%, and 10% of the responders correctly answered 65% or more of the questions. Fifty-one percent correctly identified the protein source of the formulas; 32% correctly identified the carbohydrate source. The energy content of the formulas was correctly identified by 54%. These data suggest that pediatricians have a poor understanding of the content and appropriate use of neonatal and infant formulas.

A preliminary assessment of the impact of cranial osteopathy for the relief of infantile colic

In this open, controlled, prospective study, 28 infants with colic were randomized to either cranial osteopathic manipulation or no treatment; all were seen once weekly for 4 weeks. Treatment was according to individual findings, and administered by the same practitioner. Parents recorded time spent crying, sleeping and being held/rocked on a 24-hour diary. A progressive, highly significant reduction between weeks 1 and 4 in crying (hours/24h) was detected (P<0.001) in treated infants; similarly, there was a significant improvement in time spent sleeping (P<0.002). By contrast, no significant differences were detected in these variables for the control group. Overall decline in crying was 63% and 23%, respectively, for treated and controls; improvement in sleeping was 11% and 2%. Treated infants also required less parental attention than the untreated group. In conclusion, this preliminary study suggests that cranial osteopathic treatment can benefit infants with colic; a larger, double-blind study is warranted.

Parental responses to infant crying and colic: the effect on breastfeeding duration

CONTEXT

Infant crying can cause parental distress, and colic is associated with low maternal self-efficacy and heightened risk for depression. Breastfeeding is recognized as an effective method of calming infants, but the relationship of colic and the use of breastfeeding to remedy infant crying have not been tested for any effects on breastfeeding duration.

OBJECTIVE

To evaluate the effects of infant colic (colic analysis) and breastfeeding as a method of infant calming (calming analysis) on breastfeeding duration.

DESIGN

The authors followed 700 healthy breastfeeding mother-baby dyads from birth to 1 year. Maternal interviews were conducted postpartum, and at 2, 5, 10, 16, 24, 38, and 52 weeks to ascertain demographic factors, infant crying patterns, comforting practices, physician-diagnosed colic, and breastfeeding behaviors. Cox survival analyses were used to evaluate the independent effects of: (a) physician diagnosed colic; and (b) breastfeeding as a comforting practice on breastfeeding duration. Data from all 700 breastfeeding dyads were used in the colic analyses. In the calming analyses, to assure that breastfeeding was appropriately established, data were used from the 617 couplets that had breastfed for at least 2 weeks. Using a stepwise process, models, adjusted for typical predictors of breastfeeding duration, were developed for exclusive, full and partial breastfeeding duration. Variables of interest (i.e., colic diagnosis, breastfeeding for comfort) were then forced into the baseline models to determine any independent effects.

RESULTS

In the first 16 weeks, parents found that holding (87%), breastfeeding (82%), walking (67%), and rocking (63%) were highly effective calming practices. Mothers who rated breastfeeding as highly effective had a higher frequency of breastfeeding at all contacts (p < 0.05). In adjusted analyses the use of breastfeeding to comfort infants was a significant predictor of longer partial (overall) ([hazard ratio] HR = 0.6, 95% CI 0.4 to 0.9; p = 0.02) but not exclusive or full breastfeeding duration. By 6 months, 44 mothers (6.3%) reported a diagnosis of colic. Mothers of infants with a diagnosis of colic were less likely to report breastfeeding as effective method of infant comforting (p = 0.03). In adjusted analyses the authors found that a diagnosis of colic predicted shorter full breastfeeding duration (HR = 2.4, 95% CI 1.4 to 4.2; p = 0.001) but not exclusive or partial duration.

CONCLUSIONS

Breastfeeding to comfort a crying infant is a strong predictor of partial (overall) duration and is rated as a highly effective calming method by parents. These data suggest that parents may benefit from education about normal infant crying patterns and effective methods of infant comforting, including breastfeeding. However, mothers of infants diagnosed with colic are at risk for shortened duration of full breastfeeding. Although the reasons for this are unclear, it may be helpful to specifically address the subject of colic and infant feeding and encourage mothers to fully breastfeed for the recommended 6 months.

A randomized double-blind placebo-controlled trial of a standardized extract of Matricariae recutita, Foeniculum vulgare and Melissa officinalis (ColiMil) in the treatment of breastfed colicky infants

OBJECTIVE

The aim of this randomized, double-blind, placebo-controlled trial was to investigate the effectiveness and side effects of a phytotherapeutic agent with Matricariae recutita, Foeniculum vulgare and Melissa officinalis in the treatment of infantile colic.

