Closer look at topical conditions How to treat You can earn 1 credit by completing the ELearning assessment for this article 1 CR at nzdoctor.co.nz

The irritable baby

This article, by Anne Tait, looks into the paediatrics conundrum of the crying baby, a common situation that can drive primary care practitioners and paediatricians to despair, and parents even more so. The aim is to provide a systematic approach to the crying baby aged less than six months

he conundrum of the crying baby is that the baby depression and premature cessation of breastfeeding.2 Colic, Anne Tait appears otherwise well except for their prolonged for example, can thus affect babies and their caregivers, al- Do you need to read this article? is a general crying. They are feeding, growing and developing paediatrician though it is difficult to say if this impact is direct, indirect T well and have no other significant medical symptoms. at Starship or a temporal association. But from the parent’s perspective, the baby is clearly “not Children’s This article aims to provide a systematic approach to Try this quiz right”; the baby cries for long periods with minimal respite. Hospital, the crying baby – recognising that babies cry for many rea- 1. A feature of colic is that it can begin any time The many portrayals of perfect babies on social media can Auckland sons, to express discomfort right through to life-threatening up to 12 months of age. True/False further demoralise these parents. illness. It should enable identification of the small number 2. Fewer than 5 per cent of children with inconsol- Coupled with healthcare practitioners who wish to of children with pathology (versus colicky babies, in whom able crying have organic disease. True/False do something, or fix it, this makes the condition one the crying will improve with time). The article also aims 3. For gastro-oesophageal reflux disease in babies, where many treatments (pharmaceutical and non- to allow the practitioner to avoid unnecessary or lengthy regurgitation is not that often a feature. True/False pharmaceutical) have been trialled, some with relatively medical treatments with no or minimal benefit, and 4. Any trial of omeprazole in a baby requires little benefit and contradictory evidence. to provide care and support to parents in the extremely clinical review after three or four weeks to Practitioners want to do the best for their patients, and challenging situation of a crying child. assess for significant improvement.True/False this leads to many different approaches being tried. Thus, The discussion is divided into colic, gastro- 5. For most babies, the cause of non-IgE-mediated the parents may frequently spend a lot of time and effort oesophageal reflux disease (GORD), cow’s milk protein gastrointestinal food allergy is cow’s milk. (and money) trying to find a “cure”, with minimal clinical intolerance (CMPI) and other pathology, but with a par- True/False benefit. It is also very difficult for parents to reconcile the ticular focus on colic. For some children, there may be fact there is often no medical “cause” for the crying when overlapping symptoms, to a small degree. Taking a care- Answers on page 37 their babies are clearly in distress (and so “something must ful history, reviewing the growth trajectory, a full clinical be causing that distress”). examination and occasional investigations can help tease In addition, the literature provides indirect evidence that out a most likely cause for crying. However, I appreciate EARN RNZCGP CME CREDITS infant crying, especially in the first four months of life, can this can take time, which is in short supply in primary This continuing medical education be associated with non-accidental head injury; however, it healthcare. activity has been endorsed by the is important to appreciate that this issue is complex and One of the most important roles for primary health- RNZCGP and has been approved for multifactorial, with difficulties in obtaining caregivers’ care providers is to provide support. While infant crying up to 1 CME credit for the General Practice Educational Programme acknowledgement of shaking in response to crying. A is well-recognised throughout human history, for each and continuing professional development purposes 2004 Dutch study reported 5.6 per cent of caregivers reacted family it is uniquely distressing and an issue they did 1 (1 credit/hour). To claim, complete the ELearning assess­ physically at least once to their baby’s crying. Observational not anticipate, especially if it is their first baby, or first ment at nzdoctor.co.nz. Click on the EDUCATION button. studies have reported an association with parental “crying baby”.

