Clp323116 14.17

Management of Infantile Colic: A Review
Justine Cohen-Silver and Savithiri Ratnapalan CLIN PEDIATR 2009 48: 14 originally published online 2 October 2008 The online version of this article can be found at: can be found at:
Clinical Pediatrics
Additional services and information for
Clinical Pediatrics
Management of Infantile
Colic: A Review
Justine Cohen-Silver, MD, MSc, andSavithiri Ratnapalan, MBBS, MEd Infantile colic is an easily identified childhood entity current concepts for management options of infantile that has no clear treatment guidelines. The management of infantile colic varies among physicians, and familiesare often frustrated by the medical community’s inability Keywords: general pediatrics; colic; infantile colic;
to prescribe a cure for colic. This article reviews the InfantilecolicwasoriginallydefinedbyWessel DietChange
et al1 in 1954 as ‘‘crying for 3 hours a day, on atleast 3 days a week, for at least 3 weeks.’’ Based on the theory that infantile colic is a gastroin- Although this definition has been since disputed,2 testinal pathologic condition, several groups have the presence of colic and its effect on infants and fam- examined diet modification to treat infantile colic.
ilies persist. Many studies have been conducted to The main theory resides in the contribution of whey determine the cause and management of colic. This hydrosylate to infantile colic by causing excessive article will review the current concepts for manage- gas production from poor gut digestion.
A prospective randomized controlled trial among Colic can begin anytime from early infancy to 4 to 275 infants looked at substituting standard formula 5 months of age.3 Crying associated with colic has plus simethicone pharmacotherapy with a formula been described as excessive, tends to occur in the eve- of partially hydrolysed whey proteins, probiotic oligo- nings, and has been reported to have a high-pitched saccharides (OS), and a high beta-palmitic acid quality.4,5 At times, colic has been associated with content.7 Ninety-six infants who were fed the new flushing of the face, drawing up of the legs, and formula had a significant decrease in the number of crying episodes per week (mean [SD], 1.76 [1.60] episodes in the treatment group vs 3.32 [2.06] epi- MEDLINE from 1950 to October 4, 2007. The key- sodes in the control group; P < .001). A second trial words infantile colic, colic, and therapeutics were com- among 43 infants was a double-blind randomized bined in the search. Publications were excluded if they placebo-controlled trial that demonstrated a signifi- were comments, case reports, or letters. Publications cant reduction in crying time when infants were fed were included if they were review articles or rando- whey hydrosylate formula compared with standard mized control trials. The published literature about formula.8 Crying duration was decreased by 63 the treatment of colic is discussed under the following (95% confidence interval, 1-127) min/d. A third subheadings: diet change, pharmacologic treatments, double-blind randomized placebo-controlled trial alternative therapies, and behavior modification.
placed bottle-fed infants on a whey hydrosylateformula vs regular formula, and the mothers ofbreast fed infants were asked to consume a hypoaller- From the Department of Pediatrics, Hospital for Sick Children, genic diet (free of milk, egg, wheat, and nuts) or a University of Toronto, Ontario, Canada.
control diet.9 Mothers measured infant distress Address correspondence to: Savithiri Ratnapalan, MBBS, MEd, levels using validated distress charts. After adjusting Department of Pediatrics, Hospital for Sick Children, Universityof Toronto, 555 University Ave, Toronto, ON M5G 1X8, Canada; for age and feeding mode, infants receiving the e-mail: [email protected].
treatment diets had a 39% (95% confidence interval, Management of Infantile Colic / Cohen-Silver, Ratnapalan 26%-50%) reduction in distress vs a 16% (95% distension and discomfort due to excessive gas produc- confidence interval, 0%-30%) reduction in distress tion. Although the principle of reduction in discomfort among control subjects (P = .01). One study10 makes inherent sense, studies11,12 demonstrated that attempted to specifically classify whether bovine simethicone was not superior to placebo in reducing whey protein was responsible for infantile colic.
