Dr.khalid hama salih

1. Infant COLIC managementInfant COLIC management
Dr.Khalid Hama Salih,Dr.Khalid Hama Salih,
Pediatrics specialistPediatrics specialist
M.B.Ch.; D. C.HM.B.Ch.; D. C.H
F.I.B.M.S.pedF.I.B.M.S.ped

2. CryCry

3. Babies cry to communicateBabies cry to communicate
Quotes about  12-year-old 2-month-old
Hunger “When’s dinner? I’m
starved.”
Discomfort “I’m not wearing these
dress pants. They’re too
tight.”
Over-stimulation “Leave me alone.”
Under-stimulation “I’m bored. There’s nothing
to do.”
Fatigue “I’ve had a long day”
“CRY!”
“CRY!”
“CRY!”
“CRY!”
“CRY!”

4. All babies cryAll babies cry
 Crying is normal.Crying is normal.
 Babies cry for many reasons.Babies cry for many reasons.
 ALL babies will have times when theyALL babies will have times when they
CANNOT stop crying.CANNOT stop crying.

5. Normal infant cryingNormal infant crying
Adapted from the NCSBS and Ronald G. Barr, MDCM
The amount of crying:
• Changes over time
• Varies among normally-developing babies

6. Same baby ─ same daySame baby ─ same day

7. Crying Curve for Premature BabiesCrying Curve for Premature Babies
 Timing of crying peak isTiming of crying peak is
same as full-termssame as full-terms
 4-6 weeks corrected4-6 weeks corrected
ageage
 Quality of crying may beQuality of crying may be
different than full-termsdifferent than full-terms
 ““He never cried in theHe never cried in the
nursery”nursery”

8. What is colic?
1.violent, rhythmical, screaming attacks
2.for which no cause
3.prolonged crying—really not more bouts, but much longer
4.often unpredictable—good days and bad days
5.most crying for all babies in evening, but not always
6.higher pitch—cry studies that higher pitch is more aversive to adults
7.resists soothing—what makes it so hard—unsoothable crying
8.paroxysmal--Sort of like a big attack--explosive
begin and end without warning
seemingly unrelated to other events
9.whole body cry: afternoon fist shaking rage
flushed face, red, arching back, legs drawn up

9. In Asian cultures more likely to be viewed as
part of normal development
Chinese: 1000 days of crying
Vietnamese: “three months plus ten days”
crying
Japanese: “Evening Crying”
•middle class, Caucasian parents tend to report
more colic and seek help for colic more

10. DEFINITIONDEFINITION:: refer to infant who cry forrefer to infant who cry for
no apperent reason during 1no apperent reason during 1stst
threethree
months of life &whose parent seekmonths of life &whose parent seek
help for this problemhelp for this problem..
Niels Rosen 1764
first identifiedfirst identified by British ped. Illingsowrthby British ped. Illingsowrth
colic=kolikos adjective of kolon
StJames-robert ,in :colic &excessive crying report of the 105th
Ross conf.on ped.research,columbus 1997
(
What is ColicWhat is Colic??

11. Wessel’s Rule of 3s for ColicWessel’s Rule of 3s for Colic
 Rule of 3sRule of 3s
 More than 3 hours/dayMore than 3 hours/day
 More than 3 days/weekMore than 3 days/week
 More than 3 weeksMore than 3 weeks
 No single known causeNo single known cause
 Child healthy &well fedChild healthy &well fed
Wessel, 1954

12. Diagnostic Criteria Rome IIIDiagnostic Criteria Rome III
 Diagnostic criteria Must includeDiagnostic criteria Must include all of theall of the
following in infants from birth tofollowing in infants from birth to 4 months of4 months of
age:age:
1 Paroxysms of irritability, fussing or crying that1 Paroxysms of irritability, fussing or crying that
starts and stops withoutobvious causestarts and stops withoutobvious cause
2 Episodes lasting 3 or more hours/day and2 Episodes lasting 3 or more hours/day and
occurring at least 3 days/wk foroccurring at least 3 days/wk for
 at least 1 weekat least 1 week
3. No failure to thrive3. No failure to thrive