14 April 2021 RATA AOTEAROA NEW ZEALAND DOCTOR 33 How to treat The irritable baby Consider other causes before ascribing a baby’s crying to colic

olic comes from the Greek word kolikos, meaning While known of since the beginning of time, the diagnos- colon. The typical pattern of behaviour of clenching tic criteria for colic were only defined in the medical literature PANEL 1 Cof the fists, flexion of the hips and knees, redness of in 1954, by Matthew Wessel and colleagues “Paroxysmal Rome IV criteria for colic* the face and crying leads to the observation that colic could fussing in infancy, sometimes called colic”. They described be due to abdominal discomfort.3 the “rule of threes” – crying for more than three hours a day 1. Starts at less than five months of age. Colic has been described through the ages. The earliest on more than three days a week for more than three months. 2. Prolonged, unsoothable character of crying without description in English is by Thomas Phaer, who wrote about British social anthropologist Sheila Kitzinger wrote: “The obvious cause and which cannot be prevented or resolved “Colike and rumblyng in the guttes” in the mid-1500s. Gripe sound of a crying baby…is just about the most disturbing, by caregivers. water dates from the mid-1800s, when it was used in fever demanding, shattering noise we can hear” (cited in The New 3. Crying for three hours or more per day, during three or outbreaks; at that time, it was a mixture of dill oil, sodium Yorker, 2007).4 more days in the preceding week (this is now more of a bicarbonate and alcohol. Over the years, various remedies However, while colic resolves, it cannot be treated as requirement used for entry into clinical studies). have been proposed, many touting success. But, as colic does entirely harmless. The sleep deprivation and emotion- 4. No evidence of infant faltering of growth, fever or illness. resolve typically by five or six months of age, the skeptic al distress from dealing with a colicky baby can be longer would say it was always going to be the outcome. lasting. There are a few reviews of longer-term childhood * Adapted from Zeevenhooven et al (Pediatr Gastroenterol­ outcomes of colicky babies. A Finnish observational study Hepatol Nutr 2017 Mar:20(1):1–13) from the mid-1980s showed children who had experi- CASE STUDY 1 enced colic tended to have significantly more issues with sleep initiation, behaviour, etc. A 2005 Italian study of 10- Parents’ concerns about crying baby at six-week check year outcomes in 103 children with severe infantile colic PANEL 2 The crying baby: reported significant associations (p = 0.05) with recurrent * abdominal pain, allergic disease and food allergy in child- Pathological conditions to consider hood. In addition, sleep disorders and some challenging behaviours were also associated with infantile colic.2 u Hirschsprung disease – failure to pass meconium It is unknown whether these associations are due to the within 48 hours, vomiting (especially bilious), abdominal colic, or if the colic results in more difficulties for parents distension, constipation or loose bowel motions. in dealing with subsequent issues. No studies have looked u Incarcerated hernia or testicular torsion – acute onset, into the outcomes in adulthood of colic. abdominal bulging, scrotal discolouration, scrotal tender- The initial Wessel criteria for colic have evolved into the ness to palpation. Rome IV criteria for functional disorders (see Panel 1).5 u GORD, CMPI – vomiting (especially bilious), feed refusal, The reported prevalence of colic can differ widely because diarrhoea with blood/mucus in the stool, failure to thrive. of varying definitions in studies, as well as parental percep- u Localised pain in the long bones or clavicles – tion and cultural practices, but there is a median 17.7 per non-accidental injury, osteogenesis imperfecta (rarely); cent prevalence in recent studies of functional gastrointes- look for swelling, localised redness/tenderness, bruising. tinal disorders in infants from birth to 12 months of age. u Other – hair tourniquet syndrome (naked examination), Baby Aroha and her parents are booked into your clinic by mistake; they normally This correlates with Wessel’s original observation of 25 per anal fissure, corneal abrasion, faltering growth due to inade- see your colleague who is on leave. The appointment is for a routine well-baby check. cent in the Yale New Haven Hospital nursery study. The quate nutrition, hydrocephalus. You have not met the family before. The parents look exhausted, the baby looks well. incidence is equal between the sexes and there