AN OSTEOPATHIC APPROACH TO COLIC Heather Ferrill DO, MS Associate Professor OPP Rocky Vista University College of Osteopathic Medicine

OUR GOALS TODAY

 The current research on the pathophysiological mechanisms underlying colic  The current research on the treatment for the with colic  Anatomical and physiological relationships important in the osteopathic evaluation of the infant with colic  Indications and contraindications to OMT in the infant with colic  Fast and easy OMT for the busy PCP to use with the colicky infant

COLIC DEFINED

 Scientific-defined for research efforts  Wessel criteria (1954)  Crying and fussing more than  3 hours per day  3 days a week  For more than 3 weeks  Inconsolable, excessive crying associated with hypertonicity, perceived pain, borborygmus, wakefulness  Cyclic  Onset 2-6 weeks old and lasts typically 3 months

DIFFERENTIAL DIAGNOSIS INCLUDES:

 Infection – meningitis, encephalitis, sepsis, pneumonia, UTI, osteomyelitis, septic, toxic synovitis, AOM, herpes stomatitis, oral thrush, gastroenteritis, herpangina, insect bites, cellulitis, infectious arthritis  Trauma – non-accidental trauma (skull fracture, intracranial bleed, rib fracture, pneumothorax, long bone fracture, intra-abdominal blunt trauma), accidental trauma (falls), corneal abrasion, hair tourniquets (digits, penis, clitoris)  Metabolic – inborn error of metabolism, electrolyte abnormality, acid/base derangement, hypoglycemia  Foreign body – oral, nasal, ear, pharynx, eye  GI – intussusception dehydration constipation, GERD, hernia  CV – SVT, congenital heart disease  Environmental: neglect, hunger CURRENT RESEARCH ON PATHOPHYSIOLOGY AND ETIOLOGY OF COLIC

 Dietary  Psychological  Gastrointestinal  Hormonal  Neurological immaturity

ETIOLOGY

 Dietary  :

 Clifford TJ, Campbell MK, Speechley KN, Gorodzinsky F. Infant colic: empirical evidence of the absence of an association with source of early . Arch Pediatr Adolesc Med. 2002 Nov;156(11):1123-8.

 Prospective cohort study of 856 infant dyads

 Maternal questionnaires at 1 and 6 weeks regarding feeding sources, presence of colicky behavior, maternal anxiety and alcohol consumption

 Breastfeeding did not have a protective effect on the development of colic

 Maternal anxiety was positively correlated with colic

ETIOLOGY

 Dietary  Food sensitivities  Hill D, et al. Effect of a Low-Allergen Maternal Diet on Colic Among Breastfed : A Randomized, Controlled Trial. Vol. 116 No. 5 November 1, 2005; pp. e709 -e715 (doi: 10.1542/peds.2005-0147)  RCT conducted among exclusively breastfed infants with colic (90 completed the trial)  Average cry-fuss time over 48 hours was 630-690 minutes  Active arm: mother’s excluded cow's milk, eggs, peanuts, tree nuts, wheat, soy, and fish. Control arm: continued to consume these foods  Outcomes assessed after 7 days as the duration of cry-fuss behavior over 48 hours using charts  End point 25% reduction in cry-fuss behavior over 48 hour period after 7 days of dietary intervention  Result: objective 21% less cry-fuss time in the low allergen diet group.

ETIOLOGY

 Psychological  The relationship between maternal post-partum depression and colic  Ante-partum stress and depression and colic  Association is clear—what is not clear is if there is an etiological relationship

 Maternal/familial stress and depression anxiety causes colic?

 Colic causes maternal/familial stress, depression and anxiety?

 Or they just exist together?

ETIOLOGY

 Physiological  GI related

 Gut motility and neurological immaturity

 Intestinal flora imbalance  Neurobiological

 HPA axis and adrenergic system feedback loops activated as a result of perceived danger or discomfort (on the part of the infant)

 Epigenetic modulation in the limbic system may explain correlations between regulatory problems in the first months of life and behavioral/feeding problems later in life

 Douglas PS, Hill PS. A neurobiological model for cry-fuss problems in the first three to four months of life. Med Hyp 2013. DOI: http://www.sciencedirect.com/science/article/pii/S0306987713004386 (abstract only) ETIOLOGY

 H. Pylori and Infantile Colic  Case control study (Saudi Arabia)  Used H. Pylori stool antigen testing  Case population  55 infants with colic per Wessel criteria  2-4 months age  45 (81.8%) tested positive for H. Pylori infection  Control population  30 infants without colic  Age, country of origin, gender and ethnicity matched  7 (23.3%) tested positive for H. Pylori infection

Ali, AM. Helicobactor Pylori and Infantile Colic. Arch Pediatr Adolesc Med. 2012 Jul 1;166(7):648-50.

