Effect of a low-allergen maternal diet on colic among breastfed infants: a randomized, controlled trial

Infant Colic Symptoms and Amino Acid Formula: Insights from a Prospective Cohort Study

Background/Objectives: Infant functional disorders, including colic, irritability, and sleep disturbances, often overlap with symptoms of cow's milk protein allergy (CMPA). While extensively hydrolyzed formulas are commonly used to address these issues, the short-term efficacy of amino acid formulas (AAF) for managing colic remains understudied. This secondary analysis of a previously published prospective cohort, the largest of its kind in the United States, evaluated the short-term impact of AAF in improving colic and associated symptoms in infants under six months of age with suspected CMPA. Methods: This real-world prospective cohort study analyzed data from 138 infants with suspected CMPA initiated on AAF at Visit 1. After excluding 34 infants due to incomplete data or treatment changes, 104 infants were included in the final analysis. Symptom severity and resolution were assessed through outcomes across two visits, with care provided by general pediatricians (82%) and pediatric gastroenterologists (18%). Results: At baseline, the most common symptoms were colic (n = 83), gassiness (n = 72), fussiness (n = 66), and sleep disturbances (n = 58). By the next follow-up visit (Visit 2), parents reported symptom improvements in colic (94%), gassiness (81%), fussiness (83%), and sleep disturbances (86%). Complete symptom resolution was observed in 73% of infants with colic, 68% with gassiness, 65% with fussiness, and 81% with sleep difficulties. By Visit 2, no infants had severe symptoms, with only mild residual symptoms reported. Conclusions: AAF was associated with significant short-term improvements in colic and related symptoms in infants with suspected CMPA. These preliminary findings highlight AAF as a promising dietary intervention during early infancy. Larger controlled studies are necessary to confirm these results and explore long-term outcomes.

Is there a role for nutritional advice during breastfeeding for infant colic relief? A mixed-method study

Objective

This study aimed to explore the extent and impact of maternal dietary change for colic relief in a cohort of breastfeeding women.

Method

A mixed-method non-sequential approach was devised, including a web-based survey (n = 66) and three semi-structured interviews.

Results

Most women (70 %) changed their diet while breastfeeding a baby with colic and perceived a positive impact on their babies (63 %). The choice of foods eliminated was individual, based on a process of trial and error and on the perceived benefit to the baby. A sub-group of colicky babies, those with less intense colic symptoms, benefited significantly from the removal of cruciferous vegetables (p = 0.01) and were found to be 'less windy' (p = 0.10, ES0,20), a result trending towards statistical significance. Women felt unsupported while making changes to their diet. When dietary change brought relief to the baby, it turned into a coping tool for women facilitating extended breastfeeding.

Conclusions

Maternal dietary change can play a positive role in providing relief to breastfed babies with colic. Novel findings from this study revealed that different baby subtypes got relief from the elimination of different foods. This underscores the potential of personalised nutritional advice for colic relief in breastfed babies.

Extensively Hydrolyzed Formula and Infant Colic Symptoms: Secondary Analysis of a Prospective Cohort Study

Cow's milk protein allergy (CMPA) affects 2% to 3% of infants and is managed with hypoallergenic formulas. The 2022 recalls of infant formulas due to factors including contamination led to specialty formula shortages, highlighting CMPA management challenges. Understanding health care providers' (HCPs) decision-making in transitioning to alternative formulas during shortages is crucial. Limited attention has been given to how pediatric physicians make these choices. This study utilized US HCPs' de-identified survey data to assess driving factors when switching extensively hydrolyzed formulas during shortages. A total of 104 eligible HCPs participated, including general pediatrics, pediatric allergy/immunology, and pediatric gastroenterology specialists. Safety, tolerability, and efficacy were identified as top factors for switching formulas. Formula 1 was considered well-tolerated, patient-accepted, and safe by all HCPs. Most expressed strong belief in Formula 1's safety and effectiveness. Findings inform CMPA management during shortages, offering guidance to HCPs for suitable formula selection and enhanced infant care.

Pediatric Aspects of Nutrition Interventions for Disorders of Gut-Brain Interaction

Dietary factors may play an important role in the generation of symptoms in children with disorders of gut-brain interaction (DGBIs). Although dietary modification may provide successful treatment, there is a relative paucity of controlled trials that have shown the effectiveness of dietary interventions. This study is a narrative review that explores the existing literature on food and pediatric DGBIs. The following have been shown to be beneficial: (i) in infants with colic, removing cow's milk from the infant's diet or from the maternal diet in those who are breastfed; (ii) in infants with regurgitation, adding thickeners to the formula or removing cow's milk protein from the infant's diet or the maternal diet in those who are breastfed; and (iii) in children with pain-predominant DGBIs, using soluble fiber supplementation or a low fermentable oligosaccharides, disaccharides, monosaccharides, and polyols diet. In children with functional constipation, there is no evidence that adding fiber is beneficial. Given that most dietary interventions include restriction of different foods in children, a thoughtful approach and close follow-up are needed.

Lactobacillus rhamnosus GG (ATCC 53103) for the Management of Infantile Colic: A Randomized Controlled Trial

Background: The aim of this study was to investigate the efficacy of Lactobacillus rhamnosus ATCC 53103 together with the maternal diet avoidance of cow’s milk in treating infantile colic. Methods: Forty-five colicky breastfed infants were consecutively randomized to receive L. rhamnosus for 28 days at a dosage of 5 × 10⁹ cfu per day or placebo. Faecal samples were collected from each subject before starting supplementation and at the end of the study period and were immediately analysed. Faecal calprotectin was detected via a quantitative assay. The total bacterial load and selected bacterial species were evaluated using real-time TaqMan PCR. Results: After supplementation for 28 days with Lactobacillus rhamnosus ATCC 53103, median full-force daily crying was reduced (104 versus 242 min, p < 0.001) and the values of faecal calprotectin decreased significantly (p = 0.026). Furthermore, the probiotic increased the abundance of Lactobacillus (p = 0.048) and total bacteria (p = 0.040); all these effects were not observed in the placebo group. Conclusion: Infants treated with Lactobacillus rhamnosus ATCC 53103 for 28 days, in association with the elimination of cow’s milk from the maternal diet, presented some interesting features related to the effect of this probiotic treatment: reductions in crying time and faecal calprotectin, with increased total bacteria and Lactobacillus. To validate these results, a double-blind, placebo-controlled trial on a larger cohort is required.

Diagnosis and management of Non-IgE gastrointestinal allergies in breastfed infants-An EAACI Position Paper

It is well-established that food proteins, such as egg, soya, cow's milk and wheat, are detectable in breastmilk for many hours or days after ingestion. Exposure to these proteins is important to the process of developing tolerance but can also sometimes elicit IgE-mediated and non-IgE-mediated allergic symptoms in breastfed infants. Non-IgE-mediated allergy, outside of food protein-induced allergic proctocolitis and eosinophilic oesophagitis, is not well understood, leading to variations in the diagnosis and management thereof. A primary objective of the European Academy for Allergy and Clinical Immunology is to support breastfeeding in all infants, including those with food allergies. A Task Force was established, to explore the clinical spectrum of non-IgE-mediated allergies, and part of its objectives was to establish diagnosis and management of non-IgE-mediated allergies in breastfed infants. Eight questions were formulated using the Patient, Intervention, Comparison, Outcome (PICO) system and Scottish Intercollegiate Guideline Network (SIGN) criteria for data inclusion, and consensus was achieved on practice points through the Delphi method. This publication aims to provide a comprehensive overview on this topic with practice points for healthcare professionals.

