Spotlight: infantile colic

What is colic?

Functional gastrointestinal (GI) disorders – including reflux, colic and constipation – are common in early childhood and are generally the consequence of the maturing gut and nervous system.¹ A study by one of the leading research teams estimates the prevalence of colic at approximately 20%.²

Colic, or paroxysmal crying, was initially defined in the 1950s by Wessel.³ This definition stated that colic lasted at least three hours a day, three times a week, and over a period of three weeks. This definition was modified and made less prescriptive by Hyman.⁴ This definition described colic as excessive crying lasting about three hours a day, three days a week over a period of one week, in an infant up to four weeks of age. Colic more recently is defined as recurrent and prolonged periods of infant crying. There is no evidence of failure to thrive, fever or illness, in an infant aged less than five months when symptoms start and stop.⁵

Approximately 50% of infants will suffer from at least one of the functional GI disorders before six months of age.⁶ Reported worldwide prevalence of colic ranges from 5 to 20%.² It occurs equally in males and females and in both breast and formula fed infants.

What is the recommended approach to managing colic?

NICE/Clinical Knowledge Summary (CKS) guidelines¹¹ should be used with an emphasis on reassuring the family that colic is a transitory phase that will resolve by six months of age. The baby can be held and gently rocked, with options such as the use of background white noise. As the baby has always been used to background noise in the uterus, ongoing noise may be reassuring. A warm bath and massage might settle the baby too, as touch stimulates all the organs of the body. The baby can be sat upright after a feed, with advice given about how to wind the baby correctly, with gentle tapping of the back to help bring up excess air. Families can seek support from other parents and healthcare professionals, such as GPs and health visitors. It is important for the carers to stay calm if possible, to avoid communicating their own anxieties, as this will just exacerbate the situation. If the mother is breastfeeding she should be encouraged to continue. Time out with settling the baby in their cot and leaving them to settle on their own is another option. A baby that is over handled can become more agitated and irritable, so this should be avoided.

Nutritional advice that may be helpful includes discussion around the volume and frequency of feeds, which may be causing some abdominal discomfort. As a guideline, 150-180ml per kg of baby weight over 24 hours is recommended, although this will vary from baby to baby.¹² Teat sizes with bottles may be resulting in too rapid milk flow, causing the baby to gulp excessive air during the feed. It is always important to listen to the parent’s concerns and offer practical advice.

Special infant formulas may be considered for non-breastfed infants with common GI disorders.¹⁰

NICE/CKS guidelines state “only consider medical treatments if parents feel unable to cope, despite advice and reassurance”.¹¹

How does colic present in primary care?

Symptoms can present after a few weeks with an infant drawing their knees up to their tummy, clenching their fists, or arching their back with high pitched inconsolable crying, without signs of faltering growth or other organic problems. This excessive crying may continue for a few hours until the baby settles. This pattern may be repeated at a similar time each day. There are gastrointestinal and behavioural hypotheses for infantile colic.^{8, 9}

Gastrointestinal problems involve an immature gut, imbalance of intestinal bacteria, changes in gut hormones and food sensitivities.¹⁰ Behavioural issues may include maternal anxiety and a difficult infant temperament.¹⁰

Colic is distressing for the family, who may suffer sleep deficit and time off work to cope with their crying baby. Tired parents may feel helpless to console and care for their baby and may visit their GP for medication for themselves and their infant. Therefore, it’s vital that healthcare practitioners offer reassurance and manage parents’ expectations during this difficult time. They need to know that colic will resolve over time and that about 50% of infants experience a functional GI disorder.

What approaches may not be appropriate?

Medication has not been found to be effective in clinical trials.¹⁰ Remedies such as lactase drops (such as Colief), simeticone (such as Infacol) and herbal remedies do not have sufficient clinical evidence to support their use. Gripe water contains sodium bicarbonate and dill seed oil. The only support for its use is anecdotal, and it may be due to its sweet taste. The parents and caregivers should be reassured that there is no evidence of improvement from any manipulative techniques; for example, cranial osteopathy has no scientific proof of efficacy.

It is important to ensure parents know never to shake their baby during these crying episodes. Tiny blood vessels in the brain can rupture and shaking conveys distress and lack of control, which will only exaggerate the stressful situation.

It is important that healthcare practitioners are aware of strategies that are effective to give clear and consistent advice. Reassurance and nutritional advice should be the cornerstone of management.¹⁰

TABLE 1: Comparison between three common conditions and their key characteristics

When should parents be referred on to secondary care

NICE/CKS guidelines¹¹ advise referral if:

• Parents/carers feel unable to cope with the infant’s symptoms despite reassurance and advice in primary care
• The infant is not thriving, or symptoms are not starting to improve or are deteriorating after 4 months of age
• There is a suspected underlying cause for symptoms which cannot be managed in primary care.