is no correla- You perform the six-week check, which is unremarkable: weight 25th centile, length tion with type of feeding (breast or bottle), gestational age, Red flags for serious pathology 50th centile and head circumference on the 75th centile. You reassure the parents that socioeconomic status or time of the year.6 u failure of pass meconium within 48 hours of life Aroha looks well and start the consent process for vaccinations. A meta-analysis of 8690 babies, documenting their cry- u distended abdomen However, the mother starts crying and explains that she is worried her baby is ing, showed a mean daily fuss and cry duration of 117 to u hepatosplenomegaly unwell as she cries all of the time. She is concerned it is her breastmilk or something 133 minutes in the first six weeks of life, followed by a de- u bilious vomiting else causing it. The father suggests that, surely, there is medication to stop the crying? cline in crying to a mean of 68 minutes by 10 to 12 weeks u fever They both look demoralised. of life.7 Knowing the range of normal is very important, as u poor feeding and/or faltering growth You take a quick history of the crying behaviours and feeding. There is no spilling, prolonged bouts of crying can be normal, and this is some- u lethargy baby is sleeping well and breastfeeding seems to be going well. You have already thing certain parents may not be aware of. u rapidly increasing head circumference. examined the baby and plotted out her growth. The parents are wanting “answers” – and a treatment. They ask about Infacol, omeprazole or cutting out dairy from mum’s Proposed causes of colic * Adapted from Johnson et al (Am Fam Physician 2015; diet. They have no family support nearby, Aroha is their first baby and the mother says Many causes of colic have been proposed over the years 92(7):577–82) she needs to go back to work. in the medical and lay literature. However, even today, the aetiology remains elusive, but is most likely multifactorial.­ How do you proceed? Proposed causes include gastrointestinal, hormonal, has been clearly linked to subsequent infant colic, espe- 1. Trial of omeprazole 5mg twice daily for possible GORD, for one month then review. neurodevelopmental and psychological factors.3 cially in parents who reported depression in pregnancy. 2. Trial of a maternal dairy-free diet for possible CMPI, for one month then review. Gastrointestinal factors in colic – these are the “prime sus- Commentary in one report stated that this may be a di- 3. Infacol (simethicone) treatment. pects” in the literature, although the evidence is somewhat rect association, or indirect via other socioeconomic issues.3 4. Reassurance that things will get better. sparse. A gastrointestinal Serious pathology in colic – with prolonged crying, the 5. Book them in with your colleague who knows the family when cause is mainly theorised incidence of serious pathology is approximately 5 per cent they return from leave. With prolonged crying, the because of the behaviour of across several studies. Freedman and coworkers reported 6. Book them in for a double consultation in the next few incidence of serious pathology babies: frequently drawing that, in 237 babies presenting to an emergency department days; in the meantime, give them details of the website is approximately 5 per cent up the legs and scrunching with inconsolable crying, 5.1 per cent had serious pathology, purplecrying.info for reference. across several studies their body. with urinary tract infection being the most common. History Studies trying to nar- and/or examination revealed the cause in 66 per cent of the Try not to let time-pressures dictate row down a gastrointestinal 5 per cent of children with serious pathology. Investigations This is a difficult, heart-sink situation for any practitioner, especially at the beginning cause have been contradictory. Some have demonstrated allowed the diagnosis in 1.4 per cent. Unwell appearance was of a full day of clinic bookings. The easy option is a trial of treatment (options 1–3) gastrointestinal inflammation (ie, faecal calprotectin); how- the strongest correlator with serious pathology.8 with a review in a month; the difficult and time-consuming one is option 6 (with option ever, normative values have not been ascertained in children 5 all-too-tempting). under two years of age, so this is not a recommended test. Assessment of the crying baby Explaining to parents about infant crying is a very tricky issue and not something Other studies have shown normal faecal calprotectin lev- Assessment of the crying baby rests upon taking a histo- that can be addressed