Parent training programmes for managing infantile colic

BACKGROUND

Infantile colic has an effect on both infants and their parents, who become exhausted and concerned as they attempt to comfort their child. Common approaches have focused upon physical treatments to reduce symptoms, with inconclusive evidence as to their effectiveness. An alternative approach seeks to provide training, support and psychological interventions for parents. This approach is known as parent training programmes. Programmes can include soothing techniques, advice on feeding or normalisation material in any form. The teaching format can vary including face-to-face courses, online learning, printed materials, home visits and remote support and counselling. Here, we aim to collate the evidence on the effectiveness of these interventions and examine their effectiveness at reducing infantile colic symptoms and parental anxiety levels, and their safety.

OBJECTIVES

1. To evaluate the effectiveness and safety of parent training programmes for managing colic in infants under four months of age. 2. To identify the educational content and attributes of such published programmes.

SEARCH METHODS

In June 2019 we searched CENTRAL, MEDLINE, Embase, 13 other databases and two trials registers. We also handsearched conference abstracts, inspected the references of included studies and contacted leaders in the field for more trials.

SELECTION CRITERIA

Randomised controlled trials (RCTs) and quasi-RCTs investigating the effectiveness of any form of parental training programmes, alone or in combination, versus another intervention(s) or control, on infantile colic.

DATA COLLECTION AND ANALYSIS

Two authors independently selected studies for inclusion, extracted data, and assessed the risk of bias within the included studies. We used Review Manager 5 to analyse the data. We assessed the certainty of the evidence using GRADE methodology.

MAIN RESULTS

Our search found 6064 records from which we selected 20 for full-text review. From these, we identified seven studies with 1187 participants that met our inclusion criteria. All of the studies included infants under the age of four months suffering from infantile colic. Four studies were conducted in the USA, one in Canada, one in the Netherlands and one in Iran. Four studies stated their funding sources, which included national research institutes, foundations and nutritional companies. Five studies assessed parent training versus a control group that received reassurance or routine care; and of these, one study was three-armed and also examined the effectiveness of using a specialised baby seat. One study examined parent training programmes against a milk-exclusion diet and one study assessed a parent training programme versus the same parent training programme plus swaddling. The duration of the interventions varied, with the shortest being six days and the longest being three months. Generally, most studies had low participant numbers and were at high risk of bias, prone to selection bias, performance bias, and the placebo effect. We could not complete the planned qualitative analysis (objective 2) due to lack of data in study reports and no further information being supplied by authors on request. Instead, we completed a descriptive content analysis with the limited information available. The parent training interventions were found to focus on one or a combination of the following: soothing techniques for crying infants (six studies); general care advice, including sleep (four studies); feeding advice (two studies); stress reduction and empathic programme for parents (two studies); and positive play interaction advice (one study). One study taught 'kangaroo care', a specific form of skin-to-skin cuddling. The control groups consisted of reassurance (two studies), advice to rock the infant in the crib (one study), or no intervention (two studies). Parent training versus control We conducted a meta-analysis using data from three studies (157 infants) that assessed the primary outcome of 'crying time at completion of study period'. Parent training was more effective than control: mean difference (MD) -113.58 m/d, 95% confidence interval (CI) -144.19 m/d to -82.96 m/d; low-certainty evidence (downgraded due to imprecision and some concerns with risk of bias). Parent training versus specialised baby seat One study (38 participants) found no difference in mean crying time at completion between the parent training group and the specialised baby seat group, but did not report specific figures. Parent training versus a milk-exclusion/soy milk formula One study (20 participants) comparing parent training with a milk-exclusion/soy milk formula found crying time at completion of the study to be 2.03 hours versus 1.08 hours, respectively. Parent training versus parent training plus swaddling One study (398 participants) comparing parental training with the same intervention plus training on how to swaddle an infant did not report separate data for each group. No adverse effects were reported, but these were not explicitly reported in any study.

AUTHORS' CONCLUSIONS

There is limited evidence on the effectiveness and safety of parent training programmes for managing infantile colic. Despite a single meta-analysis showing that parent training may reduce crying times for infants, compared to control, the certainty of the evidence was low. Evidence for other comparisons was sparse. We were unable to identify comprehensively the educational content and attributes of the included programmes due to a lack of information in study reports. Further RCTs are needed: they should define interventions clearly to ensure replicability, address all appropriate outcome measures, and minimise risk of bias in order to assess definitively the role of parent training programmes in managing infantile colic.

Approach to infantile colic in primary care

Infantile colic is a common self-limiting condition that causes significant distress to parents and caregivers. There is no clear cause, gold standard remedy or preventative action. The role of the family physician is to rule out sinister causes while providing counselling and reassurance for parents. The mainstay of management is parental support and reassurance while looking out for red flags in the baby such as fever, lethargy, distended abdomen and failure to thrive. This article provides a framework to approaching infantile colic and practical pointers to share with parents.

Probiotics to prevent infantile colic

BACKGROUND

Infantile colic is typically defined as full-force crying for at least three hours per day, on at least three days per week, for at least three weeks. Infantile colic affects a large number of infants and their families worldwide. Its symptoms are broad and general, and while not indicative of disease, may represent a serious underlying condition in a small percentage of infants who may need a medical assessment. Probiotics are live microorganisms that alter the microflora of the host and provide beneficial health effects. The most common probiotics used are of Lactobacillus, Bifidobacterium and Streptococcus. There is growing evidence to suggest that intestinal flora in colicky infants differ from those in healthy infants, and it is suggested that probiotics can redress this balance and provide a healthier intestinal microbiota landscape. The low cost and easy availability of probiotics makes them a potential prophylactic solution to reduce the incidence and prevalence of infantile colic.

OBJECTIVES

To evaluate the efficacy and safety of prophylactic probiotics in preventing or reducing severity of infantile colic.

SEARCH METHODS

In January 2018 we searched CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL, 10 other databases and two trials registers. In addition, we handsearched the abstracts of relevant meetings, searched reference lists, ran citation searches of included studies, and contacted authors and experts in the field, including the manufacturers of probiotics, to identify unpublished trials.

SELECTION CRITERIA

Randomised control trials (RCTs) of newborn infants less than one month of age without the diagnosis of infantile colic at recruitment. We included any probiotic, alone or in combination with a prebiotic (also known as synbiotics), versus no intervention, another intervention(s) or placebo, where the focus of the study was the effect of the intervention on infantile colic.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures of Cochrane.