METHODS

93 breastfed colicky infants were enrolled, the diagnosis was made according to Wessel's criteria. After a 3 day observation period, the infants were randomly divided into two groups, one treated with phytotherapeutic agent (PA) and the other with placebo twice a day for 1 week. Crying time and side effects were recorded.

RESULTS

88 infants completed the trial: 41 in the PA group and 47 in the control. The daily average crying time for the PA was 201.2 min/day (SD 18.3) at the baseline and 76.9 min/day (SD 23.5) at the end of the study; for the placebo it was 198.7 min/day (SD 16.9) and 169.9 min/day (SD 23.1) (p < 0.005). Crying time reduction was observed in 85.4% subjects for the PA and in 48.9% subjects for the placebo (p < 0.005). No side effects were reported.

CONCLUSION

The present study shows that colic in breastfed infant improves within 1 week of treatment with an extract based on Matricariae recutita, Foeniculum vulgare and Melissa officinalis.

Gastrointestinal symptoms in infancy: a population-based prospective study

BACKGROUND

During the first months of life, infants can suffer from many 'minor' gastroenterological disturbances. However, little is known about the frequency of these problems and the factors which predispose or facilitate their onset.

AIMS

(a) To ascertain the frequency of the most common gastrointestinal symptoms in infants during the first 6 months after birth; (b) to evaluate the influence of some variables on the onset of the symptoms.

STUDY DESIGN AND PATIENTS

Each of the 150 paediatricians distributed throughout Italy followed 20 consecutive infants from birth to 6 months. 2879 infants (1422 f, 1457 m) concluded the study. The presence of the following symptoms was evaluated: constipation, diarrhoea, vomiting, regurgitation, failure to thrive and prolonged crying fits (colic). Symptoms were recorded whenever the parents requested a clinical check-up or during a set monthly examination.

RESULTS

1582/2879 (54.9%) infants suffered from one of the gastrointestinal symptoms. Regurgitation was the most common disturbance (present in 23.1% of infants), followed by colic (20.5%), constipation (17.6%), failure to thrive (15.2%), vomiting (6%) and diarrhoea (4.1%). Low birth weight was the factor most frequently associated with the onset of gastrointestinal symptoms, followed by low gestational age. Feeding habits did not influence the onset of symptoms, with the exception of constipation, which was linked to a low frequency of breast-feeding. Ninety-three infants (3.2%) were hospitalised for one or more of the gastrointestinal symptoms which were considered. During the whole study period the type of formula-milk was changed in 60% of the infants with one or more gastrointestinal symptoms, and in 15.5% of the infants who did not suffer from any gastrointestinal troubles.

CONCLUSIONS

Gastrointestinal symptoms are very common in infants during the first 6 months after birth. These symptoms required hospitalisation only in a small percentage of cases, but led to the prescription of a 'dietary' milk formula in approximately 60% of the cases. Low birth weight and low gestational age were the main factors influencing the onset of the symptoms.

Long term cognitive development in children with prolonged crying

BACKGROUND

Long term studies of cognitive development and colic have not differentiated between typical colic and prolonged crying.

OBJECTIVE

To evaluate whether colic and excessive crying that persists beyond 3 months is associated with adverse cognitive development.

DESIGN

Prospective cohort study. A sample of 561 women was enrolled in the second trimester of pregnancy. Colic and prolonged crying were based on crying behaviour assessed at 6 and 13 weeks. Children's intelligence, motor abilities, and behaviour were measured at 5 years (n = 327). Known risk factors for cognitive impairment were ascertained prenatally, after birth, at 6 and 13 weeks, at 6, 9, and 13 months, and at 5 years of age.

RESULTS

Children with prolonged crying (but not those with colic only) had an adjusted mean IQ that was 9 points lower than the control group. Their performance and verbal IQ scores were 9.2 and 6.7 points lower than the control group, respectively. The prolonged crying group also had significantly poorer fine motor abilities compared with the control group. Colic had no effect on cognitive development.

CONCLUSIONS

Excessive, uncontrolled crying that persists beyond 3 months of age in infants without other signs of neurological damage may be a marker for cognitive deficits during childhood. Such infants need to be examined and followed up more intensively.