in a 15-minute primary care consult; there is no quick solution. els in colicky babies. ry of crying duration, behaviour of the baby during crying, I would tell them that, in my opinion, this sounds like colic as there are no red flags Maternal dietary modifications (ie, dairy, cruciferous resolution strategies, feeding, micturition and defecation in the history or examination to suggest particular disease processes. However, it vegetables, onions, etc), intestinal gas, lactose intolerance/ patterns, sleep, developmental progress, vomiting, fevers is important to go through their concerns and discuss the pros and cons of various malabsorption, variation in feeding technique, burping and and other medical symptoms. Knowing the perinatal his- treatments without there being time pressure. My recommendation is to book the double other behaviours have all been proposed. But the studies tory, especially the timing of meconium passage, is helpful. appointment to talk about what colic is, address their worries and discuss the various are contradictory and, often, the initial proposed causes Clinical examination consists of a good “top-to-toe” ex- treatments they may have thought about, or had suggested by other people. are not replicable. amination: checking for cardiovascular and gastrointestinal The microbiome/dysbiosis is the latest proposed causa- function; the genitalia; peripheral/central muscular tone; Purple crying (aka colic) tive mechanism. Several studies have reported differences ear, nose and throat issues; movement at the joints; palpat- P = peak of crying. Your baby may cry more each week; most in month two, then less in faecal microbiome populations in babies with colic ver- ing the long bones; and checking naked weight, length on a in months three to five. sus those without. Babies with colic had reduced levels of board and head circumference. U = unexpected. Crying can come and go, and you don’t know why. microbial diversity, and this has led to a surge in interest in It is my routine practice to always do a full examination R = resists soothing. Your baby may not stop crying no matter what you try. using probiotics to treat colic. on all babies and measure and plot their current and previ- P = pain-like face. A crying baby may look like they are in pain, even when they are not. Psychosocial factors in colic – various studies have ous growth measurements on an electronic WHO growth L = long-lasting. Crying can last as much as five hours a day, or more. looked into psychosocial factors, such as parent–infant in- chart. This is important in terms of not missing any seri- E = evening. Your baby may cry more in the late afternoon and evening. teraction, parental anxiety, maternal smoking, parental ous pathology (see Panel 2),6 and to reassure parents you purplecrying.info age, parental depression. Again, there are numerous are not putting the crying down to “just colic” without contradictory observational studies. Parental depression considering other causes.

34 NEW ZEALAND DOCTOR RATA AOTEAROA 14 April 2021 How to treat The irritable baby Gastro-oesophageal reflux disease requires symptoms associated with feeds

his article is primarily a review about colic; howev- er, a brief discussion of gastro-oesophageal reflux Figure 1. (GOR) – or spilling/infant regurgitation – is worth- Features useful T in the differential Colic while as it is very common. GOR affects 67 to 87 per cent diagnosis of the • typical crying symptoms (prolonged periods): of children by two to four months of age.5 This is the effort- crying baby redness in the face, drawing up of legs less spilling of gastric contents without distress, a normal • no significant spilling phenomenon that does not require any treatment other • no bowel symptoms than an explanation of normal infant gastrointestinal phys- Colic • feeds well iology. Feed thickeners, such as Gaviscon, are not clinically • good growth indicated; their use can lead to the development of other issues, such as constipation. GOR tends to peak at three to four months of age, with 60 per cent of babies resolving by six months of age, and CMPI more than 95 per cent resolution by 12 months. Symptoms • spilling (+) rarely start before one week of age or after six months of • diarrhoea with blood GORD 9 CMPI/non- age (see Panel 3). • spilling (+++) +/- mucus IgE-mediated GORD For gastro-oesophageal reflux disease – or GORD – regur- • distress post-spilling • eczema food allergy gitation is present in almost all cases. Other characteristic • family history of atopy • feeding difficulties +/- oral aversion symptoms include post-feed