MAIN RESULTS

Our search yielded 3284 records, and of these, we selected 21 reports for full-text review. Six studies with 1886 participants met our inclusion criteria, comparing probiotics with placebo. Two studies examined Lactobacillus reuteri DSM, two examined multi-strain probiotics, one examined Lactobacillus rhamnosus, and one examined Lactobacillus paracasei and Bifidobacterium animalis. Two studies began probiotics during pregnancy and continued administering them to the baby after birth.We considered the risk of bias for randomisation as low for all six trials; for allocation concealment as low in two studies and unclear in four others. All studies were blinded, and at low risk of attrition and reporting bias.A random-effects meta-analysis of three studies (1148 participants) found no difference between the groups in relation to occurrence of new cases of colic: risk ratio (RR) 0.46, 95% confidence interval (CI) 0.18 to 1.19; low-certainty evidence; I² = 72%.A random-effects meta-analysis of all six studies (1851 participants) found no difference between the groups in relation to serious adverse effects (RR 1.02, 95% CI 0.14 to 7.21; low-certainty evidence; I² not calculable (only four serious events for one comparison, two in each group: meconium plug obstruction, patent ductus arteriosus and neonatal hepatitis).A random-effects meta-analysis of three studies (707 participants) found a mean difference (MD) of -32.57 minutes per day (95% CI -55.60 to -9.54; low-certainty evidence; I² = 93%) in crying time at study end in favour of probiotics.A subgroup analysis of the most studied agent, Lactobacillus reuteri, showed a reduction of 44.26 minutes in daily crying with a random-effects model (95% CI -66.6 to -21.9; I² = 92%), in favour of probiotics.

AUTHORS' CONCLUSIONS

There is no clear evidence that probiotics are more effective than placebo at preventing infantile colic; however, daily crying time appeared to reduce with probiotic use compared to placebo. There were no clear differences in adverse effects.We are limited in our ability to draw conclusions by the certainty of the evidence, which we assessed as being low across all three outcomes, meaning that we are not confident that these results would not change with the addition of further research.

Randomised clinical trial: reducing the intake of dietary FODMAPs of breastfeeding mothers is associated with a greater improvement of the symptoms of infantile colic than for a typical diet

BACKGROUND

Therapeutic diets for infantile colic lack evidence. In breastfed infants, avoiding "windy" foods by the breastfeeding mother is common.

AIM

To examine the effects of a maternal low-FODMAP (Fermentable, Oligosaccharides, Disaccharides, Monosaccharides, And Polyols) diet compared to a typical-Australian diet on infant crying-fussing durations of infants with colic in a randomised, double-blind, crossover feeding study.

METHODS

Between 2014 and 2016 exclusively breastfed infants aged ≤9 weeks meeting Wessel criteria for colic were recruited. Mothers were provided a 10-day low-FODMAP or typical-Australian diet, then alternated without washout. Infants without colic (controls) were observed prospectively and mothers remained on habitual diet. Infant crying-fussing durations were captured using a Barr Diary. Measures of maternal psychological status and samples of breast milk and infant faeces were collected.

RESULTS

Mean crying-fussing durations were 91 min/d in seven controls compared with 269 min/d in 13 colicky infants (P < 0.0001), which fell by median 32% during the low-FODMAP diet compared with 20% during the typical-Australian diet (P = 0.03), confirmed by a two-way mixed-model analyses-of-variance (ƞ_p ²  = 0.719; P = 0.049) with no order effect. In breast milk, lactose concentrations remained stable and other known dietary FODMAPs were not detected. Changes in infant faecal calprotectin were similar between diets and groups, and faecal pH did not change. Median maternal anxiety and stress fell with the typical-Australian diet (P < 0.01), but remained stable on the low-FODMAP diet.

CONCLUSIONS

Maternal low-FODMAP diet was associated with enhanced reduction in crying-fussing durations of infants with colic. This was not related to changes in maternal psychological status, gross changes in breast milk or infant faeces. Mechanisms require elucidation. Trial Registration Australian New Zealand Clinical Trials Registry (ANZCTR): 12616000512426 - anzctr.org.au.

Dietary modifications for infantile colic

BACKGROUND

Infantile colic is typically defined as full-force crying for at least three hours per day, on at least three days per week, for at least three weeks. This condition appears to be more frequent in the first six weeks of life (prevalence range of 17% to 25%), depending on the specific location reported and definitions used, and it usually resolves by three months of age. The aetiopathogenesis of infantile colic is unclear but most likely multifactorial. A number of psychological, behavioural and biological components (food hypersensitivity, allergy or both; gut microflora and dysmotility) are thought to contribute to its manifestation. The role of diet as a component in infantile colic remains controversial.

OBJECTIVES

To assess the effects of dietary modifications for reducing colic in infants less than four months of age.

SEARCH METHODS

In July 2018 we searched CENTRAL, MEDLINE, Embase , 17 other databases and 2 trials registers. We also searched Google, checked and handsearched references and contacted study authors.

SELECTION CRITERIA

Randomised controlled trials (RCTs) and quasi-RCTs evaluating the effects of dietary modifications, alone or in combination, for colicky infants younger than four months of age versus another intervention or placebo. We used specific definitions for colic, age of onset and the methods for performing the intervention. We defined 'modified diet' as any diet altered to include or exclude certain components.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Our primary outcome was duration of crying, and secondary outcomes were response to intervention, frequency of crying episodes, parental/family quality of life, infant sleep duration, parental satisfaction and adverse effects.