Twenty-four infants in a double-blind crossoverstudy were fed capsules of bovine whey protein (treat- Alternative Therapies
ment) or human albumin (placebo) within a hyperal-lergenic formula (Nutramigen; Mead Johnson Co, Probiotics, Glucose, and Herbal Remedies
Evansville, Indiana). Daily crying durations were 3.2hours for the infants receiving whey protein and 1.0 Several alternative pharmacologic agents have been hour for those receiving placebo (P < .001).
assessed for their ability to decrease symptoms of Based on these studies, physicians recommend infantile colic. A recent prospective randomized changing to formulas containing whey hydrosylate study13 assessed the effectiveness of Lactobacillus for formula-fed infants, as well as maternal dietary acidophilus vs simethicone in reducing colic in 90 modifications for breastfed infants. However, exclu- breastfed infants. Daily median crying durations sive hypoallergenic formula feeds should be reserved were reduced from 159 minutes to 51 minutes in for children with true allergy to cow’s milk protein, the probiotic group and from 177 minutes to 145 and the parents of children with infantile colic minutes in the simethicone group. No adverse effects Another study14 assessed oral hypertonic glucose solution vs sterile water for the treatment of colic in Pharmacologic Treatments
25 infants in a randomized double-blind crossovertrial; results were measured using parents’ scores.
Several trials have examined pharmacotherapy as a The group receiving glucose, 30%, had significantly treatment of infantile colic. Pharmacologic agents less colic than the placebo group (P = .03).
are aimed at reducing gastrointestinal discomfort, Two studies assessed whether herbal remedies which has been theoretically linked with infantile were superior to placebo. In a study15 of 93 breastfed colic. Anticholinergic medications such as dicyclo- infants, a significant reduction in crying time of 85.4% mine hydrochloride and dicycloverine have been in the treatment group was observed vs 48.9% in the shown to be effective in reducing the increased peri- control group (P < .005). A randomized placebo- staltic cholinergic activity of the gut.6 Unfortunately, controlled study16 assessed whether fennel oil was the adverse effect profile reported for these medica- superior to placebo and found that 63% of infants in tions is significantly morbid. Adverse effects include the treatment group had a response to treatment vs loose bowel movements, accidental overdose of the 23.7% of infants in the control group (P < .01).
medication, and the appearance of patients as dopey, There were no reported adverse effects in these 2 A randomized double-blind placebo-controlled trial revisited the concept of administering an alternative Spinal Manipulation
anticholinergic to dicyclomine, namely, cimetropiumbromide.10 Ninety-seven infants were included in the Evidence for the efficacy of spinal manipulation in study. The mean (SD) duration of crying during crisis treating infantile colic is inconclusive. A randomized was 17.3 (12.6) minutes in the treatment group vs controlled trial demonstrated that 32 of 46 infants 47.5 (28.5) minutes in the placebo group (P < .005).
(69.6%) in the treatment group and 24 of 40 infants A placebo response was significant at P < .05. The (60.0%) in the control group demonstrated a response main adverse effect noted in the treatment group vs to treatment, but the effect of spinal manipulation the placebo group was increased sleepiness.
was statistically nonsignificant.17 Another study18 of Simethicone is an alternative pharmacologic agent 50 patients randomized to spinal manipulation or that acts as a detergent to facilitate gas bubbles within dimethicone study groups demonstrated a reduction the gut to coalesce, as well as to decrease abdominal in crying duration by 1 hour in the dimethicone group Clinical Pediatrics / Vol. 48, No. 1, January 2009 vs 2.7 hours in the spinal manipulation group the self-limiting nature, the perceived pathogenesis, (P = .004). Physicians should be cautious about spinal and the concept of altered perception to normal manipulation in infants and should discourage families stimuli), as well as a discussion of the different treat- from treating infantile colic with spinal manipulation.
ment options (including dietary modifications). Allparents should be counseled and encouraged to trybehavior modification, which would help reduce mater- Behavior Modification
nal stress. Other treatment options such as probiotics,glucose water, or herbal remedies could be considered Behavior modification for infantile colic is largely in nonresponders with severe symptoms.
based on intervening with parents to provide reassur-ance and to offer alternative behavioral methods fortreating colic. A study19 examined the effectiveness References
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seed oil emulsion in infantile colic: a randomized,

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