irritability, prolonged feed- • feeding difficulties • poor weight gain ing or feeding refusal. However, the symptoms can vary • faltering growth widely and be non-specific. Other associated symptoms can include excessive crying, back arching and general irri- tability. This presents very similarly to colic (see Figure 1), explaining perhaps the increased rates of acid-suppressant medication prescription in infants. The diagnosis of GORD is based primarily on history. long-term use of PPIs in children due to: Investigations (used previously) included barium stud- • increased risks of gastrointestinal and respiratory tract PANEL 3 * ies, upper gastrointestinal endoscopies, manometry/ infection GORD symptoms in babies motility studies and pH probe studies. An extensive liter- • vitamin B12 deficiency ature review by the North American Society for Pediatric • hypomagnesaemia u general – discomfort/irritability,† failure to thrive, feeding Gastroenterology, Hepatology and Nutrition (naspghan. • higher rates of bone fractures in later childhood refusal, dystonic neck-posturing (Sandifer syndrome) org) showed insufficient evidence for such investigations • increased risk of allergic disease. u gastrointestinal – recurrent regurgitation in paediatric GORD.9 An increased association between PPI use and allergic u respiratory – apnoeic spells, recurrent pneumonia Some parents worry about so-called “silent reflux” with ir- diseases in early childhood is posited to be due to an inter- associated with aspiration, recurrent otitis media. ritable babies. This is a bit of an oxymoron as GORD typically ruption in the microbiome. A 2018 review by Edward Mitre has a number of different symptoms. However, difficulties and colleagues showed that, in nearly 800,000 children, the † If excessive irritability/pain is the single manifestation, resulting from a lack of reliable investigations coupled with adjusted hazard ratios (HR) for acid-suppression medica- it is unlikely to be due to GORD. an active pharmaceutical marketing campaign and parents tion prescription were: *Adapted from Rosen et al (J Pediatr Gastroenterol Nutr wanting something to be done – as well as social media and • food allergy (HR 1.7–2.18) 2018;66(3):516–44) internet information about proton-pump inhibitors (PPIs) – This trial of treatment is not • anaphylaxis (HR 1.45) have resulted, previously, in large numbers of prescriptions a valid approach and should • allergic rhinitis (HR 1.44) for acid-suppression medications. not be used without good • asthma (HR 1.25–1.41).11 This also varies between the different PPIs.9 supportive evidence of GORD Acid suppressants reduce Given the issues with a lack of reliable investigations in Proton-pump inhibitor use in infants protein digestion, which the context of GORD, a short (two to four-week) treatment A 2017 New Zealand population-based study of children can affect how antigens are trial with a PPI in a crying baby is used by some practition- born between 2005 and 2012 showed 22,643 children were processed in the intestine. Acid suppression has also been ers, especially where the parents or primary care provider prescribed a PPI before 12 months of age. The prevalence of shown to increase IgE production in response to orally in- are concerned about “silent reflux”. However, no paediatric use increased from 2.4 per cent for children born in 2005 to gested antigens, in animal studies.11 study has been done to validate this trial of treatment.9 It is 5.2 per cent for children born in 2012. The majority were Other studies have raised concerns about the pharma- not a valid approach and should not be used without good prescribed a PPI prior to three months of age, and 8.7 per cokinetics of PPIs being different in infants, especially those supportive evidence of GORD in the form of other symp- cent within the first month of life. Before PPI initiation, under six months, compared with older children. Studies toms and the association of symptoms with feeds. My own only 7.0 per cent of infants had a hospital-based diagnosis have shown an increased drug exposure at certain doses of practice has changed as a result of concerns about the long- of GORD. So, the assumption is, most PPIs were prescribed omeprazole (ie, 1–1.5mg/kg) in children under five months term negative impacts and lack of proven effectiveness, as, in primary care.10 of age. This is presumably due to the different rates of mat- previously, I would have carried out the occasional “trial of More recent studies have raised concerns about the uration of enzymes required for the metabolism of PPIs. treatment” in this situation. Cow’s milk protein intolerance a non-IgE- mediated gastrointestinal food allergy