Higher risk of colic in infants of nonmanual employee mothers with a demanding work situation in pregnancy

In this population-based study, we assessed the relation between socioeconomic and psychosocial conditions in 1,094 pregnant women and subsequent infantile colic by means of self-administered questionnaires measuring exposures in the 17th pregnancy week and telephone interviews at infant age 5 weeks. There was a higher risk of colic in infants born to younger mothers, mothers with low instrumental support in pregnancy, and mothers with nonmanual occupations. Having an "active" job situation, that is, high demands and high decision latitude at work, acted synergistically with a nonmanual occupation, yielding even higher odds ratios for colic as did concomitant low instrumental support and nonmanual occupation. An expected synergy between low social participation and nonmanual occupation could not be demonstrated. Findings from gender-related research may partly explain some of these results.

A comprehensive definition of infant colic: parents' and nurses' perspectives

Colic is a term that is often used for crying in infancy. There is no unified definition, the aetiology is disputed and there is no effective method of treatment. Therefore, the crying infant constitutes a problem for parents and for nurses in child health clinics. The purpose of the study was to develop a clinically acceptable framework for describing colic. The design is exploratory, and data were collected through qualitative in-depth interviews with nurses and parents of crying babies. The infants identified by parents and nurses had periods of crying or fussing for more than 3 hours a day, the crying occurring on more than 3 days in any 1 week and lasting for more than 3 weeks. Three categories of crying emerged (intense crying, non-specific fussing and crying, feeding-related crying) that presumably differ in aetiology. An overall definition of colic is proposed that incorporates these categories. The proposed definition may function as a diagnostic tool for nurses when they encounter problems of infant crying. The definition provides nurses with clinical criteria that can guide data collection. More specific assessment and categorization of infant crying will be helpful for nurses in addressing problems of colic.

Victim, perpetrator, family, and incident characteristics of infant and child homicide in the United States Air Force

OBJECTIVE

The present study describes factors related to fatal abuse in three age groups in the United States Air Force (USAF).

METHOD

Records from 32 substantiated cases of fatal child abuse in the USAF were independently reviewed for 60 predefined factors.

RESULTS

Males were over-represented in young child victims (between 1 year and 4 years of age) and child victims (between 4 years and 15 years of age) but not in infant victims (between 24 hours and 1 year of age). African-American infant victims and perpetrators were over-represented. Younger victims were more likely to have been previously physically abused by the perpetrator. Perpetrators were predominantly male and the biological fathers of the victims. Infant and young child perpetrators reported childhood abuse histories, while child perpetrators reported the highest frequency of mental health contact. Victims' families reported significant life stressors. Families of young child victims were more likely divorced, separated, or single. Incidents with infants and young children tended to occur without witnesses; incidents with child victims tended to have the victim's sibling(s) and/or mother present. Fatal incidents were more frequent on the weekend, in the home, and initiated by some family disturbance.

CONCLUSIONS

Differences among groups in factors related to infant and child homicide across age groups may assist in the development of more tailored abuse prevention efforts and may also guide future investigations.

Relation between infantile colic and asthma/atopy: a prospective study in an unselected population

OBJECTIVE

To assess whether children with history of infantile colic may be at increased risk of subsequently developing asthma and/or atopy.

METHODS

We used data collected in a large, prospective study from an unselected population. Infantile colic and concurrent feeding method were determined from the 2-month well-infant visit form completed by the physician for 983 children who were enrolled at birth. Markers of atopy (total serum immunoglobulin E and allergy skin prick test), allergic rhinitis, asthma, wheezing, and peak flow variability were the main outcome measures studied at different ages between infancy and 11 years.

RESULTS

Ninety (9.2%) children had infantile colic. Prevalence of colic was similar among children fed either breast milk or formula. There was no association between infantile colic and markers of atopy, asthma, allergic rhinitis, wheezing, or peak flow variability at any age.

CONCLUSION

Our data cannot support the hypothesis that infantile colic provides increased risk for subsequent allergic disease or atopy.

Excessive infant crying: often not confined to the first 3 months of age

Excessive crying/fussing in infancy may account for serious problems in mother-infant interactions but is believed to be self-limiting around the age of 3 months. A random digit dialling telephone survey weighted by sex, age, and population density and yielding 662 children aged 9 to <36 months was used to estimate prevalence and the proportion of cases where this problem extends beyond the third month postpartum. Excessive infant crying/fussing during the first 3 months of age was found in 21.0% (95% CI 17.9-24.1) and persisted for longer in 39.6% (95% CI 31.5-47.7) of these. Professionals consulting parents on crying problems should take into account its possible persistence for longer periods of time.