MAIN RESULTS

We included 15 RCTs involving 1121 infants (balanced numbers of boys and girls) aged 2 to 16 weeks. All studies were small and at high risk of bias across multiple design factors (e.g. selection, attrition). The studies covered a wide range of dietary interventions, and there was limited scope for meta-analysis. Using the GRADE approach, we assessed the quality of the evidence as very low.Low-allergen maternal diet versus a diet containing known potential allergens: one study (90 infants) found that 35/47 (74%) of infants responded to a low-allergen maternal diet, compared with 16/43 (37%) of infants on a diet containing known potential allergens.Low-allergen diet or soy milk formula versus dicyclomine hydrochloride: one study (120 infants) found that 10/15 (66.6%) breastfed babies responded to dicyclomine hydrochloride, compared with 24/45 (53.3%) formula-fed babies. There was little difference in response between breastfed babies whose mother changed their diet (10/16; 62.5%) and babies who received soy milk formula (29/44; 65.9%).Hydrolysed formula versus standard formula: two studies (64 infants) found no difference in duration of crying, reported as a dichotomous outcome: risk ratio 2.03, 95% confidence interval (CI) 0.81 to 5.10; very low-quality evidence. The author of one study confirmed there were no adverse effects. One study (43 infants) reported a greater reduction in crying time postintervention with hydrolysed formula (104 min/d, 95% CI 55 to 155) than with standard formula (3 min/d, 95% CI -63 to 67).Hydrolysed formula versus another hydrolysed formula: one study (22 infants) found that two types of hydrolysed formula were equally effective in resolving symptoms for babies who commenced with standard formula (Alimentum reduced crying to 2.21 h/d (standard deviation (SD) 0.40) and Nutramigen to 2.93 h/d (SD 0.70)).Hydrolysed formula or dairy- and soy-free maternal diet versus addition of parental education or counselling: one study (21 infants) found that crying time decreased to 2.03 h/d (SD 1.03) in the hydrolysed or dairy- and soy-free group compared with 1.08 h/d (SD 0.7) in the parent education or counselling group, nine days into the intervention.Partially hydrolysed, lower lactose, whey-based formulae containing oligosaccharide versus standard formula with simethicone: one study (267 infants) found that both groups experienced a decrease in colic episodes (secondary outcome) after seven days (partially hydrolysed formula: from 5.99 episodes (SD 1.84) to 2.47 episodes (SD 1.94); standard formula: from 5.41 episodes (SD 1.88) to 3.72 episodes (SD 1.98)). After two weeks the difference between the two groups was significant (partially hydrolysed: 1.76 episodes (SD 1.60); standard formula: 3.32 episodes (SD 2.06)). The study author confirmed there were no adverse effects.Lactase enzyme supplementation versus placebo: three studies (138 infants) assessed this comparison, but none reported data amenable to analysis for any outcome. There were no adverse effects in any of the studies.Extract of Foeniculum vulgare, Matricariae recutita, and Melissa officinalis versus placebo: one study (93 infants) found that average daily crying time was lower for infants given the extract (76.9 min/d (SD 23.5), than infants given placebo (169.9 min/d (SD 23.1), at the end of the one-week study. There were no adverse effects.Soy protein-based formula versus standard cows' milk protein-based formula: one study (19 infants) reported a mean crying time of 12.7 h/week (SD 16.4) in the soy formula group versus 17.3 h/week (SD 6.9) in the standard cows' milk group, and that 5/10 (50%) responded in the soy formula group versus 0/9 (0%) in the standard cows' milk group.Soy protein formula with polysaccharide versus standard soy protein formula: one study (27 infants) assessed this comparison but did not provide disaggregated data for the number of responders in each group after treatment.No study reported on our secondary outcomes of parental or family quality of life, infant sleep duration per 24 h, or parental satisfaction.

AUTHORS' CONCLUSIONS

Currently, evidence of the effectiveness of dietary modifications for the treatment of infantile colic is sparse and at significant risk of bias. The few available studies had small sample sizes, and most had serious limitations. There were insufficient studies, thus limiting the use of meta-analysis. Benefits reported for hydrolysed formulas were inconsistent.Based on available evidence, we are unable to recommend any intervention. Future studies of single interventions, using clinically significant outcome measures, and appropriate design and power are needed.

Infant colic: mechanisms and management

Infant colic is a commonly reported phenomenon of excessive crying in infancy with an enigmatic and distressing character. Despite its frequent occurrence, little agreement has been reached on the definition, pathogenesis or the optimal management strategy for infant colic. This Review aims to delineate the definitional entanglement with the Rome IV criteria, which were published in 2016, as the leading, most recent diagnostic criteria. Moreover, neurogenic, gastrointestinal, microbial and psychosocial factors that might contribute to the pathophysiology of infant colic are explored. This Review underlines that a comprehensive medical history and physical examination in the absence of alarm symptoms serve as guidance for the clinician to a positive diagnosis. It also highlights that an important aspect of the management of infant colic is parental education and reassurance. Management strategies, including behavioural, dietary, pharmacological and alternative interventions, are also discussed. Owing to a lack of large, high-quality randomized controlled trials, none of these therapies are strongly recommended. Finally, the behavioural and somatic sequelae of infant colic into childhood are summarized.

Mental health and well-being in parents of excessively crying infants: Prospective evaluation of a support package

BACKGROUND

During the first 4 months of age, approximately 20% of infants cry a lot without an apparent reason. Most research has targeted the crying, but the impact of the crying on parents, and subsequent outcomes, need to receive equal attention. This study reports the findings from a prospective evaluation of a package of materials designed to support the well-being and mental health of parents who judge their infant to be crying excessively. The resulting "Surviving Crying" package comprised a website, printed materials, and programme of Cognitive Behaviour Therapy-based support sessions delivered to parents by a qualified practitioner. It was designed to be suitable for United Kingdom (UK) National Health Service (NHS) use.

METHODS

Parents were referred to the study by 12 NHS Health Visitor/Community Public Health Nurse teams in one UK East Midlands NHS Trust. Fifty-two of 57 parents of excessively crying babies received the support package and completed the Edinburgh Postnatal Depression Scale and Generalized Anxiety Disorder-7 anxiety questionnaire, as well as other measures, before receiving the support package and afterwards.

RESULTS

Significant reductions in depression and anxiety were found, with numbers of parents meeting clinical criteria for depression or anxiety halving between baseline and outcome. These improvements were not explained by reductions in infant crying. Reductions also occurred in the number of parents reporting the crying to be a large or severe problem (from 28 to 3 parents) or feeling very or extremely frustrated by the crying (from 31 to 1 parent). Other findings included increases in parents' confidence, knowledge of infant crying, and improvements in parents' sleep.

CONCLUSIONS

The findings suggest that the Surviving Crying package may be effective in supporting the well-being and mental health of parents of excessively crying babies. Further, large-scale controlled trials of the package in NHS settings are warranted.

The costs of functional gastrointestinal disorders and related signs and symptoms in infants: a systematic literature review and cost calculation for England

OBJECTIVES

To estimate the cost of functional gastrointestinal disorders (FGIDs) and related signs and symptoms in infants to the third party payer and to parents.

STUDY DESIGN

To estimate the cost of illness (COI) of infant FGIDs, a two-stage process was applied: a systematic literature review and a COI calculation. As no pertinent papers were found in the systematic literature review, a 'de novo' analysis was performed. For the latter, the potential costs for the third party payer (the National Health Service (NHS) in England) and for parents/carers for the treatment of FGIDs in infants were calculated, by using publicly available data. In constructing the calculation, estimates and assumptions (where necessary) were chosen to provide a lower bound (minimum) of the potential overall cost. In doing so, the interpretation of the calculation is that the true COI can be no lower than that estimated.

RESULTS

Our calculation estimated that the total costs of treating FGIDs in infants in England were at least £72.3 million per year in 2014/2015 of which £49.1 million was NHS expenditure on prescriptions, community care and hospital treatment. Parents incurred £23.2 million in costs through purchase of over the counter remedies.

CONCLUSIONS

The total cost presented here is likely to be a significant underestimate as only lower bound estimates were used where applicable, and for example, costs of alternative therapies, inpatient treatments or diagnostic tests, and time off work by parents could not be adequately estimated and were omitted from the calculation. The number and kind of prescribed products and products sold over the counter to treat FGIDs suggest that there are gaps between treatment guidelines, which emphasise parental reassurance and nutritional advice, and their implementation.

Reducing the maternal dietary intake of indigestible and slowly absorbed short-chain carbohydrates is associated with improved infantile colic: a proof-of-concept study

BACKGROUND

To investigate if a low fermentable oligo-, di- and mono-saccharides and polyols (FODMAP) diet consumed by breastfeeding mothers may be associated with reduced symptoms of infantile colic.

