PEDIATRICS “THE GRIPE”: AN INTEGRATIVE APPROACH TO INFANT COLIC Lawrence D. Rosen, MD abies cry. In fact, crying is consid- Karp speculates that some babies have a colic will fade by the time newborns are 12 ered part of normal infant devel- more difficult time adjusting to what he to 16 weeks of age. There is encouraging opment. Noted psychologist terms the “fourth trimester,” a three- evidence that parenting intervention can B Gwen Gustafson offers this scien- month period of time in which infants reduce crying time in colicky babies.10,11 tific explanation: “Neonatal crying is a must cope with potentially overwhelming Many families, though, seeking a more ac- species-specific behavior which achieves sensory stimuli.6 Just like adults, babies tive role in reducing infants’ distress, turn its likely evolutionary function (infant sur- vary in how well they integrate these exter- to complementary and alternative medical vival) by reliably eliciting responses from nal stimuli, and colic may well represent (CAM) therapies. Surveys of CAM use in caregivers.”1 The great behavioral observer an adjustment disorder—the far end of an culturally diverse populations indicate Charles Darwin described his own baby’s infant irritability syndrome. Most parents that colic is a common reason for use of distress in superb biological detail: “With claim that their colicky babies seem to suf- herbal and nutritional therapies in early 12,13 one of my own infants, from his eighth fer abdominal pain, and interestingly, childhood. Even in the 1950s, Wessel day and for some time afterwards, I often there is now mounting evidence that the noted that among the most prevalent observed that the first sign of a screaming- gastrointestinal tract may be involved in treatments used by parents were dietary fit, when it could be observed coming on colic via neuroimmune connections. In modifications and various soothing regi- 4 gradually, was a little frown, owing to the fact, babies with food allergy and other mens, sometimes today termed as CAM. contraction of the corrugators of the atopic disorders are more likely to be diag- But are these therapies actually alterna- 7 brows; the capillaries of the naked head nosed with colic. Exposure to cigarette tive? In the case of colic, it is difficult to and face becoming at the same time red- smoking, a known link to colic for quite distinguish conventional from unconven- dened with blood.”2 Harvard develop- some time, is thought to exacerbate dis- tional approaches, as culture and geogra- tress by a connection to gastroesophageal phy play such a large role in what is com- mentalist T. Berry Brazelton observed that 8 the typical baby cries up to 2.25 hours reflux. A recently published 10-year pro- monly used. spective study challenges a commonly The largest systematic review to date of daily,3 supporting current speculation that held view that there are no long-term treatments for colic found little evidence crying, like most things, exists along a health-related issues in children who had to support many conventional therapies, spectrum. Yet, there are those babies (and colic in infancy.9 Approximately 100 in- including the widely used simethicone, their families) that seem to suffer more fants were evaluated at one to three while noting that several nutritional and than most; these infants in Darwin’s En- months of age, and then again at the age of botanically based approaches were indeed gland were said to have “the gripe.” Today 10 years. There was an association noted evidence based.14 An integrative ap- we call it colic. We have widely accepted between infantile colic and later recurrent proach, combining the best conventional the “Rule of 3s” definition first offered by abdominal pain, atopic disease, and sleep and CAM prevention and treatment strat- pediatrician Morris Wessel in 1954.4 Dr disorders. This association does not, of egies, is a wonderful paradigm for the Wessel, who studied infant crying behav- course, prove causation, but suggests that management of infantile colic. Integrative ior as part of the Yale Rooming-In Project, whatever processes are involved in the de- medicine, with its focus on family-cen- defined colic as paroxysmal fussing in in- velopment of colic may also predispose tered and culturally sensitive holistic care, fancy for more than three hours per day, at children to subsequent health concerns. provides practitioners and families with least three days per week, for at least three We need to evaluate these potential links the best opportunities for successful out- weeks duration. Surveys indicate that up closely, as any connection would support comes. to 26% of infants are diagnosed with col- actively working with families to prevent 5 ic, making the condition one of the most and treat excessive infant irritability. common reasons for infant visits to pri- SPECIFIC THERAPIES mary care practitioners today. The integrative management of colic de- We know colic when we see it, but we RATIONALE FOR AN INTEGRATIVE