ow’s milk protein intolerance (non-IgE-mediated) is a common manifestation, with up to 60 per cent of rectal overdiagnosis due to the lack of gold-standard testing (eg, often confused with cow’s milk allergy and lactose bleeding being due to AP. There can be a family history in up blinded oral food challenge). C intolerance. CMA is an IgE-mediated allergy, where to 25 per cent of cases. These symptoms can present from For most babies, the cause of non-IgE-mediated gastroin- there is sudden onset of symptoms (eg, hives, angio-oede- shortly after birth until six months of age. Some babies may testinal food allergy is cow’s milk, either directly (formula) or ma, anaphylaxis) in an immediate response to cow’s milk also have increased gas, intermittent vomiting, pain with de- indirectly (breast milk). Soy can be a co-allergy in 7 to 11 per ingestion. Lactose intolerance results in explosive, watery faecation and abdominal pain. Most food culprits are dairy, cent of cases and, rarely, other foods (wheat, egg, corn, etc). diarrhoea and a significant failure to thrive. This is rare in but others can be soy, egg and corn.12 Treatment is by dietary elimination of the food, followed children younger than 10 years. Symptoms that can be suggestive of non-IgE-mediated by re-challenge. Typically, parents would be advised that Non-IgE-mediated gastrointestinal food allergy can vary gastrointestinal food allergy, and which can present between symptoms should resolve dramatically with avoidance of from profuse vomiting on any exposure to a food (food several days to six months or so of age, include: the offending food (within several weeks), but if there is protein-induced enterocolitis syndrome; FPIES) through to • rectal bleeding no significant improvement within two weeks, usually, this intermittent bloody stools but with minimal other symp- • diarrhoea particular food is not the cause. Other eliminations, such toms. FPIES is a severe manifestation of non-IgE-mediated • associated mucus in bowels as for soy, wheat and egg, can be trialled but, again, there gastrointestinal food allergy. • vomiting should be dramatic improvement within two weeks. If a Diagnosis can be challenging as there are no tests for • failure to thrive dietary elimination trial is started, a re-challenge trial is non-IgE-mediated gastrointestinal food allergy. Radio­ • distress/crying (never as the only presenting symptom). necessary to demonstrate the improvement and subse- allergosorbent testing (RAST) and skin-prick tests are not The literature on this subject can be confusing, as there quent deterioration of symptoms.13 Most babies can tolerate indicated. is often overlap with other non-IgE-mediated allergies, soy formula but, if it is not tolerated, extensively hydrolysed Rectal bleeding as a result of allergic proctocolitis (AP) is such as FPIES. In addition, there is generally thought to be formula can be used instead.

36 NEW ZEALAND DOCTOR RATA AOTEAROA 14 April 2021 How to treat Treatment for the crying baby – the art of medicine is important

oing nothing is one of the more difficult options for However, this contrasts with a recent Cochrane Review treatment but, for a lot of crying babies, that is the on probiotics (2019). Teck Guan Ong and co-workers looked Figure 2. Baby meets criteria for colic only treatment of benefit. Healthcare professionals at RCTs of infants under one month of age and included Primary care (see Figure 1) D approach to are trained in the science of treatments; however, the art of any probiotic, alone or in combination with a prebiotic, ver- the baby with medicine is often what is important. sus no intervention, another intervention(s) or placebo. inconsolable Today, parents can access a wealth of information using They found six studies with 1886 participants. Two inves- crying History and full examination online searches but, while the algorithms help in offering tigated L. reuteri, two examined multi-strain probiotics, one various diagnoses, they do not provide human experience Lactobacillus paracasei and another Bifidobacterium animalis. and support, or a kind shoulder to cry on. There were no differences in adverse effects. Organic pathology excluded An awareness of the nature of colic, and teasing out col- A subgroup analysis of L. reuteri (the most studied) ic from possible GORD, CMPI and other causes, is always showed a reduction of 44 minutes in daily crying with the the first step. There is no point in starting babies on un- treatment. The authors concluded: “There is no clear ev- Reassurance, information (see purplecrying.info), necessary treatment trials if the history and examination idence that probiotics are more effective than placebo at support, regular clinical review is consistent with colic (Figure 2). preventing infantile colic; however, daily crying time ap- My own practice is to review the history of the baby and, peared to reduce with probiotic use compared to placebo…”15 for the caregivers, to draw a picture of the gastrointestinal Most of the current literature on probiotics shows some tract, explain what GORD is and its typical symptoms, ex- effectiveness for L. reuteri in breastfed infants, but there is Consider a three-week trial of L. reuteri plain what CMPI is and its typical symptoms and, then, go insufficient evidence for formula-fed infants.2 if the baby is exclusively breastfed through what colic is: what we know about it and what we do not. I then explain the considerable cons and only very occa- Ask, are you okay? sional pros relating to various treatments (ie, PPIs, dietary Asking “Are you okay?” is important because it gives parents manipulations, probiotics, manual therapy and Infacol). the space to voice their own distress, worries and concerns Key points Occasionally, I prescribe a treatment trial of a PPI if there about what is causing their child’s crying, and to convey how are additional symptoms suggestive of GORD (ie, frequent they are coping and what supports they have. u Colic is hard work for parents and caregivers. spilling, significant post-prandial crying, active gulping/ My own practice has evolved over the years. I now rou- u Crying in healthy babies increases after birth, peaks at about five to six back-arching and/or Sandifer syndrome). Any trial of PPI tinely ask parents what they have googled or what other weeks of age (up to two hours a day in non-colicky babies) and then declines comes with a strict proviso of a clinical review after three people (online and in real-life) have suggested as possible at three months. or four weeks, with discontinuation if there is not a very causes. I have been surprised at what “causes” parents are u The cause is not silent reflux, GORD or CMPI in the absence of other symptoms. significant improvement in symptoms. In the past, I have worried about – from silent reflux and various food allergies u Fewer than 5 per cent of children with inconsolable crying have organic disease. prescribed PPIs as a treatment trial for crying babies for to brain tumours and other forms of cancer, among others. u Reassurance and support from primary healthcare practitioners is important – whom the parents are desperate; however, that practice has It is easy and less time-consuming to offer reassurance, this can be regular clinical review to document growth, examine the baby and to been discontinued with the current evidence around PPI use. but, if possible, also to provide a reason why you, as their review development. healthcare provider, are not worried about these conditions. u Encourage caregivers to utilise support from whānau and friends. Conventional approaches to soothing Explain the usual presentations of such diseases and why u A three-week trial with an L. reuteri probiotic may be considered. Conventional approaches for soothing such as swaddling, their baby does not demonstrate that. Scheduling regular u PPIs are not recommended and should be actively discouraged; Infacol motion, soothing noise, being held close (eg, in slings) are follow-ups to plot growth and re-examine the baby also (simethicone) has no benefit; and manual therapy has marginal benefit – standard recommendations. While not having been as- helps to provide additional reassurance. trials for all three options have been poorly designed. sessed in trials, they are good recommendations without any side effects. In summary Researching and writing this article has been helpful for my Lactation consultants own clinical practice. I have previously prescribed PPIs for Parent resources for colic If a breastfeeding parent has not seen a lactation consultant, crying babies, and now, reflecting on that, I know I should this is often to be recommended as a first step. This can be not have. I have also facilitated the ongoing prescription Raising Children Network helpful, especially for women who feel their breast milk sup- of PPIs to crying babies without actively counselling the https://raisingchildren.net.au/newborns/behaviour/crying-colic/colic ply is lacking or the baby is not being satisfied. Sometimes, parents of their risks and the lack of evidence surrounding changing positions can help resolve some crying behaviours, their use. I