COLIC AND MIGRAINE

 Children with personal history of migraine  208 kids aged 6-18 with headache history; 471 without  72.6% of children with migraine also had infantile colic  26.5% of children without headache had infantile colic Romanello S, et al. Association between childhood migraine and history of infantile colic. JAMA 2013;309(15):1607-1612  with migraine and their kids  Maternal migraine was associated with a more than 2-fold increase in prevalence of infantile colic Gelfand AA, et al. Before the headache: Infant colic as an early life expression of migraine. Neurology 2013;79;1392-1396.

COLIC AND OTHER CHILDHOOD PROBLEMS

 Prospective study comparing infants with and without severe colic during infancy and 10 years later.  Significantly increased incidence of

 Recurrent abdominal pain (abdominal migraine)

 Allergic diseases (asthmatic bronchitis, rhinitis, conjunctivitis, atopic eczema, food allergy)

 Psychological disorders (sleep disorders, aggressiveness, fussiness, ‘supremacy’)

Savino F, et al. A prospective 10-year study on children who had severe infantile colic. Acta Paediatrica, 2005; 94(suppl 449):129-132.

FACILITATION

Floyd Henry Allport. "The Physiological Basis of Human Behavior." Chapter 2 in Social Psychology. Boston: Houghton Mifflin Company (1924): 17-41. Visceral Afferents (VII, IX, X) Visceral Efferents (X) Spinal Trigeminal nucleus Motor Efferents (IX, X) C1 Rootlets

Adapted from: Nolte, John. The Human Brain An Introduction to its Functional Anatomy,6th ed. Philidelphia: Mosby Elsevier, 2009. Print. TREATMENT OF COLIC

 Rule out organic disease  Medication  Reassurance, reassurance,  Simethicone reassurance  Dicyclomine  Dietary interventions  Methylscopalamine  Maternal diet restriction  Behavioral (big 5: gluten, dairy, egg,  Quiet area/decreased citrus, soy) stimulation  Formula changes  Vibration (car ride, sitting  Herbal teas on the dryer, etc)  Sugar water  Intensive parental training  Supplements  High fat diet per mother  Manual treatment/therapy or fats added to infant diet  OMT  Pro- and pre-biotics  Chiropractic  Massage

WHAT MAY WORK (ACCORDING TO THE LITERATURE)

 Fennel extract tea  Chamomile, vervain, licorice, fennel, balm mint  Fennel has analgesic effect  Sucrose/glucose solutions  Sweetness may induce analgesic effect  Manipulation (of any sort)  Several showed benefit, but lack of blinding, small ‘n’ limited usefulness of the studies  Studies not well funded or of good trial design  Need better studies  Probiotics  L reuteri has been found to be helpful in several studies

QUICK OMT FOR THE COLICKY BABY

 High yield areas to evaluate and treat as necessary  OA

 Suboccipital inhibition/soft tissue  Mid thoracic

 Rib raising  Thoracolumbar junction

 Myofascial release  Lumbar spine Allie  Myofascial, especially upper lumbars  Pelvic diaphragm

 Myofascial release  Indications  Somatic dysfunction  Organic disease ruled out and “functional” cause is suspected  Contraindications  ??  Rule out organic disease  Follow contraindications for modalities  How often to treat?  Depends-weekly is most often, usually  Gauge how much help parents need

 Treat parents as well if necessary

PELVIC DIAPHRAGM Myofascial release

LUMBAR SPINE 1157 #256

Myofascial release subjectBody Gray'sAnatomy the of Human THORACOLUMBAR JUNCTION

 Myofascial release

MID-THORACIC SPINE AND RIBS

Rib raising

Gray's Anatomy of the Human Body Plate # 839 OCCIPITOATLANTAL JOINT

Soft tissue/inhibition  Also addresses upper cervical spine

WHAT WE LEARNED

 Colic is tough  There are no answers, lots of questions, lots of interesting research going on  Focus on helping parents cope  OMT for colic is focused on  Augmenting circulatory motion in the abdomen  Treating viscero-somatic and/or somato-visceral reflexes  Areas to focus on in the busy practice  Look at diaphragms  pelvic, thoracic diaphragm  Mesenteric root  Mid-thoracic region  OA/upper cervicals

THANK YOU!