mands consideration of every tool in the still do not know what causes it. The most APPROACH practitioner’s toolbox. Individualization popular conventional medical theory is There is no widely accepted conventional of treatment, as is typical in integrative that colic is an extreme variant of infant treatment for colic. Practitioners will offer practice, is crucial in these cases. Some ap- irritability, perhaps related to neural regu- families psychological support, with the proaches work quite well for some families lation differences. Pediatrician Harvey hope that with time—as is often the case— and not at all for others. An integrative Pediatrics EXPLORE July/August 2007, Vol. 3, No. 4 417 primary care practitioner will openly dia- The power of touch is quite apparent and amounts of alcohol. This practice should logue with families and collaborate with remarkable in colicky infants. A recent Co- be discouraged. It is important to ask fam- various CAM therapists as warranted. The chrane Database Systematic Review of mas- ilies specifically about the use of gripe wa- most commonly used therapies, including sage intervention in infants acknowledges ter and other herbal blends, and to figure mind-body medicine, infant massage, bo- that there is “evidence of benefits on out which substances are being ingested tanical and homeopathic remedies, nutri- mother-infant interaction, sleeping and by the baby. The Natural Medicines Com- tional modulation, and probiotics, will all crying, and on hormones influencing prehensive Database lists five separate be discussed in the following sections. stress levels.”19 Infant massage is effective products labeled as “gripe water,” and all in reducing excessive crying in even the have different constituents.25 Mind-Body Medicine most vulnerable of infants, including pre- Other available botanical products are mature babies and cocaine-exposed neo- marketed as gastrointestinal soothers and Perhaps no period of relative wellness in a 20,21 family’s life is more stressful than the first nates. Families can be taught to use used by parents for colic symptom relief. few months of infancy. Even typical infant simple and safe massage techniques, and Some of these carry the same name, are crying and sleep patterning is disruptive they appreciate the power of this self-care made by different companies, but have approach. This effect seems to be superior radically different ingredients. For exam- and unsettling. The entire family dynamic 22 to simple vibration devices and may be ple, Chinese star anise (Illicium verum)isa is shifted, and caregivers may experience 23 severe mood lability and tension. Wessel enhanced by the use of essential oils. spice used in many cultures for infantile believed it was this family tension that was Whether this latter effect is related to the colic. Although this specific herb is gener- responsible for colic symptoms in in- oil as aromatherapy or simply adds to the ally recognized as safe, its close relative, fants4; we now understand that stress can physical massage technique, or both, is Japanese star anise (Illicium anisatum), ab- indeed modulate neurological responses, unknown. For safety reasons, caution solutely is not. It contains constituents therefore supporting the need to promote should be taken with the application of with the potential for neurologic and gas- parental stress-coping mechanisms. There essential oils in children; they should not trointestinal toxicity, as noted in a case are clear links between maternal mood generally be used directly on the skin, but report of seven infants significantly af- states, including postpartum depression, mixed first in a carrier oil (eg, sesame, al- fected by this herb.26 Of great concern, and the development of colic in infants.15 mong, or grape seed). One must be careful these babies were given a Chinese star an- Screening for postpartum psychological about allergies and skin sensitivity as well ise product adulterated with Japanese star disorders is feasible in pediatric offices16 with these products. anise. In another report, a case of pseudo- and should be standard practice. Reducing monal bacterial sepsis in an infant was parenting stress is a proven method of Botanically Based Therapies linked to the use of an imported Indian helping families cope with irritable in- gripe water preparation.27 As with all 17 Many cultures have used botanical reme- fants, and there are many strategies to do dies for fussy babies for thousands of herbal supplements, one must be aware of so. Despite the lack of randomized con- years. There are as many herbs used for regulatory and quality control issues. trolled trials proving efficacy or cost-effec- colic as there are babies with the condi- Herbs commonly found in today’s tiveness in colic management, practices tion. One of the more widely known ther- gripe water preparations include dill, fen- such as guided imagery, self-hypnosis, apies, gripe water, dates back to the 1850s, nel, ginger, and chamomile.