Colic: Making the Family Happy Again · Case: The cry baby Mississippi Center for Advanced Medicine 9/24/2019 4. ... Natural history of colic and crying time Harvey Karp Method: 5

Colic: Making the Family Happy AgainNEELESH A TIPNIS, MD

PROFESSOR, PEDIATRICS

9/24/2019Mississippi Center for Advanced

Medicine1

DISCLOSURES

No relevant financial disclosures

9/24/2019Mississippi Center for Advanced Medicine 2

Objectives

Identify the peak of crying severity in infants

List at least one cause of colic in infantsDefine a the role of the gut microbiome in

colic


Case: The cry baby


Here’s a story

Of a 2 month baby, who cried and cried all mornings and at night

He was spitty, and a little gassy

And he drove his parents absolutely batty


Approaching the irritable infantIT CRIES

I = Infections (ex, UTI, Meningitis, Sepsis)

T = Trauma (ex, Subdural Hematoma, Fractures, Non-accidental trauma)

C = Cardiac Disease (ex, SVT)

R = Reaction to meds, Reflux, Rectal/Anal Fissure

I = Intussusception

E = Eyes (ex, corneal abrasion, foreign body, glaucoma)

S = Strangulation, Surgical Processes (ex, Hernia, Testicular/Ovarian Torsion)


Spectrum of FGID in infants and children


Normal crying pattern in infants


Wessel MA, et at. Pediatrics. 1954 Nov;14(5):421-35

Brazelton TB. Crying in infancy. Pediatrics 1962:29:579-588.Barr RG,et al. 2000 Brighton Conference.

Infant colic

Wessel’s criteria of 3

Excess and worrisome crying last for 3 or more hours per day

3 or more days per week

3 or more weeks


Rome IV criteria for infant colic

Infant less than 5 months of age at symptom start and stop

Caregiver reports periods of prolonged crying, fussing, or irritability

Symptoms occur without obvious cause Caregiver cannot prevent or resolve symptoms

No symptoms of failure to thrive, fever, or illness


What are the causes of infant colic?GastrointestinalHormonalNeurodevelopmentalPsychological


What are the causes of infant colic?Gastrointestinal

MalnourishmentAllergy/IntoleranceExcess gas fermentation

Inflammation/Dysbiosis



Brain-gut axis

Cow Milk Protein and ColicL Lothe and T Lindberg. Pediatrics. 1989 Feb;83(2):262-6.


CMP Formula HydrolyzedHydrolyzed + WheyHydrolyzed + Placebo

Responders

CMP Formula HydrolyzedHydrolyzed + WheyHydrolyzed + Placebo

Responders

Cow Milk Protein and Colic DBPC Crossover study

17 infants 51 crossovers between CM formula and protein-hydrolysate

BW Forsyth. J Pediatr. 1989 Oct;115(4):521-6.


Cow Milk Protein and Colic

Open-label study of an amino acid formula in 6 infants

Estep DC1, Kulczycki A Jr. Acta Paediatr. 2000 Jan;89(1):22-7.



Is Dysbiosis the KEY?

Actinobacteria

Lactobacillus Bifidobacteracea


Potential effects of dysbiosis Increased Fermentation

Increased Bowel Inflammation


What are the causes of infant colic? Hormonal

Histamine

Cortisol

Neurodevelopmental

Exaggerated response to normal infant development

Migraine

Missing 4th Trimester

Psychological

Impaired parent-child interaction

Anxiety/Depression

Advance parental age

Maternal smoking


Treatment of infant colic

Parental Reassurance and Education

Nutrition Therapy

Pharmacotherapy

Probiotics



Parental Reassurance and Education Natural history of colic and crying time

Harvey Karp Method: 5 S’s Swaddle

Side lying

Swing

Shhh

Suck

Address comorbid conditions



Nutrition Therapy Recognize hunger and satiation cues

Decrease Fermentation Reduce lactose exposure?

Protein hydrolysate formula in formula fed infants?



Parental Reassurance and Education

Nutrition Therapy Pharmacotherapy Probiotics



Pharmacotherapy No role for acid suppression therapy

Antispasmodics

Visceral hyperalgesia

Complementary Medicines (Fennel and Chamomile)


Probiotics: The holy grail of colic?


Its too early to tell

Crying time and fussing reduced in both probiotic and placebo groups

Fecal calprotectin reduced in both probiotic and placebo groups

No statistical difference

BMJ 2014;348:g2107 doi: 10.1136/bmj.g2107 (Published 1 April 2014)


Meta analysis: l. reuteri

Xu M, et al. PLoS ONE 2015:10(10): e0141445.doi: 10.1371/journal.pone.0141445


Effect of Prebiotics and Probiotics on Prevention of Colic

0

10

20

30

40

50

60

Content Criers

Prebiotic Probiotic Placebo

P=0.02


ND

Partty A, et al;2013, J Pediatrics. 163(5): 1272–1277.e2

Prevention of colic


Savino F, et al. Benef Microbes. 2015;6(3):245-51. doi: 10.3920/BM2014.0090

Summary

Colic Ends at Some PointReassurance is bestGrowing role for probioticsTreatmentPrevention


Probiotic Products

Lactobacillus L rhamnos (LGG)

Culturelle

L. reuteri

Biogaia proctectis

Gerber Good Start Probiotic

Gerber Soothe

Bifidobacter B. lactis

Gerber Gentle:

B. infantis

Align


Blends Yogurts

Activia

Danactive

VSL#3

Align

Saccharomyces S. boulardi

Florastor

Documents

Colic: Making the Family Happy Again · Case: The cry baby Mississippi Center for Advanced Medicine 9/24/2019 4. ... Natural history of colic and crying time Harvey Karp Method: 5