Providing effective parental reassurance using motivational interviewing principles

Parental reassurance and the provision of nutritional advice is the cornerstone of management of infant functional GI disorders.¹⁰ Reassurance is a subjective state, influenced by a parent’s perception and is achieved when a change in a parent’s behaviour, thoughts or understanding occurs.¹³ Good communication underpins high quality care and plays a crucial role in meeting the objectives of both the practitioner and patient.^{14, 15} Key qualities considered to impact positively on the parent-practitioner relationship include empathy and warmth.¹³

Parents will not be reassured if they do not feel that their difficulties have been listened to and understood.¹⁶ Sub-optimal approaches to reassurance can cause a great deal of distress to parents and may result in repeated consultations and high use of healthcare resources.¹⁶ Repeated reassurance-seeking is often driven by parent anxiety, for example, concerns about a child’s health. In the short-term this may reduce anxiety, but in the long term it perpetuates a vicious cycle of reassurance – seeking behaviour (Figure 1), which can be broken by providing effective reassurance to parents utilising effective communication skills.

Fig 1 – The reassurance-seeking cycle

Where can you find information to help improve how effectively you reassure parents?

Healthcare practitioners can refer to the educational module developed by the Gut Feelings panel, hosted on MIMS Learning, which provides bite-sized learning resources (Managing Functional GI Disorders in infancy: integrating clinical recommendations with effective communication skills). For more information visit www.mimslearning.co.uk/infantGIhealth.

This resource has been developed to improve knowledge of infant colic, reflux and constipation and provide more effective parental reassurance.

Also, see the section on providing effective parental reassurance.                  

What other practical information can you provide to parents?

There are other online resources, for example, NHS Choices. Practical tips have been developed for HCP use only in the educational module. Support groups, like Cry-Sis helpline, offer help to those with crying, irritable babies. For more information visit https://www.cry-sis.org.uk/.

Motivational interviewing is an evidence-based, collaborative, guiding communication style which aims to strengthen a person’s motivation and commitment for change.¹⁷ A ‘guiding’ style of communication utilises a balance of skilled listening, asking some questions and offering information when necessary. Four key skills assist in listening.

• Open ended questions to encourage parents to fully express their opinions and concerns
• Providing affirmations by commenting positively on strengths you have observed in a parent
• Forming statements of understanding, known as reflective listening, that will help you to gain insight into a parent’s lived experience
• Periodically summarising what the parent has said to demonstrate that they have been listened to and understood.           

Conclusion

Improved health outcomes could be achieved if healthcare practitioners provide reassurance and nutritional advice, rather than recommend solutions that have no proven clinical evidence.

Without effective support there is the risk that the mother will discontinue breastfeeding, as she may think that her breastmilk is adversely affecting her baby. The stress involved with caring for an unsettled baby that cries uncontrollably increases the risk of child maltreatment.

There is also the potential for significant cost savings, both to the NHS and to families if the treatment guidelines for colic are followed and universally accepted. The Gut Feelings educational resource has been developed to provide the tools to support healthcare practitioners in their day to day work with young families, where the issue of functional GI disorders is so commonplace. The most important point to make to parents and caregivers is that colic is self-limiting and will resolve on its own.

Top tips for effective parental reassurance

• The conversational style should be collaborative, empathic and autonomy-respecting
• Listen to the parent more than you ‘tell’. A useful guideline is that the parent does at least 50% of the talking
• Agree an agenda
• Take the time to listen to the parent’s concerns, with the aim of understanding their dilemma
• Avoid the ‘expert trap’ where advice/information is provided before understanding what the parent wants or needs
• Ask permission before you share advice/information
• Provide information/advice in small doses and avoid using jargon
• Allow the parent time to process the information
• Explore and build the parent’s confidence to use the techniques/implement the advice.

References

1. Vandenplas Y et al. J Paediatric Gastroenteral Nutr. 2009;49:498-547
2. Vandenplas Y et al. J Paediatr Gastroenterol Nutr. 2015;61(5): 531-537
3. Wessel MA et al. Paediatr. 1954;14: 421-434
4. Hyman PE et al. Gastroenterol. 2006;130:1519-1526
5. Benninga MA et al. Gastroenterol. 2016;150:1443-1445
6. Iacono G et al. Dig Liver Dis. 2005;37(6): 432–8
7. Mahon J et al; BMJ Open. 2017;7:e015594
8. Shamir R et al. J Pediatr Gastroenterol Nutr. 2013;57
9. Savino F. Acta Paediatr. 2007;96:1259-64
10. Salvatore S et al. Acta Paediatr. 2018;doi: 10.1111/apa.14378
11. National Institute for health and care excellence (NICE)/Clinical Knowledge Summary. Colic, infantile. London. NICE. 2017. https://cks.nice.org.uk/colic-infantile [Last accessed June 2018]
12. https://www.unicef.org.uk/babyfriendly/baby-friendly-resources/leaflets-and-posters/simple-formula-guide-for-parents/ [Last accessed June 2018]
13. Linton SJ et al. Pain. 2008;134(1): 5-8
14. Safran JD & Segal ZV.1990. Interpersonal process in cognitive therapy. New York: Basic Books
15. Ha JF, Anat S & Longnecker N. The Ochsner Journal. 2010;10:38-43
16. Donovan JL & Blake DR. Br Med J. 2000;320: 541-544
17. Motivational Interviewing: Helping people change, Fifth edition. New York: Guildford Press.

Alison Wall

Health visitor

Dr Vanessa Bogle

Psychologist and motivational interviewing expert

Both are members of the Gut Feelings expert panel