13. Colic isColic is NotNot Linked toLinked to::
 Birth orderBirth order
 GenderGender
 Feeding styleFeeding style
 Colic can occur in healthyColic can occur in healthy
babies, in spite ofbabies, in spite of
excellent parentingexcellent parenting
 been there since thebeen there since the
beginning about 20% ofbeginning about 20% of
allall; not caused by our; not caused by our
modern lifemodern life
 seems to be in all culturesseems to be in all cultures

15. If symptoms started suddenly and recently, consider:
 Intussusception
 volvulus
 strangulated hernia
 Torsion of the testis
 Corneal abrasion
 Non-accidental injury
Differential
Diagnosis
Rare, serious
causes such
as:
Seizures;
infantile
spasms.
Cerebral
palsy.
Chromosomal
abnormalities.
Constipation
GERD
Transient cow’s
milk intolerance
Parental depression or
anxiety, or inability to
interact normally with the
baby
Discomfort.
-Hunger or thirst
-Too hot or too
-Too itchy Nappy rash
-Woman's diet if breastfeeding (e.g. too much
coffee, tea, or soft drinks that contain caffeine, or
too much alcohol or spicy food(.

16. Management of ColicManagement of Colic
GOALSGOALS
11..To provide strategies to help soothe a crying babyTo provide strategies to help soothe a crying baby
22..To reduce parental anxiety and stressTo reduce parental anxiety and stress

17. 1st line: advice and1st line: advice and
reassurancereassurance
What advice should I give to the parentsWhat advice should I give to the parents??
Reassure the parents that
their baby is well, they are not doing
something wrong, the baby is not rejecting them,
and that colic is common and is a phase
that will pass within a few months.

18.  1. Swaddling, safe swaddling carefully avoiding overheating,1. Swaddling, safe swaddling carefully avoiding overheating,
covering the head, using bulky or loose blankets, and allowing thecovering the head, using bulky or loose blankets, and allowing the
hips to be flexedhips to be flexed
 2. Side or stomach (holding a baby on the back is the only safe2. Side or stomach (holding a baby on the back is the only safe
position for sleep, but it is the worst position for calming a fussyposition for sleep, but it is the worst position for calming a fussy
baby.baby.
 3. Shhh sound (making a strong shush sound near the3. Shhh sound (making a strong shush sound near the
baby's ear .baby's ear .
 4. Swinging the baby ,movements (no more than 1" back and4. Swinging the baby ,movements (no more than 1" back and
forth) always supporting the head and neckforth) always supporting the head and neck
 5. Sucking (Letting the baby suckle on the breast, or a pacifier5. Sucking (Letting the baby suckle on the breast, or a pacifier

five S's" baby sleep strategy outlined in Karp's bestselling book,five S's" baby sleep strategy outlined in Karp's bestselling book, The HappiestThe Happiest
Baby on the BlockBaby on the Block
5Ss approach

19.  Only consider trying medical treatments if parents feelOnly consider trying medical treatments if parents feel
unable to cope despite advice and reassuranceunable to cope despite advice and reassurance..
2nd line: Medical Treatment

20. FormulasFormulas
 HypoallergenicHypoallergenic — — Some randomized studies and Some randomized studies and
systematic reviews suggest that infants with colic may systematic reviews suggest that infants with colic may
benefit from hypoallergenic formulasbenefit from hypoallergenic formulas ,, In a double- In a double-
blind trial in which 43 infants with colic were randomly blind trial in which 43 infants with colic were randomly
assigned to whey hydrolysate or standard formula, mean assigned to whey hydrolysate or standard formula, mean
daily crying decreased by approximately 60minutedaily crying decreased by approximately 60minute
 Lucassen PL,GubbelJW,.infantile colic:crying time reduction with awhey hydrolsate, pediatrics 2000,106,1349Lucassen PL,GubbelJW,.infantile colic:crying time reduction with awhey hydrolsate, pediatrics 2000,106,1349

21.  Soy — Soy — The effects of soy protein compared to cow's-milk The effects of soy protein compared to cow's-milk
formula were compared in a randomized controlled trial . The formula were compared in a randomized controlled trial . The
mean weekly duration of colic symptoms decreased during mean weekly duration of colic symptoms decreased during
periods of feeding with soy compared with control periods periods of feeding with soy compared with control periods
(8.7 versus 18.8 hours)(8.7 versus 18.8 hours)
 Lothe L,Lindberg T.cow milk allergy as a cause of infantile colic,DBS pediatrics 1982,70,7Lothe L,Lindberg T.cow milk allergy as a cause of infantile colic,DBS pediatrics 1982,70,7