have witnessed breastfeeding women go on in- The Period of Purple Crying although this is only anecdotal evidence. creasingly restrictive diets in response to a crying baby, to https://purplecrying.info the detriment of their own nutrition and without any sig- Manual therapy, Infacol and nificant improvement. I have also seen caregivers spend proton-pump inhibitors large amounts of money on complementary and alternative Many parents choose to take their babies to an osteopath therapies, with minimal benefit. Maternal/parental depression or chiropractor for treatment, others will ask about the Hospital waiting lists allow the paediatrician some time use of Infacol (simethicone) or probiotics. A comparison between referral from primary care to being seen in a clin- It is important to screen for this common issue using screening­ tools such study of common interventions reviewed meta-analyses of ic, such that the crying and irritability has often resolved. as the Edinburgh Postnatal Depres­sion Scale. Māori, Pacific peoples and treatments for colic published between 2009 and 2019.7 Primary care, therefore, sees the vast majority of crying ba- other minority ethnicities, as well as people of lower socioeconomic status, Of 201 review studies, only 32 were analysed due to poor bies, and has to actively manage this issue for caregivers. can have higher rates of postnatal depression, and these groups should be study quality (see table). Most used crying time as the re- This article has attempted to provide an updated review actively screened to ensure that known health inequities are not perpetuated. ported outcome, but some reported other outcomes, such of the literature, reinforce the “de-medicalisation” of colic A baby in an environment of significant maternal depression is at risk of as crying episodes. and give primary healthcare providers explanations to give toxic stress and its consequences, affecting the baby’s social–emotional Arriving at conclusions from the different meta- parents about why medications are not indicated and, in- development, which may lead to attachment disorders and adverse health analyses of colic treatments was a challenge due to the deed, can be harmful in some situations. It also aims to give outcomes for both mother and baby.16 poor study quality and different populations, durations providers a framework for teasing out the majority of cry- of assessment and outcomes being compared. Some stud- ing babies with colic, from the small minority with GORD, ies compared treatments with placebo, others treatments CMPI and occasional organic illnesses. n versus treatments. Quiz answers The use of PPIs in crying babies was discussed earlier; Go to ELearning at nzdoctor.co.nz for the the take-home message is PPIs are not indicated in colic. references to this article 1. False 2. True 3. False 4. True 5. True

Probiotics for colic Probiotics are the most recently advocated treatment for Results from 32 reviewed meta-analysis studies colic. A number of randomised-controlled trials (RCTs) and trials of other designs have looked at the use of probiotics. Many trials have issues with comparisons, including small Treatment Findings of treatment benefit sample sizes, different doses, comparisons in breastfed versus formula-fed babies, etc. The trials show mixed Probiotics – 10 meta-analyses (>6100 babies) Reduction in crying time of 25 to 65 minutes per day in breastfed infants results, some of improvement, others no effect. (quality and strength of probiotics RCT meta-analysis higher than for manual therapy RCTs) The most promising probiotic, to date, is Lactobacillus reuteri (DSM 17938). A recent Australian meta-analysis Manual therapy – 11 meta-analyses (>8510 babies) Reduction in overall crying time of about 33 to 76 minutes per day looked at RCTs of L. reuteri versus placebo in infants with (low-to-moderate quality RCTs; larger, blinded RCTs were recommended) colic. The primary outcomes were infant crying duration and treatment success at 21 days. The analysis was of 345 Simethicone – six meta-analyses (>2858 babies) Five studies showed no improvement or worsening of symptoms with simethicone infants (174 on probiotic, 171 placebo). The study showed a reduction in daily crying from baseline in the treatment Proton-pump inhibitors – one meta-analysis (404 babies) No difference between PPI and placebo group of 25 minutes, with the treatment group more likely to experience treatment success, especially in * Adapted from Ellwood et al (BMJ Open 2020;10:e035405) breastfed babies (number needed to treat 2.6).14

14 April 2021 RATA AOTEAROA NEW ZEALAND DOCTOR 37