St. Mary’s Glacier, Colorado REFERENCES

 Wessel, MA, et al. Paroxysmal fussing in infancy, sometimes called colic. Pediatrics 1954;14;421.  Carreiro, Jane E. An osteopathic approach to children. Churchill Livingstone, 2003.  Sergueef, Nicette. Cranial osteopathy for infants, children and adolescents: a practical handbook. Elsevier Health Sciences, 2007.  Clifford TJ, Campbell MK, Speechley KN, Gorodzinsky F. Infant colic: empirical evidence of the absence of an association with source of early infant nutrition. Arch Pediatr Adolesc Med. 2002 Nov;156(11):1123-8.  Ali, AM. Helicobactor Pylori and Infantile Colic. Arch Pediatr Adolesc Med. 2012 Jul 1;166(7):648- 50  Nolte, John. The Human Brain An Introduction to its Functional Anatomy,6th ed. Philidelphia: Mosby Elsevier, 2009. Print.  Garrison MM, Christakis DA. A Systematic Review of Treatments for Infant Colic. Pediatrics 2000;106(1):184-190.  Sung, V, et al. Probiotics to improve outcomes of colic in the community: Protocol for the Baby Biotics randomised controlled trial. BMC Pediatrics 2012; 12:135.  Szajewska H, Gyrczuk E, Horvath A. Lactobacillus reuteri DSM 17938 for the management of infantile colic in breastfed infants: a randomized, double-blind, placebo-controlled trial. J Pediatr. 2013 Feb;162(2):257-62. doi: 10.1016/j.jpeds.2012.08.004. Epub 2012 Sep 14.  Savino F, et al. A prospective 10-year study on children who had severe infantile colic. Acta Paediatrica, 2005; 94(suppl 449):129-132.  Hill D, et al. Effect of a Low-Allergen Maternal Diet on Colic Among Breastfed Infants: A Randomized, Controlled Trial. Pediatrics Vol. 116 No. 5 November 1, 2005; pp. e709 -e715 (doi: 10.1542/peds.2005-0147)

REFERENCES

 Miller JE, Phillips HL. Long-tern effects of infant colic: A survey comparison of chiropractic treatment and non- treatment groups. J Manipulative Physiol Ther. 2009 Oct;32(8):635-8. doi: 10.1016/j.jmpt.2009.08.017.

 Dobson D, et al. Manipulative therapies for infantile colic. Cochrane Database Syst Rev. 2012 Dec 12;12: CD004796. doi:10.1002/14651858.CD004796.pub2.

 Bronfort G, et al. Effectiveness of manual therapies: the UK evidence report. Chiropr Osteopat. 2010 Feb 25;18:3. doi: 10.1186/1746-1340-18-3.

 Perry R, Hunt K, Ernst E. Nutritional Supplements and Other Complementary Medicines for Infantile Colic: A Systematic Review. Pediatrics. 2011 Apr;127(4):720-33. doi: 10.1542/peds.2010-2098. Epub 2011 Mar 28.

 Hayden C, Mullinger B. A preliminary assessment of the impact of cranial osteopathy for the releif of infantile colic. Complement Ther Clin Pract. 2006 May;12(2):83-90. Epub 2006 Feb 8.

 Akman I, et al. Mothers' postpartum psychological adjustment and infantile colic. Arch Dis Child. 2006 May;91(5):417- 9. Epub 2006 Feb 1.

 Kheir, AEM. Infantile colic: facts and fiction. Ital J Pediatr 38 (2012): 34.

 Radesky, JS, et al. Inconsolable and maternal postpartum depressive symptoms. Pediatrics. 2013 Jun;131(6):e1857-64. doi: 10.1542/peds.2012-3316. Epub 2013 May 6.

 Gelfand AA, Thomas KC, Goadsby PJ. Before the headache: Infant colic as an early life expression of migraine. Neurology 2013;79;1392-1396.

 Carson L et al. Abdominal Migraine: An underdiagnosed cause of recurrent abdominal pain in children. Headache 2011;51(5):707-712.

 Romanello S, et al. Association between childhood migraine and history of infantile colic. JAMA 2013;309(15):1607- 1612.

 Roos S, et al. 454 Pyrosequencing analysis on faecal samples from a randomized DBPC trial of colicky infants treated with lactobacillus reuteri DSM 17938. PLoS One 2013; 8(2): e56710. doi: 10.1371/journal.pone.0056710.

 Szajewska H, et al. Lactobacillus reuteri DSM 17938 for the management of infnatile colic in breastfed infnats: a randomized, double-blind, placebo controlled trial. J Pediatr 2013 Feb; 162(2):257-62. doi: 10.1016/j.peds.2012.08.004. Epub 2012 Sep 14.