22.  Fiber-enriched — The study of the effect of Fiber-enriched — The study of the effect of
fiber on colic symptoms is based upon the fiber on colic symptoms is based upon the
hypothesis that colic is similar to irritable hypothesis that colic is similar to irritable
bowel syndromebowel syndrome
 the evidence does not support the use of fiber-the evidence does not support the use of fiber-
enriched formulas to treat colic .enriched formulas to treat colic .
 Garrison MM,christaski DA.asystemic review of treatment for infantile colic pediatrics 2000,106,184Garrison MM,christaski DA.asystemic review of treatment for infantile colic pediatrics 2000,106,184

23.  Other formula typesOther formula types : The use of a : The use of a
partially hydrolyzed whey protein formula partially hydrolyzed whey protein formula
supplemented with fructo- and galacto-supplemented with fructo- and galacto-
oligosaccharides with a high beta-palmitic acid oligosaccharides with a high beta-palmitic acid
content was found to reduce the number of content was found to reduce the number of
crying episodes after 7 and 14 days when crying episodes after 7 and 14 days when
compared to standard formula and simethiconecompared to standard formula and simethicone
 Savino F,palumer E,castago E,et al.reduction ofcrying episodeowing to infantile colic.Eur Jclin nutr Savino F,palumer E,castago E,et al.reduction ofcrying episodeowing to infantile colic.Eur Jclin nutr
2006;6013042006;601304

24.  Maternal diet Maternal diet
A decrease in maternal milk product A decrease in maternal milk product
consumption or a hypoallergenic maternal diet consumption or a hypoallergenic maternal diet
may be beneficial in decreasing the symptoms may be beneficial in decreasing the symptoms
of colic, particularly if the mother is atopic or of colic, particularly if the mother is atopic or
the baby has symptoms of cow's-milk allergy the baby has symptoms of cow's-milk allergy
(eg, eczema, wheezing, diarrhea, or vomiting)(eg, eczema, wheezing, diarrhea, or vomiting)
 Schmitt BD.crying Baby(colic).In:Instructionfor pediatric patients 1Schmitt BD.crying Baby(colic).In:Instructionfor pediatric patients 1stst
ed,wB ed,wB
Saunder,philadalphia 1992.p141Saunder,philadalphia 1992.p141

25.  Herbal remediesHerbal remedies — Herbs such as — Herbs such as
chamomile, fennel, and balm-mint have been chamomile, fennel, and balm-mint have been
shown to have antispasmodic properties. Their shown to have antispasmodic properties. Their
effects on colic were studied in a randomized, effects on colic were studied in a randomized,
double-blind, controlled trialdouble-blind, controlled trial
 Weizman Zalkrinawi S,Goldfarb D,Bitran C.efficacy of herbal tea preparation in Weizman Zalkrinawi S,Goldfarb D,Bitran C.efficacy of herbal tea preparation in
infantile colic, J pediatric 1993:122:650infantile colic, J pediatric 1993:122:650

26.  Sucrose — Sucrose has been studied as a Sucrose — Sucrose has been studied as a
treatment for colic because it may produce an treatment for colic because it may produce an
analgesic effect on infants through the release analgesic effect on infants through the release
of endogenous opioidsof endogenous opioids
 However, the effect was short-lived (30 However, the effect was short-lived (30
minutes to one hour maximum)minutes to one hour maximum)
 Markestad T.use of sucrose as a treatment for infantile colic.Arch Dis Markestad T.use of sucrose as a treatment for infantile colic.Arch Dis
Child1997;76:356Child1997;76:356

27.  SimethiconeSimethicone — Existing data show little — Existing data show little
possible benefit of simethicone in the possible benefit of simethicone in the
treatment of colic. One of three randomized treatment of colic. One of three randomized
controlled trials comparing simethicone and controlled trials comparing simethicone and
placebo noted a decrease in crying with placebo noted a decrease in crying with
simethicone,other 2 study show no benefitsimethicone,other 2 study show no benefit
 May cause hypothyroidismMay cause hypothyroidism
 Metcalf TJ,Irons TG,Sher LD, YOUNG PC.simethicone in the treatment of infantile colic.pediatrics Metcalf TJ,Irons TG,Sher LD, YOUNG PC.simethicone in the treatment of infantile colic.pediatrics
1994;94;291994;94;29