METHODS

Exclusively breastfeeding mothers and their typically-developing healthy infants who met the Wessel Criteria for infantile colic were recruited from the community, to this single-blind, open-label, interventional study. After a 3-day qualifying period, mothers were provided a low FODMAP 7-day diet. On days 5, 6 and 7 mothers completed a Baby Day Diary. At baseline and at the end of the 7-day dietary intervention, breast milk was analysed for FODMAP content and infant faecal samples for pH.

RESULTS

Eighteen breastfeeding mothers (aged 27-40 years) adhered (100%) to the low FODMAP diet. Infants were of gestational age 37-40.3 weeks and aged 2-17 weeks. At entry, crying durations were a mean [95% CI] of 142 [106-61] min and fell by 52 [178-120] min (P = 0.005; ancova). Combined crying-fussing durations fell by 73 [301-223] min (n = 13; P = 0.007), as did crying episodes (P = 0.01) and fussing durations (P = 0.011). Infant sleeping, feeding, or awake-and-content durations did not change. Infant faecal pH did not change. Breast milk lactose content was stable and other known FODMAPs were not detected. At end of study, mothers reported their baby 'is much more content' and 'can be put down without crying'.

CONCLUSIONS

Maternal low FODMAP diet may be associated with a reduction in infant colic symptoms. A randomized controlled study is warranted to determine if a maternal low FODMAP diet is effective in reducing symptoms.

Pediatric Integrative Medicine

The practice of pediatrics from an integrative framework is based on physician-patient relationship, informed by evidence, and approaches the health of children and their families from a broad perspective. This article reviews the basic principles of integrative pediatrics and summarizes data and integrative approaches to common pediatric conditions seen in the primary care setting.

Adapting the low FODMAP diet to special populations: infants and children

Management of gut-related symptoms in the pediatric population can be challenging. Many factors need to be taken into consideration including psychological, behavioral, social and family environments, and growth and developmental requirements. This review focuses on two issues: potential dietary therapies that are thought to relieve the symptoms of infantile colic, a condition that is believed to be gastrointestinal in nature; and the evidence and dietary considerations surrounding children with irritable bowel syndrome.

Non-IgE-mediated gastrointestinal food allergies in children

Non-IgE-mediated gastrointestinal food allergic disorders (non-IgE-GI-FA) including food protein-induced enterocolitis syndrome (FPIES), food protein-induced enteropathy (FPE), and food protein-induced allergic proctocolitis (FPIAP) are relatively uncommon in infants and young children, but are likely under-diagnosed. Non-IgE-GI-FA have a favorable prognosis, with majority resolving by age 3-5 years. Diagnosis relies on the recognition of symptoms pattern in FPIAP and FPIES and biopsy in FPE. Further studies are needed for a better understanding of the pathomechanism, which will lead eventually to the development of diagnostic tests and treatments. Limited evidence supports the role of food allergens in subsets of constipation, gastroesophageal reflux disease, irritable bowel syndrome, and colic. The immunologic pathomechanism is not fully understood and empiric prolonged avoidance of food allergens should be limited to minimize nutrient deficiency and feeding disorders/food aversions in infants.

Probiotics to prevent infantile colic

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows:

To assess the effectiveness and safety of prophylactic probiotics for preventing or reducing colic in infants. To identify the likely effective probiotic strains for such an approach.

Infant Colic-What works: A Systematic Review of Interventions for Breast-fed Infants

OBJECTIVES

To determine the strength of evidence for commonly used interventions for colic in breast-fed and mixed-fed infants younger than 6 months.

METHODS

Searches of PubMed, CINAHL, Embase, AMED, and Web of Science databases were conducted from July 2014 to July 2015. Included studies were randomised controlled trials involving mothers and their colicky infants younger than 6 months; assessed colic against the Wessel or modified Wessel criteria; and included phytotherapies, prescription medicines, and maternal dietary interventions. Studies with <16 participants were excluded. Meta-analyses were conducted where data were sufficient to enable pooling. Quality was assessed against the Cochrane Risk Bias Assessment Tool.

RESULTS

A total of 17 articles met the inclusion criteria for this review. The 6 studies included for subgroup meta-analysis on probiotic treatment, notably Lactobacillus reuteri, demonstrated that probiotics appear an effective treatment, with an overall mean difference in crying time at day 21 of -55.8 min/day (95% CI -64.4 to -47.3, P = 0.001). The 3 studies included for subgroup meta-analysis on preparations containing fennel suggest it to be effective, with an overall mean difference of -72.1 min/day (95% CI -126.4 to -17.7, P < 0.001).

CONCLUSIONS

Probiotics, in particular L reuteri, and preparations containing fennel oil appear effective for reducing colic, although there are limitations to these findings. The evidence for maternal dietary manipulation, lactase, sucrose, glucose, and simethicone is weak. Further well-designed clinical trials are required to strengthen the evidence for all of these interventions.

Does maternal diet affect infantile colic?

OBJECTIVE

The aim of this study was to investigate the effect of maternal diet on infantile colic without any interventions or food restrictions.

METHODS

Thirty colicky and 29 non-colicky infants were included in this prospective study. Mother's diet and baby crying time were recorded for 1 week by mothers; nutritionist classified contents of mother's diet and compared the diet of mother in colicky and non-colicky infants.

RESULTS

It was found that mothers of non-colicky infants consumed significantly more grapes and lemons than mothers of colicky infants (p = 0.044). The crying time was moderately negatively correlated with the percentage of protein in the maternal diet (R = -0.45, p = 0.01) and the presence of potatoes in the maternal diet (R = -0.38, p = 0.034) and positively correlated with the maternal consumption of walnut (R = 0.38, p = 0.034), banana (R = 0.44, p = 0.01).

CONCLUSIONS

Removing bananas from the maternal diet may reduce colic. The consumption of a protein-rich maternal diet, grapes, lemons and potatoes by breastfeeding mothers may protect infants from colic.

Probiotic Lactobacillus rhamnosus GG therapy and microbiological programming in infantile colic: a randomized, controlled trial

BACKGROUND

Probiotic Lactobacillus reuteri and reduced allergen load may lessen the daily crying of colic infants, but the role of Lactobacillus rhamnosus GG (LGG) has remained obscure.

METHODS

Infants with colic (n = 30) were enrolled during the first 6 wk of life. All families received behavioral support and allergen avoidance diet: breastfeeding mothers followed cow's milk elimination diet and formula-fed infants received extensively hydrolyzed casein formula. The randomized, double-blind intervention employed of LGG 4.5 × 10(9) cfu/d or placebo for a 4-wk study period. Daily crying was recorded by diaries and parental interviews. Fecal calprotectin and gut microbiota composition by quantitative PCR were evaluated before and after the intervention.

RESULTS

Daily crying time was comparable between the probiotic (173 min) and the placebo group (174 min; P = 0.99) at the end of the intervention according to the parental diary. However, parents reported a decrease of 68% (95% confidence interval (CI): 58-78) in daily crying in the probiotic and 49% (95% CI: 32-66) in the placebo group (P = 0.05).

CONCLUSION

LGG in infants treated in tandem with behavioral support and a cow's milk elimination diet did not provide additional treatment effect for diary-verified colic crying although parental report of crying suggested the probiotic intervention effective.