Systematic review of the occurrence of infantile colic in the community

AIMS

To assess the occurrence of infantile colic in the community and the need for professional help; and to study the influences of potential determinants of infantile colic.

METHODS

Surveys were identified by a systematic search in Medline (1966-98) and Embase (1988-98). Retrieved publications were checked for references. Studies selected were community based, prospective, and retrospective surveys on the occurrence of infantile colic published in English, German, French, or Dutch. Occurrence rates were calculated as percentages. Methodological quality of the surveys was assessed by two assessors independently with a standardised criteria list containing items on method of data gathering, definition of colic, and drop out rate.

RESULTS

Fifteen community based surveys were identified. The methodological quality varied considerably and was generally low. Even the two most methodologically sound prospective studies yielded widely varying cumulative incidence rates of 5-19%. Referral rates or the need to seek help because of crying were consistently lower than occurrence rates for prolonged crying as such. Gender, socioeconomic class, type of feeding, family history of atopy, and parental smoking were not shown to be associated with colic.

CONCLUSION

Occurrence rates of infantile colic vary greatly according to methodological quality. A considerable number of parents reporting prolonged crying do not seek or need professional help.

Infant colic syndrome--maternal fantasies of aggression and infanticide

This study examined the impact of infant colic on the emotional state of the mother. Subjects were 23 pairs of mothers and their colicky infants. Structured interviews were conducted with mothers to elicit details around the colic episode and included (1) the emotional state experienced by the mother, (2) the quality and content of the mother's fantasies in response to her infant, and (3) the emotional impact on the parents. Explicit aggressive thoughts and fantasies were revealed by 16 (70%) of the mothers while six (26%) admitted thoughts of infanticide during their infant's colic episodes, a finding notable because previously this has not been documented in medical literature. All mothers experienced physical and psychological symptoms in response to their infant's colic. More than 90% of the mothers with a colicky infant experienced significant marital tension and disruption in their social contacts. The findings suggest that physician receptivity and skill in uncovering the physical and psychological impact of colic on parents is essential for the physical and emotional well-being of the family. Active support and counseling by physicians is critical to diminish any potential for abuse and infanticide in these infants.

Role of food protein intolerance in infants with persistent distress attributed to reflux esophagitis

BACKGROUND

Distressed behavior is common in infants and is often attributed to gastroesophageal reflux (GER) or food protein intolerance.

OBJECTIVE

To examine the effect of a hypoallergenic amino acid-based infant formula (AAF) on distressed behavior and GER symptoms in infants who failed to respond to extensively hydrolyzed formula and antireflux medications.

STUDY DESIGN

Nineteen distressed infants (9 boys and 10 girls; median age, 5.0 months) with presumed GER underwent gastroscopy (n = 17) and esophageal 24-hour pH monitoring (n = 14). Double-blind placebo-controlled (DBPC) formula challenges of AAF versus previously besttolerated formula were conducted.

RESULTS

Nine infants had histologic evidence of esophagitis, and 9 had inflammatory changes in the stomach and/or duodenum. Symptoms remitted in all infants within 2 weeks of the start of feeding with AAF. On DBPC challenge after a median period of 3 months of receiving AAF, 12 infants were intolerant to active formula (distress score, 287 vs 580 min/wk,P =. 01; symptom score, 23.1 vs 36.1, P =.03). Seven infants did not relapse and were considered tolerant (distress score, 470 vs 581, P =.77; symptom score, 29.5 vs 20.2; P =.89).

CONCLUSION

Treatment with AAF may reduce distressed behavior and symptoms of GER in infants with food protein intolerance.

Crying and behavior pattern in breast- and formula-fed infants

Breast- and formula-fed infants were compared with regard to behavior patterns, especially crying behavior. A diary concerning seven behaviors was completed by 188 mothers of breast- and formula-fed infants at the well baby clinic. Breast-fed infants were fed more frequently with longer feeding duration. They slept more, but their long bouts were shorter than those of formula-fed infants. The crying pattern of formula-fed infants was different from that of breast-fed infants in that they displayed an evening cluster and a 7-week peak of crying. Since the educational level of the formula group mothers was higher and there are more later born babies in that group, it is speculated that these mothers have a Westernized tendency in their caretaking style and, as a result, the crying pattern of formula-fed infants are similar to that of Western babies. In multivariate analysis, contact, play, sleep durations and mothers' education contributed significantly to cry duration. These results imply that contact with the mother and other caretaking practices are closely associated with infants' crying.

