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Colic - infantile - Management
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Overview of management

  • Infantile colic is defined as repeated episodes of excessive and inconsolable crying in an infant that otherwise appears to be healthy and thriving.
  • Offer support and reassurance to parents.
  • Soothing strategies that may help some babies include:
    • Holding the baby through the crying episode.
    • Gentle motion (e.g. a walk in the pram or a ride in the car).
    • 'White noise' (e.g. vacuum cleaner, hairdryer, running water).
    • Bathing in a warm bath.
  • Encourage parents to look after their own well-being by arranging to take a break, resting when the baby is asleep, and seeking peer support.
  • If parents still feel unable to cope despite advice and reassurance consider the following options:
    • A 1-week trial of simeticone drops (breastfed or bottle-fed).
    • A 1-week trial of exclusion of cows milk protein:
      • Breastfed babies: 1-week trial of dairy-free diet for the mother.
      • Bottle-fed babies: 1-week trial of hypoallergenic formula.
    • A 1-week trial of lactase drops (off-licence use) (breastfed or bottle-fed).

What 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.
  • Holding the baby through the crying episode may be helpful. However, if there are times when the crying feels intolerable, it is best to put the baby down somewhere safe (e.g. their cot) and take a few minutes' 'time out'.
  • Other strategies that may help to soothe a crying infant include:
    • Gentle motion (e.g. pushing the pram or a ride in the car).
    • 'White noise' (e.g. vacuum cleaner, hairdryer, running water).
    • Bathing in a warm bath.
  • Encourage parents to look after their own well-being:
    • Ask family and friends for support — parents need to be able to take a break.
    • Rest when the baby is asleep.
    • Meet other parents with babies of the same age.
  • CRY-SIS is a support group for families with excessively crying, sleepless, and demanding children. Their helpline is available every day from 9 a.m. to 10 p.m. Tel: 08451 228 669. The CRY-SIS website (www.cry-sis.org.uk) also contains useful information.
Basis for recommendation
  • The good practice recommendations on reassurance, peer support, and holding the baby through the crying episode are taken from the NICE guideline Postnatal care: routine postnatal care of women and their babies [National Collaborating Centre for Primary Care, 2006].
  • Soothing motion (e.g. car rides), 'white noise' (e.g. vacuum cleaner, hairdryer, running water), or reducing stimulation have not been studied adequately, but professional opinion is they may be worth trying as they are safe, inexpensive, and involve the parents [Hiscock, 2006].

When should treatment for infantile colic be considered, and with what?

  • The most useful intervention is support for parents and reassurance that infantile colic will resolve.
  • Only consider trying medical treatments if parents feel unable to cope despite advice and reassurance. The options for medical treatments are:
    • A 1-week trial of simeticone drops (breastfed or bottle-fed).
    • A 1-week trial of diet modification to exclude cow's milk protein:
      • Breastfed babies: dairy-free diet for the mother.
      • Bottle-fed babies: hypoallergenic formula.
    • A 1-week trial of lactase drops (breastfed or bottle-fed).
  • Only continue treatment if there is a response (i.e. the duration of crying shortens).
    • If there is no response to one medical treatment, consider trying another.
    • Breastfeeding mothers should take a calcium supplement if they are going to remain on a dairy-free diet long term.
  • If the baby does respond to lactase or hypoallergenic diet, reassure the parents that this does not necessarily mean that they are lactose intolerant or allergic to cow's milk. These are rare conditions that affect very few babies with infantile colic.
Clarification / Additional information
    • For further information on how to use lactase drops, and which hypoallergenic formulas are available on the NHS, see Prescribing information.
Basis for recommendation
  • Although there are many studies of interventions for infantile colic, most are of poor methodological quality, making it difficult to evaluate the effectiveness of any treatment. No treatment has been clearly shown to be of substantial benefit (apart from antimuscarinics, which have serious adverse effects and are therefore not recommended).
  • Simeticone: although studies of simeticone have not demonstrated any benefit in infantile colic [Garrison and Christakis, 2000], CKS suggests that a 1-week trial as a placebo may still be worth a try: simeticone is easily available, licensed for this indication, and cheap. It has no reported adverse effects, and the simple act of being able to give their baby something may help parents cope better with the crying.
  • Hypoallergenic diet: there is limited evidence that switching to a hypoallergenic formula for bottle-fed babies, or to a hypoallergenic diet for breastfeeding mothers (free of milk, eggs, wheat, and nuts) may help ease the symptoms of colic [Evans et al, 1981; Hill et al, 1995; Lucassen et al, 2000].
    • The randomized controlled trials with whey hydrolysate are of better quality than those evaluating casein hydrolysate. However, both casein and whey hydrolysate are probably effective in cases of true intolerance to cow's milk protein or lactose.
    • A dairy-free diet is recommended as a pragmatic strategy for a trial of diet modification in primary care [Hiscock, 2006]. Advice should be sought from a dietitian before a stricter hypoallergenic diet is considered.
    • The Chief Medical Officer recommends that soya infant milk formulas should not be the first choice of treatment for cow's milk sensitivity or lactose intolerance [CMO, 2004]. This is because they have a high phytoestrogen content, and this may pose a risk to future fertility and sexual development [Committee on Toxicity, 2003].
  • Lactase: the available evidence suggests that lactase drops may help ease symptoms for some babies, providing that the lactase is given some time to incubate in the feed before it is given [Kearney et al, 1998; Kanabar et al, 2001]. However, the studies are small and require confirmation by studies independent of industry.
  • Low-lactose formula is not recommended:
    • The effectiveness of switching to a low-lactose formula is unknown; previous systematic reviews did not find any studies of low-lactose formula with adequate methodology for inclusion, and CKS found no subsequent studies of low-lactose formula.
    • There are theoretical reasons to suggest that a lactose-free formula may not be beneficial in the longer term. Lactase is an inducible enzyme and requires the presence of some lactose in the intestine for optimal development [Shulman et al, 2005].
  • For a discussion of the evidence on these and other treatments for infantile colic, see Supporting evidence.

When should I consider stopping treatment?

  • If there is no response to the trial of treatment stop it.
  • If there is a response to treatment: after the age of 3 months (and by 6 months of age at the latest), wean off treatment over a period of about 1 week.
Basis for recommendation
  • These are pragmatic recommendations from CKS. We found no review articles from experts that discussed this aspect of care.

When should I refer a baby with infantile colic?

  • Seek advice from a paediatrician if:
    • The parents are not coping despite advice, reassurance, and primary care interventions.
    • There is diagnostic doubt (e.g. the baby is not thriving; crying is not starting to get better or is getting worse after 4 months of age; significant gastro-oesophageal reflux is suspected).
    • Unable to wean off treatment by the age of 6 months.
Basis for recommendation
  • These are pragmatic recommendations from CKS. We found no review articles from experts that discussed this aspect of care.

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