Non-IgE-mediated gastrointestinal food allergy

Non-IgE-mediated gastrointestinal food-induced allergic disorders (non-IgE-GI-FAs) account for an unknown proportion of food allergies and include food protein-induced enterocolitis syndrome (FPIES), food protein-induced allergic proctocolitis (FPIAP), and food protein-induced enteropathy (FPE). Non-IgE-GI-FAs are separate clinical entities but have many overlapping clinical and histologic features among themselves and with eosinophilic gastroenteropathies. Over the past decade, FPIES has emerged as the most actively studied non-IgE-GI-FA, potentially because of acute and distinct clinical features. FPIAP remains among the common causes of rectal bleeding in infants, while classic infantile FPE is rarely diagnosed. The overall most common allergens are cow's milk and soy; in patients with FPIES, rice and oat are also common. The most prominent clinical features of FPIES are repetitive emesis, pallor, and lethargy; chronic FPIES can lead to failure to thrive. FPIAP manifests with bloody stools in well-appearing young breast-fed or formula-fed infants. Features of FPE are nonbloody diarrhea, malabsorption, protein-losing enteropathy, hypoalbuminemia, and failure to thrive. Non-IgE-GI-FAs have a favorable prognosis; the majority resolve by 1 year in patients with FPIAP, 1 to 3 years in patients with FPE, and 1 to 5 years in patients with FPIES, with significant differences regarding specific foods. There is an urgent need to better define the natural history of FPIES and the pathophysiology of non-IgE-GI-FAs to develop biomarkers and novel therapies.

The controversial role of food allergy in infantile colic: evidence and clinical management

Food allergies (FAs) are an increasing problem in Western countries, affecting up to 10% of young children. FAs are frequently associated with gastrointestinal manifestations. The role of FAs as a potential causative factor for infantile colic (IC) is still controversial. We report the most recent evidence on the pathogenesis, clinical and diagnostic aspects of FA-induced infantile colic (IC) and suggest a stepwise diagnostic approach. We selected articles on clinical and immunologic features, pathogenesis and management of FAs and IC from of 1981 to 2015. Original and review articles were identified through selective searches performed on PubMed, using the following terms: colic, infantile colic, food allergy and infantile colic, infantile colic treatment. The possible relationship between FAs and IC derives from the presence of dysmotility with visceral hypersensitivity and dysbiosis, demonstrated in both conditions, and the clinical response to dietary interventions. Unfortunately, the design of the studies, poor characterization of atopy and different dietary approaches limit the understanding of the importance of FAs in subjects with IC. The role of FAs in IC subjects without other symptoms of atopy remains controversial. However, where there is a suspicion of FAs, a short trial with an extensively hydrolyzed cow's proteins formula or, if breast fed, with maternal elimination diet may be considered a reasonable option.

BSACI guideline for the diagnosis and management of cow's milk allergy

This guideline advises on the management of patients with cow's milk allergy. Cow's milk allergy presents in the first year of life with estimated population prevalence between 2% and 3%. The clinical manifestations of cow's milk allergy are very variable in type and severity making it the most difficult food allergy to diagnose. A careful age- and disease-specific history with relevant allergy tests including detection of milk-specific IgE (by skin prick test or serum assay), diagnostic elimination diet, and oral challenge will aid in diagnosis in most cases. Treatment is advice on cow's milk avoidance and suitable substitute milks. Cow's milk allergy often resolves. Reintroduction can be achieved by the graded exposure, either at home or supervised in hospital depending on severity, using a milk ladder. Where cow's milk allergy persists, novel treatment options may include oral tolerance induction, although most authors do not currently recommend it for routine clinical practice. Cow's milk allergy must be distinguished from primary lactose intolerance. This guideline was prepared by the Standards of Care Committee (SOCC) of the British Society for Allergy and Clinical Immunology (BSACI) and is intended for clinicians in secondary and tertiary care. The recommendations are evidence based, but where evidence is lacking the panel of experts in the committee reached consensus. Grades of recommendation are shown throughout. The document encompasses epidemiology, natural history, clinical presentations, diagnosis, and treatment.

A neurobiological model for cry-fuss problems in the first three to four months of life

Although problem crying in the first three to four months of life is usually self-limiting, it is not a trivial condition. Early intervention is important, yet families receive conflicting advice from health professionals. The past decade has seen significant advances in neuroscience, lactation science, and developmental psychology, including new insights into the significance of developmentally sensitive windows. We propose a neurobiological model to explain the mechanisms of cry-fuss problems in the first months of life, and the mechanisms which underlie effective intervention, with a view to facilitating research collaboration and consistency of advice across health disciplines. We hypothesise that crying in the first three to four neurodevelopmentally sensitive months signals activation of the hypothalamic-pituitary-adrenal axis and adrenergic neuronal circuitry in response to perceptions of discomfort or threat. Susceptible infants may be conditioned by early stress, for example, by unidentified feeding difficulties, into a sensitised stress response, which usually settles at three to four months of age with neurodevelopmental maturity. Bouts of prolonged and unsoothable crying result from positive feedback loops in the hypothalamic-pituitary-adrenal and adrenergic systems. Importantly, epigenetic modulation of the infant's limbic neuronal circuitry may explain correlations between regulatory problems in the first months of life, and behavioural problems including feeding problems in later childhood.

Testing children for allergies: why, how, who and when: an updated statement of the European Academy of Allergy and Clinical Immunology (EAACI) Section on Pediatrics and the EAACI-Clemens von Pirquet Foundation

Allergic diseases are common in childhood and can cause a significant morbidity and impaired quality-of-life of the children and their families. Adequate allergy testing is the prerequisite for optimal care, including allergen avoidance, pharmacotherapy and immunotherapy. Children with persisting or recurrent or severe symptoms suggestive for allergy should undergo an appropriate diagnostic work-up, irrespective of their age. Adequate allergy testing may also allow defining allergic trigger in common symptoms. We provide here evidence-based guidance on when and how to test for allergy in children based on common presenting symptoms suggestive of allergic diseases.

Probiotics to improve outcomes of colic in the community: protocol for the Baby Biotics randomised controlled trial

BACKGROUND

Infant colic, characterised by excessive crying/fussing for no apparent cause, affects up to 20% of infants under three months of age and is a great burden to families, health professionals and the health system. One promising approach to improving its management is the use of oral probiotics. The Baby Biotics trial aims to determine whether the probiotic Lactobacillus reuteri DSM 17938 is effective in reducing crying in infants less than three months old (<13.0 weeks) with infant colic when compared to placebo.

METHODS/DESIGN

DESIGN

Double-blind, placebo-controlled randomised trial in Melbourne, Australia.

PARTICIPANTS

160 breast and formula fed infants less than three months old who present either to clinical or community services and meet Wessel's criteria of crying and/or fussing.

INTERVENTION

Oral once-daily Lactobacillus reuteri (1x108 cfu) versus placebo for one month.

PRIMARY OUTCOME

Infant crying/fussing time per 24 hours at one month.