Infantile colic and food hypersensitivity

In this article, some aspects of the phenomenon of infantile colic or fussing and crying behavior in early infancy are reviewed. The major points addressed are as follows: 1) evidence that infants with colic differ significantly in their pattern of distressed behavior from noncolicky infants; 2) the evidence of colic in children with known food allergy; 3) the incidence of food allergy in children with colic; 4) the outcome of trials focusing on the dietary management of colic; 5) the outcome of studies involving behavior modification in colic; 6) the outcome of a preliminary trial of modification of maternal diet in very young infants with colic; and 7) findings of a systematic review of different treatments for colic.

Changing partners: the dance of infant formula changes

The purpose of the study was to establish the frequency of, reasons for, and outcome of formula changes in infants. In this survey, we interviewed a convenience sample of 100 parents in our pediatric outpatient clinic and 75 parents in private pediatric office practices regarding their baby's initial formula, changes in formula, age at change, reason for change, initiator of the change, and outcome. The infants were 30-210 days old. Sixteen of the 175 infants (9%) were started on nonstandard formulas at birth. Fifty-eight of the remaining 159 infants (36%) were changed from regular to nonstandard formulas. After using nonstandard formulas, only seven infants (4%) were ever challenged subsequently with regular formula and all did well. Colic and regurgitation were the main reasons for switching formulas. In 47% the decision to change the formula was made by the mother and in 44% by the pediatrician. Following the formula change, mothers reported improvement or complete resolution of symptoms in 80% of infants. Although published estimates of formula intolerance range from 2% to 7.5%, one in three infants experiences a formula change, suggesting that nonstandard formulas are used excessively by both mothers and physicians. Nevertheless, in the vast majority of cases, parents report that the changes result in improvement or resolution of symptoms. Thus, while this practice appears to be a simple and effective intervention, it produces a significant population of soy and other nonstandard formula-fed babies who should be drinking regular formulas. Such changes encourage a belief by parents that their infants are allergic or otherwise abnormal and could have a negative impact on subsequent child development.

The short-term effect of spinal manipulation in the treatment of infantile colic: a randomized controlled clinical trial with a blinded observer

OBJECTIVE

To determine whether there is a short-term effect of spinal manipulation in the treatment of infantile colic.

DESIGN

A randomized controlled trial.

SETTING

A private chiropractic practice and the National Health Service's health visitor nurses in the suburb Ballerup (Copenhagen, Denmark).

SUBJECTS

Infants seen by the health visitor nurses, who fulfilled the diagnostic criteria for infantile colic.

INTERVENTION

One group received spinal manipulation for 2 weeks, the other was treated with the drug dimethicone for 2 weeks.

OUTCOME MEASURE

Changes in daily hours of crying as registered in a colic diary.

RESULTS

By trial days 4 to 7, hours of crying were reduced by 1 hour in the dimethicone group compared with 2.4 hours in the manipulation group (P = .04). On days 8 through 11, crying was reduced by 1 hour for the dimethicone group, whereas crying in the manipulation group was reduced by 2.7 hours (P = .004). From trial day 5 onward the manipulation group did significantly better that the dimethicone group.

CONCLUSION

Spinal manipulation is effective in relieving infantile colic.

Mothers' reports of infant crying and soothing in a multicultural population

OBJECTIVES

To investigate the prevalence of infant crying and maternal soothing techniques in relation to ethnic origin and other sociodemographic variables.

DESIGN

A questionnaire survey among mothers of 2-3 month old infants registered at six child health clinics in Amsterdam, the Netherlands.

SUBJECTS

A questionnaire on sociodemographic characteristics and crying behaviour was completed for 1826 of 2180 (84%) infants invited with their parents to visit the child health clinics. A questionnaire on soothing techniques was also filled out at home for 1142 (63%) of these infants.

RESULTS

Overall prevalences of "crying for three or more hours/24 hour day" "crying a lot", and "difficult to comfort" were 7.6%, 14.0%, and 10.3%, respectively. Problematic infant crying was reported by 20.3% of the mothers. Of these infants, only 14% met all three inclusion criteria. Problematic crying occurred less frequently among girls, second and later born children, Surinamese infants, and breast fed infants. Many mothers used soothing techniques that could affect their infant's health negatively. Shaking, slapping, and putting the baby to sleep in a prone position were more common among non-Dutch (especially Turkish) mothers than among Dutch mothers. Poorly educated mothers slapped their baby more often than highly educated mothers.