28.  Antispasmodics Antispasmodics
 Dicyclomine performed better than did Dicyclomine performed better than did
placebo in three randomized controlled trials . placebo in three randomized controlled trials .
However, the adverse effects (eg, apnea, However, the adverse effects (eg, apnea,
seizures, and coma), which are most common seizures, and coma), which are most common
in infants younger than seven weeks old, in infants younger than seven weeks old,
preclude its use in the treatment of colicpreclude its use in the treatment of colic
 its use is contraindicated in infants younger its use is contraindicated in infants younger
than six months of agethan six months of age
 Garrison MM,christaski DA.asystemic review of treatment for infantile colic pediatrics Garrison MM,christaski DA.asystemic review of treatment for infantile colic pediatrics
2000,106,1842000,106,184

29.  Lactase enzymes — Lactase has not been Lactase enzymes — Lactase has not been
shown to improve colic symptomshown to improve colic symptom
 Miller JJ,McVeagh P,fleet GH,efficasy of yeastlactase enzyme in colic in infant fed human Miller JJ,McVeagh P,fleet GH,efficasy of yeastlactase enzyme in colic in infant fed human
milk.Jpediatrc 1990,117:216milk.Jpediatrc 1990,117:216

30.  Probiotics — The potential benefits of Probiotics — The potential benefits of
treatment with Lactobacillus reuteri in the treatment with Lactobacillus reuteri in the
treatment of colic have been demonstrated in treatment of colic have been demonstrated in
two randomized trialstwo randomized trials
 Savino F,cordisco L,Tarasco V,lactobacillus reuteriDSM 17938in infantile Savino F,cordisco L,Tarasco V,lactobacillus reuteriDSM 17938in infantile
colic.pediatrics 2010;’126526colic.pediatrics 2010;’126526

31. How Long does Colic LastHow Long does Colic Last??
Begins early:Begins early:
 100% by 3 weeks100% by 3 weeks
End variesEnd varies::
 50% by 2 months50% by 2 months
 80% by 3 months80% by 3 months
 90% by 4 months90% by 4 months
Weissbluth, 1998

32. Risks to Behavior & DevelopmentRisks to Behavior & Development
Severe colic/persistent excessive crying in infancy past Severe colic/persistent excessive crying in infancy past
5 months has been linked to the following child 5 months has been linked to the following child
outcomes:outcomes:
• Motor, language, and cognitive delays Motor, language, and cognitive delays
• Behavioral problems (“temper tantrums”)Behavioral problems (“temper tantrums”)
• Negative reactivity (“fussiness”)Negative reactivity (“fussiness”)
• Sleep disordersSleep disorders
• Feeding problemsFeeding problems
• HyperactivityHyperactivity
DeGangi et al., 2000; DeSantis et al, 2005; Kries, Kalies, & Papousek, 2006; Papousek &
von Hofacker, 1998; Rautava et al., 1995; Savino et al., 1995; Wake et al., 2006; Wolke,
Rizzo, & Woods, 2002

33. What is colicWhat is colic??
 Colic is a common condition that affects otherwise healthy babies.Colic is a common condition that affects otherwise healthy babies.
 Normally starts soon after birth and lasts until the baby is threeNormally starts soon after birth and lasts until the baby is three
or four months old – sometimes longer (around 6 months).or four months old – sometimes longer (around 6 months).
 The most common symptom of colic is excessive andThe most common symptom of colic is excessive and
inconsolable crying in a baby that otherwise appears to beinconsolable crying in a baby that otherwise appears to be
healthy and well-fed.healthy and well-fed.
 Colic is a common condition which can affect up to 1 in 5 babies Colic is a common condition which can affect up to 1 in 5 babies
Colic affects both girls and boys equallyi.Colic affects both girls and boys equallyi.
 Colic affects both breast-fed and formula-fed babies equallyi.Colic affects both breast-fed and formula-fed babies equallyi.
 The cause (or causes) of colic is unclear.The cause (or causes) of colic is unclear.
 There is is no specific treatment, ressurance of There is is no specific treatment, ressurance of
parent with 5sparent with 5s