SECONDARY OUTCOMES

i) number of episodes of infant crying/fussing per 24 hours and ii) infant sleep duration per 24 hours (at 7, 14, 21, 28 days and 6 months); iii) maternal mental health scores, iv) family functioning scores, v) parent quality adjusted life years scores, and vi) intervention cost-effectiveness (at one and six months); and vii) infant faecal microbiota diversity, viii) infant faecal calprotectin levels and ix) Eschericia coli load (at one month only).

ANALYSIS

Primary and secondary outcomes for the intervention versus control groups will be compared with t tests and non-parametric tests for continuous data and chi squared tests for dichotomous data. Regression models will be used to adjust for potential confounding factors. Intention-to-treat analysis will be applied.

DISCUSSION

An effective, practical and acceptable intervention for infant colic would represent a major clinical advance. Because our trial includes breast and formula-fed babies, our results should generalise to most babies with colic. If cost-effective, the intervention's simplicity is such that it could be widely taken up as a new standard of care in the primary and secondary care sectors.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN95287767.

Infantile colic, facts and fiction

Infantile colic is one of the major challenges of parenthood. It is one of the common reasons parents seek medical advice during their child's first 3 months of life. It is defined as paroxysms of crying lasting more than 3 hours a day, occurring more than 3 days in any week for 3 weeks in a healthy baby aged 2 weeks to 4 months. Colic is a poorly understood phenomenon affecting up to 30% of babies, underlying organic causes of excessive crying account for less than 5%. Laboratory tests and radiological examinations are unnecessary if the infant is gaining weight normally and has a normal physical examination. Treatment is limited and drug treatment has no role in management. Probiotics are now emerging as promising agents in the treatment of infantile colic. Alternative medicine (Herbal tea, fennel, glucose and massage therapy) have not proved to be consistently helpful and some might even be dangerous. In conclusion infantile colic is a common cause of maternal distress and family disturbance, the cornerstone of management remains reassurance of parents regarding the benign and self-limiting nature of the illness. There is a critical need for more evidence based treatment protocols.

A randomized control trial of integrated care for families managing infant colic

This article presents a randomized clinical trial examining the effectiveness of a unique model of integrated care for the treatment of infant colic. Families seeking help for infant colic were randomized to either the family-centered treatment (TX; n = 31) or standard pediatric care (SC; n = 31). All parents completed 3 days of Infant Behavior Diaries (Barr et al., 1998) and the Colic Symptom Checklist (Lester, 1997), Beck Depression Inventory (Beck & Steer, 1984), and Parenting Stress Index 3rd ed.-SF (Abidin, 1995). TX families were seen three times by a pediatrician and a mental health clinician within 1, 2, and 6 weeks of baseline data. TX families received individualized treatment plans addressing problem areas of sleep, feeding, routine, and family mental health. SC families were seen only by their own healthcare provider. All families were visited at home by a research assistant to retrieve data at 2, 6, and 10 weeks after baseline. Family-based treatment accelerated the rate of reduction of infant crying faster than did standard pediatric care. Infants in the TX group had more hours of sleep at 2 weeks posttreatment and spent less time feeding at 2, 6, and 10 weeks posttreatment than did SC infants. Results indicate that individualized family-based treatment reduces infant colic more rapidly than does standard pediatric care.

[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.

Infantile colic: a systematic review of medical and conventional therapies

AIM

Infantile colic is a prevalent and distressing condition for which there is no proven standard therapy. The aim of this paper is to review medical and conventional treatments for infantile colic.

METHODS

A systematic literature review was undertaken of studies on medical and conventional interventions for infantile colic from 1980 to March 2009. The results and methodological rigour of included studies were analysed using the CONSORT (Consolidated Standards Of Reporting Trials) 2001 statement checklist and Centre for Evidence Based Medicine critical appraisal tools.

RESULTS

Nineteen studies and two literature reviews were included for review. Pharmacological studies on Simethicone gave conflicting results and with Dicyclomine hydrochloride and Cimetropium bromide results were favourable but side effects were noted along with issues in study methodology. Some nutritional studies reported favourable results for the use of hydrolysed formulas in bottle-fed infants or low-allergen maternal diets in breastfed infants but not for the use of additional fibre or lactase. There were several issues in regards to methodological rigour. Behavioural studies on the use of increased stimulation gave unfavourable results, whereas results from the use of decreased stimulation and contingent music were favourable. These studies demonstrated poor methodological rigour.

CONCLUSION

There is some scientific evidence to support the use of a casein hydrolysate formula in formula-fed infants or a low-allergen maternal diet in breastfed infants with infantile colic. However, there is little scientific evidence to support the use of Simethicone, Dicyclomine hydrochloride, Cimetropium bromide, lactase, additional fibre or behavioural interventions. Further research of good methodological quality on low-allergenic formulas and maternal diets is indicated.

The crying baby: what approach?

PURPOSE OF REVIEW

Cry-fuss problems are among the most common clinical presentations in the first few months of life and are associated with adverse outcomes for some mothers and babies. Cry-fuss behaviour emerges out of a complex interplay of cultural, psychosocial, environmental and biologic factors, with organic disturbance implicated in only 5% of cases. A simplistic approach can have unintended consequences. This article reviews recent evidence in order to update clinical management.

RECENT FINDINGS

New research is considered in the domains of organic disturbance, feed management, maternal health, sleep management, and sensorimotor integration. This transdisciplinary approach takes into account the variable neurodevelopmental needs of healthy infants, the effects of feeding management on the highly plastic neonatal brain, and the bi-directional brain-gut-enteric microbiota axis. An individually tailored, mother-centred and family-centred approach is recommended.

SUMMARY

The family of the crying baby requires early intervention to assess for and manage potentially treatable problems. Cross-disciplinary collaboration is often necessary if outcomes are to be optimized.

A pilot study of ST36 acupuncture for infantile colic

OBJECTIVE

To conduct a pilot study to assess the feasibility of a proposed design of an acupuncture trial to relieve symptoms of infantile colic.

METHOD

An open randomised single-blinded controlled trial, using standardised bilateral treatment of the acupuncture point ST36. Infants fulfilling Wessel's definition of infantile colic were included.

PATIENTS

were randomised to active treatment or to no-treatment control. General practitioners (GPs) educated in Western medical acupuncture did the interventions. Parents and GPs' assistants were blinded. Active treatment was the bilateral insertion of 0.20×15 mm Seirin needles to 12 mm depth at ST36. The intervention consisted of daily treatments of 30 s duration for three consecutive workdays. Blinding was done with a red point mark on the skin and circular adhesive dressing covering. The parents were asked two blinding validation questions in the course of the study period. The primary end point was the effect of the intervention assessed as change in crying time per 24 h measured with a crying registration form.

RESULTS

The authors improved the standardisation and changed the blinding procedure as a result of the pilot study. Blinding validation questions were considered necessary. The changes made in the main study protocol are discussed.

CONCLUSION

The pilot study led to important changes that were implemented into the final trial protocol. Blinding validation is essential in no-treatment controlled trials of acupuncture on infants, where the parents are blinded assessors of symptom reduction. The authors suggest that blinding validation questions, and the answers to these questions, should be reported. Clinical Trial Registry Identifier: NCT00907621.

