The Unsettled Baby and Infantile Colic
This post accompanies the very informative podcast based on the Healthier Together Pathway by Aude Cholet, dietician and developer of the Hampshire Infant Feeding Guidelines.
"My baby is always crying, and I don't know what's wrong. I've tried everything, and I'm worried I'm missing something. Help! What can I do?"
Inconsolable crying has a huge effect on bonding and attachment and is the most common reason for stopping breast feeding early, as well as being the main reason for shaken baby syndrome.
When parents consult health professionals about their crying baby, they want to find out if they are doing anything to cause the crying, to find out if there is a medical cause for the crying and to be given support and ideas on how to cope.
It may be helpful to hear that the majority of babies cry for 2-3 hours per day, and that's completely normal, it's just how babies express themselves!
And whilst 5% of unsettled babies will be found to have an organic reason for their distress, the rest will be completely healthy, and may well have infantile colic.
Infantile colic is excessive, inconsolable crying, in a healthy, thriving infant for more than three hours a day, more than three days a week and more than three weeks (NICE CKS).
It tends to occur in the late afternoon or evening, and the baby will often draw its knees up to its abdomen or arch its back. Infantile colic tends to resolve by around three to four months of age.
In a confusing twist of terminology, colic has nothing to do with digestion or the colon.
But just to add to the confusing twist, some babies who cry excessively do so because of a problem with their gut. So if it's not infantile colic, the problem may well be a gastro-intestinal problem such as cows milk protein allergy (CMPA), transient lactose intolerance or gastro-oesophageal reflux disease (GORD).
Making a diagnosis
Taking a good history
General health of the baby including growth
Antenatal and perinatal history
Onset and length of crying
Bowel habit and nature of the stools
Feeding assessment including whether breast or bottle fed, type of formula, timings, volume, technique
Mother's diet if breastfeeding
Family history of atopy
Parents' response to the baby's crying
Factors which lessen or worsen the crying
Maternal mental health
Once you have ruled out red flags in the history and examination:
seizures, cerebral palsy, chromosomal abnormality
unwell child/fever/altered responsivenessunexplained faltering growth
severe atopic eczema
frequent projectile vomiting
blood in vomit or stool
bulging fontanelle/rapidly increasing head circumference
immediate allergic reaction
And thought about simple things like hunger, thirst, baby being too hot or too cold, nappy rash, constipation or wind...
Think about the best fit for the likeliest cause:
If there's a family history of atopy, with one or two systems involved (GI, skin or respiratory) and two or more symptoms (eg reflux and constipation) and if symptoms started with infant formula use, think about CMPA.
This can be IgE or non-IgE mediated. IgE mediated reactions are much faster than non-IgE, and less common. Non-IgE mediated reactions involve a slower process.
In formula-fed babies an extensively hydrolysed formula (eg Similac Alimentum) are far cheaper than amino acid formulas and should be used as a first line. The hydrolysed formula should be used for two to four weeks before re-introducing standard formula, to see if symptoms return, and thus confirming the diagnosis. If CMPA is confirmed, continue on the extensively hydrolysed formula and avoid milk for at least a further six months, at which point milk products can start to be re-introduced in a controlled manner.
Breast milk can itself be thought of as an extensively hydrolysed milk, so CMPA is rare in breast fed babies with an with an incidence of 0.5% and tends to be less severe. Management involves mum trying a milk-free and soya-free diet.
Transient lactose intolerance
If there are lower GI symptoms only, eg persistent diarrhoea (occasionally green) and wind, with a recent history of gastroenteritis and no history or family history of atopy, think about transient lactose intolerance
...and the key word is transient
which is caused by damage to the gut lining - eg by a bout of viral gastroenteritis. This destroys lactase-containing cells leading to the accumulation of lactose, which ferments, giving rise to the explosive diarrhoea and wind.
Just to add a layer of complexity, the gut lining can also be damaged by CMPA, leading to superadded CMPA induced lactose intolerance.
Management involves dealing with the underlying cause, after which the gut will repair itself within two to four weeks. There is rarely a role for lactose-free milk. In fact the gut lining needs lactose to stimulate the production of lactase, and removing lactose form the diet can be detrimental to this process.
Gastro Oesophageal Reflux Disease
Reflux in babies is normal.
Reflux is simply the effortless regurgitation of milk through the relatively lax pyloric sphincter into the oesophagus. It's more likely to happen in babies because they can't yet sit up. Parents perceive reflux to be a problem when it is associated with crying. Yet often no treatment is required.
A very small proportion of babies will have gastro-oesophageal reflux disease (GORD - prevalence <1%) with oesophagitis requiring treatment with H2 antagonists, PPIs etc. Babies at risk include premature babies or those with neurological problems. GORD may present with faltering growth, recurrent otitis media or pneumonia.
After checking how feeds have been made up and helping parents with an effective feeding position, perhaps consider changing the teat and ensure parents are giving optimal feed volumes (think 150ml/kg/day). If that's all good, suggest a brief trial of thickened formula, available over the counter. If there is no improvement after two weeks, consider Infant Gaviscon, but be warned, thicker milk in the belly leads to constipation. Try and stop Gaviscon at regular intervals - as the baby's pyloric sphincter matures and it spends more time upright, reflux should become less of a problem.
If the baby under three months is crying for more than three hours a day, three days a week for three weeks, if the crying occurs most often in the late afternoon or evening, if the baby is growing normally with no overt vomiting, no constipation or diarrhoea, no skin symptoms and no red flags this is infantile colic, a condition shared with 20% of babies.
In other words: Exclude the red flags, environmental factors and gastro-intestinal issues - you've got infantile colic.
Getting the diagnosis of infantile colic right is really important, so we can acknowledge the problem and reassure parents that their baby is healthy and that this crying is likely to resolve by 4 months of age. We can then offer ongoing support and review, advising strategies one at a time, e.g try holding the baby through the crying, use gentle motion, use white noise, bathe in warm water...providing reassurance and support until the baby grows out of it naturally.
Listen to Aude Cholet here
Other useful links:
Managing the unsettled baby pathway
Cry-sis Support for crying and sleepless babies
A very useful article from BMJ about infantile colic