CONCLUSIONS

Mothers' reports of infant crying and soothing varied sociodemographically. Much harm may be prevented by counselling parents (especially immigrants) on how and how not to respond to infant crying. Health education should start before the child's birth, because certain soothing techniques could be fatal, even when practised for the first time.

Disorders of the oesophagus and stomach in infants

Pathological processes and disease entities in the upper gastrointestinal (GI) tract, specifically those of the oesophagus and the stomach in infancy, have received a disproportionately small amount of attention until recently when appreciation of their pathophysiology and concordant importance in terms of symptomatology has been highlighted. This is probably a phenomenon secondary to improved diagnostic yield from the recent technical advances in areas such as infant endoscopy and a shift in opinion regarding the pathophysiological origin of ubiquitous symptoms of infancy such as feeding disorders, colic and irritability. In addition, the apparently complex interactions of various aetiological factors such as pH-independent gastro-oesophageal reflux (GOR), cow's milk protein intolerance (CMPI), Helicobacter pylori gastritis and upper GI motor disorders have in the past 1-2 years become underlined in terms of aetiopathogenesis and have radically changed thinking regarding diagnosis and therapy of infants with apparent upper-GI-associated symptoms. The contribution to comprehension of infant upper GI disorders of inflammatory paradigms and ontogeny of the upper GI tract is also a recent area worthy of mention. The recent advances in all of these areas and their contribution to the understanding, and subsequent diagnosis and therapy, of upper GI symptoms and their explanation by way of aetiopathogenesis will be explored in this chapter.

Gastrointestinal gas formation and infantile colic

Gastrointestinal gas causes distress in many patients and their parents. Most often, patients do not have an actual increase in gastrointestinal gas volume, but rather their complaints derive from a misunderstanding of normal physiology, a misinterpretation of symptoms (colic), or an increase in intestinal sensitivity (irritable bowel syndrome). Symptoms from actual increases in intestinal gas volume are seen most frequently in children who swallow excessive amounts of air, have a dysmotility syndrome, or consume foods containing poorly absorbed carbohydrates. Although many therapies are used in the treatment of gas-related symptoms, under close scrutiny, the commonly recommended agents (e.g. simethicone) do not have proven efficacy. An understanding of the physiology of gas production and disposal is of practical use to pediatricians in determining the appropriate method of intervention for patients with these complaints.

A low allergen diet is a significant intervention in infantile colic: results of a community-based study

BACKGROUND

The effect of diet change in 38 bottle-fed and 77 breast-fed "colicky" infants, referred from community-based pediatric facilities was studied over a 1-week period in a double-blind (within each feeding mode), randomized, placebo-controlled trial.

METHODS

Bottle-fed infants were assigned to either casein hydrolysate or cow's milk formula. All mothers of breast-fed infants were started on an artificial color-free, preservative-free, additive-free diet and also randomized to an active low allergen diet (milk-, egg-, wheat-, nut-free) or a control diet.

RESULTS

The response to diet was assessed on day 1 and day 8 with the use of a previously validated infant distress chart on which parents recorded distress levels. If successful outcome was defined as a reduction in distress of 25% or more, after adjusting for age and feeding mode, infants on active diet had a significantly higher rate of improvement than those on the control diet (odds ratio, 2.32; 95% confidence interval, 1.07-5.0; p = 0.03). Analysis of the day 8 to day 1 distress ratio, again adjusted for age and feeding mode, showed that infants on the active diet had distress reduced by 39% (95% confidence interval, 26-50) compared with 16% (95% confidence interval, 0-30) for those on the control diet (p = 0.012).

CONCLUSION

The results suggest a period of dietary modification with a low allergen diet and appropriate nutritional support should be considered in healthy infants with colic.

A comparison of temperament and maternal bother in infants with and without colic

This descriptive, retrospective study compared the temperament styles of 25 4- to 8-month-old infants who had colic with the temperament styles of 30 infants of similar age without colic. Infant temperament style was characterized by the mother's ratings of her infant's behavioral style. The degree of bother that the mother experienced in relationship to her infant's temperament also was examined. Results indicated that mothers of infants with colic rated their infants' temperaments differently than mothers of infants without colic in the temperament dimensions of activity and mood. Mothers of infants with colic were more bothered by the infants' temperament dimension of mood than were mothers of infants without colic. More infants in the colic group were characterized as difficult than were infants in the noncolic group. Individual temperament characteristics should be considered in the differential diagnosis of primary excessive crying (colic) during the newborn and infant periods.