Cow's-milk allergy is a risk factor for the development of FGIDs in children

OBJECTIVES

Functional gastrointestinal disorders (FGIDs) are common in children. Their pathogenesis remains unknown and is most likely multifactorial. We hypothesized that noninfectious causes of inflammation affecting the gastrointestinal (GI) tract early in life, such as cow's-milk allergy (CMA), can predispose to the development of FGIDs later in childhood.

PATIENTS AND METHODS

Case-control study. Subjects were patients between 4 and 18 years diagnosed with CMA in the first year of life at Children's Memorial Hospital in Chicago, IL, between January 2000 and June 2009. Diagnosis of CMA was based on history and clinical findings. Siblings 4 to 18 years of age without a history of CMA were selected as controls. Cases completed the parental form of the Pediatric Gastrointestinal Symptoms Rome III version questionnaire to assess for GI symptoms.

RESULTS

Fifty-two subjects (mean age 8.1 ± 4.48 years, 62% girls) and 53 controls (mean age 9.7 ± 4.20 years, 55% girls) participated in the study. Twenty-three of 52 subjects (44.2%) reported GI symptoms that included abdominal pain, constipation, or diarrhea compared with 11 of 53 controls (20.75%) (odds ratio 3.03, P = 0.01). Abdominal pain was significantly more common in cases (16/52, 30.8%) versus controls (5/53, 9.43%) (odds ratio 4.27 [1.43-12.7]) (χ² = 7.47, P = 0.01). Abnormal stool habits were more common in cases (15/52, 28.8%) versus controls (7/53, 13.2%), but the difference was not statistically significant. Ten of 52 subjects (19.2%) met the Questionnaire on Pediatric Gastrointestinal Symptoms Rome III version criteria for diagnosis of an FGID (7 irritable bowel syndrome, 2 functional dyspepsia, 1 functional abdominal pain), whereas none in the control group did.

CONCLUSIONS

CMA constitutes a risk factor for the development of FGIDs in children.

The unsettled baby: crying out for an integrated, multidisciplinary primary care approach

Unsettled behaviour in the first few months of life is a common clinical problem, with the associated risks of postnatal depression, premature cessation of breastfeeding, long-term psychological disturbance, and child abuse. Parents of new babies complain of difficulty accessing appropriate care and receiving conflicting advice. Although organic disturbance is implicated in only 5% of cases, gastro-oesophageal reflux disease, food allergies and lactose intolerance are often mistakenly diagnosed in unsettled babies. There is no evidence that acid-suppressive medications help in treating unsettled behaviour and, until the hypothesis that proton-pump inhibitors may predispose to food allergies has been properly investigated, treatment with acid-suppressive medications should be avoided in this population. Although unsettled behaviour in infants is commonly a transient neurodevelopmental phenomenon that peaks at 6 weeks of age, failure to diagnose other correctable problems, including breastfeeding difficulty and cows milk allergy, risks entrenching anxiety and disrupted mother-infant interactions in the long term. In the current climate of health system reform, the design and evaluation of an integrated, evidence-based, multidisciplinary primary care approach to management of unsettled babies and their mothers is a priority.

Probiotics and prebiotics in pediatrics

This clinical report reviews the currently known health benefits of probiotic and prebiotic products, including those added to commercially available infant formula and other food products for use in children. Probiotics are supplements or foods that contain viable microorganisms that cause alterations of the microflora of the host. Use of probiotics has been shown to be modestly effective in randomized clinical trials (RCTs) in (1) treating acute viral gastroenteritis in healthy children; and (2) preventing antibiotic-associated diarrhea in healthy children. There is some evidence that probiotics prevent necrotizing enterocolitis in very low birth weight infants (birth weight between 1000 and 1500 g), but more studies are needed. The results of RCTs in which probiotics were used to treat childhood Helicobacter pylori gastritis, irritable bowel syndrome, chronic ulcerative colitis, and infantile colic, as well as in preventing childhood atopy, although encouraging, are preliminary and require further confirmation. Probiotics have not been proven to be beneficial in treating or preventing human cancers or in treating children with Crohn disease. There are also safety concerns with the use of probiotics in infants and children who are immunocompromised, chronically debilitated, or seriously ill with indwelling medical devices. Prebiotics are supplements or foods that contain a nondigestible food ingredient that selectively stimulates the favorable growth and/or activity of indigenous probiotic bacteria. Human milk contains substantial quantities of prebiotics. There is a paucity of RCTs examining prebiotics in children, although there may be some long-term benefit of prebiotics for the prevention of atopic eczema and common infections in healthy infants. Confirmatory well-designed clinical research studies are necessary.

New treatments for infant colic

PURPOSE OF REVIEW

Infantile colic is a common problem within the first 3 months of life and causes considerable distress for parents and paediatricians. Despite 40 years of research, its pathogenesis is incompletely understood and treatment remains an open issue. This review will describe recent studies that have examined different kinds of interventions.

RECENT FINDINGS

Important advances in understanding the aetiopathogenesis of infantile colic have been recently proposed and opened new perspectives in its management.The composition of intestinal microbiota, specially an inadequate amount of lactobacilli and an increased concentration of coliforms, might influence the pathogenesis of infantile colic. The benefit of supplementation with Lactobacillus reuteri has been recently reported and experimental data showed the effect of probiotics may be related to the influence on gut motility and pain perception.

SUMMARY

Infantile colic is a clinical entity with a wide range of clinical presentations and outcome. Firstly, paediatricians have to exclude other underlying diseases with a medical examination and prevent feeding disorders. Then, considering the favourable clinical course of the disturbance, well tolerated strategies should be adopted. The findings highlighted in this review may promote the implementation of new researches and treatments to reduce abdominal pain related to infantile colic.

Predictive value of the cow's milk skin prick test in infantile colic

BACKGROUND AND OBJECTIVES

Infantile colic is a common problem among young infants. Cow's milk allergy has been suggested as one of the causes. We aimed to investigate the value of the cow's milk skin test for the diagnosis of cow's milk allergy in exclusively breast-fed infants with infantile colic.

METHODS

Exclusively breast-fed infants with infantile colic were enrolled in this study. On the first visit, the average hours of crying of the infant in a 24-h period were recorded and the cow's milk skin test was performed. If the infant had a positive skin test, elimination of cow's milk from the mothers' diet was advised. Infants with negative skin tests were divided into case and control groups. Cow's milk was eliminated from the diet of mothers in the case group. After 2 weeks, the number of hours of crying were recorded again. The reduction in the crying hours was compared between the two groups using the chi-square test.

RESULTS

Skin tests were positive in 3 of 114 cases (2.6%) of infantile colic. All three cases recovered completely following elimination of cow's milk from the mother's diet. Among the 111 patients with negative skin tests, 77 patients completed the study: 35 in the case group and 42 in the control group. The reduction in crying hours in infants in the case group was not significantly different from that in the control group.

CONCLUSION

Elimination of cow's milk from the mothers' diet is not beneficial for infants with a negative skin test. Infants with a positive skin test may benefit from this management.