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Colic is a topic that many parents worry about, and there is so much conflicting information out there that it is hard to know where to start. Having a baby with colic can be very upsetting (and exhausting!) for many parents, who can easily feel helpless in supporting their baby. We caught up with Shel Banks, Internationally Board Certified Lactation Consultant, author of “Why Formula Feeding Matters” who is currently working on the Cochrane systematic reviews on Infantile Colic.
Infantile colic was defined in 1954 by Paediatrician Dr Morris Wessel, as “crying lasting 3 hours per day, on more than 3 days per week for at least 3 weeks” – this same definition has been used fairly universally until very recently, and is known as the Rule of Three.
More recently a new definition has been proposed. It refers to a clinical condition of fussing and crying for at least one week in an otherwise healthy infant. ‘Rome III’ (which is the diagnostic tool for functional gastrointestinal disorders) now includes infantile colic, with diagnostic criteria including all of the following in infants from birth to four months of age: paroxysms of irritability, fussing or crying that starts and stops without obvious cause; episodes lasting three or more hours per day and occurring at least three days per week for at least three weeks; and no failure to thrive.
As you can see, these definitions don’t mention pain, or even the abdomen!
Babies cry for all kinds of reasons, but mostly to communicate a need to their parent or carer. They might be hungry, or tired, or cold, or lonely, or have tummy ache. They might feel poorly, they might be over-stimulated, or they might be telling you something else. If the parent or carer is really tuned-in to their child, they might be able to recognise what the communication means, and hold the baby in a certain way, avoid doing certain things, or whatever – but even on our best days, sometimes our babies’ clues are tricky to read, and we may feel nothing but helpless, whilst holding a red-faced creaming child. And baby’s crying is upsetting for the parents as well as the baby – studies show elevated levels of cortisol, the stress hormone.
There’s a common tendency of medical professionals to attempt to reassure parents that colic is NORMAL – when actually what it is, is common – and that it will stop by the time the baby is three months old. If it’s simply immaturity of the gut, gastro-oesophageal valve or other parts of the digestive system, or if it is frustration at being unable to communicate or regulate their feelings of over-stimulation or indeed under-stimulation in terms of attachment to their main carer, then of course this may be true: baby simply gets used to it and by 12-13 weeks will often have settled down. But if the issue is an allergy or intolerance to something in the milk, or is painful trapped wind, or is caused by something seemingly small like discomfort from seams or tight clothing and so on, then sadly it will not magically end at the three month mark.
Colic is a word used to describe seemingly inexhaustible and frequent crying: it’s not a diagnosis in and of itself. What it tells us, is that there is colicky crying as a symptom of a cause – or perhaps causes plural – in the baby. The baby is trying to communicate with us about what’s going on for them.
Colic has many causes, some of them complex and not all of them fully understood. What we do know is that typically the baby experiences some sort of tummy pain that makes him cry frequently and often inconsolably, sometimes arching his back and drawing his legs up as he struggles to find relief.
There are a number of medications available over the counter or online. There are a variety of things sold to help with colicky symptoms but they work in specific ways and address just one potential cause so won’t work for everyone.
For example, Infacol is simeticone which basically just reduces the surface tension of bubbles of gas trapped in liquid so they join together. Dentinox is dimethicone which does the same thing. Colief (or Lactaid) is lactase drops, which help break down lactose (a milk sugar) in the milk if the body has a lactase shortage or the milk has too much lactose for the body to handle: it splits the molecules of lactose into glucose and galactose.
Gripe water has different ingredients depending on the brand, but the UK’s most sold brand Woodwards contains dill oil which they say ‘warms and relaxes the tummy, breaking down trapped air bubbles’ and sodium hydrogen carbonate (we know it as bicarbonate of soda) which they dubiously claim ‘neutralises acid in the baby’s tummy’. These are non-evidenced claims: 5ml of drinkable liquid does not contain enough of anything to change the temperature or ph of the stomach. The other thing is that the sodium bicarb works on the hydrochloric acid in the stomach, forming a combination of sodium chloride (salt), carbon dioxide (gas) and water – so gripe water can actually CAUSE the formation of gas.
It’s thought a possible action is of the dill is actually as an oligosaccharide (complex carbohydrate) which feeds the so-called ‘friendly bacteria’, and the reason gripe water seems to work is that it tastes nice to baby so they are simply happier. Of course, when we were babies, gripe water contained alcohol…!
There are various herbal and sweet tasting remedies which either aim to make baby care less about the cramps tummy or to feed the good bacteria in baby’s tum, but the efficacy of each depends on what baby needs.
Experts believe that some colicky symptoms are feeding-related, triggered by the milk itself or the way the baby drinks. Some parents try to rid the infant of their colicky symptoms by making a change to the milk baby drinks, and opting for a so-called ‘comfort’ milk, marketed as ‘for colic and constipation’. These milks are still based on cows’ milk protein but this protein has been slightly broken down (called ‘partial hydrolysation’) and has a lower level of lactose – which means some of the lactose has been replaced by glucose, another sugar. There is no robust evidence which shows that these milks prevent or relive colic, but if baby is suffering from a mild form of cows’ milk protein allergy, then these milks may been to be effective versus standard infant formula. However it is unlikely they will be gentler than breastmilk, and may actually trigger a reaction in a sensitive child who had previously been breastfed.
However it is entirely likely that diet may affect the intestinal comfort of the baby. A recent systematic review looking at dietary modifications to manage infantile colic found that removing cows’ milk protein from the diet of the baby if formula fed, or from the diet of the mother where the baby is breasted, in some cases was able to reduce the colicky crying symptoms. This suggests that the cause of colicky symptoms for some babies is a cows milk protein allergy.
Working out where the gas is coming from i.e. how it’s getting down there to begin with, is a good place to start. Usually from crying, or from issues with the latch to the breast or air swallowed when bottle feeding. See below for more on bottle feeding. Sometimes the gas comes from fermentation actually in the gut, because of intolerance or allergy triggered by something in baby’s milk – see above. If you cannot figure it out, then expert and experienced infant feeding support is the best bet.
Desperate parents will purchase a variety of differing devices promising solutions to their infant’s apparent discomfort, including small tubes which are intended to be inserted into the rectum to release any trapped gas from the infant’s bowels (these are definitely not recommended, not evidence based, unsafe and potentially dangerous!) and vibrating cushions with straps onto which the manufacturers suggest babies are placed face down, to gently vibrate their cares away (these are not safe for sleep and the manufacturer stresses that babies should never be left on them unattended – so arguably what is the point, when the same thing, or better as more upright, can be achieved in the carer’s arms…?)
There are some ways of holding baby which help – both during feeding and after – but these need to be taught to the individual. What seems to work best immediately after a feed is having baby upright, facing you, with their tummy pressed against you, their bottom half in the middle of your body, and their head on your left shoulder in line with your left shoulder. This position places any bubbles of air which are in the stomach, directly under the gastro-oesophageal valve, (that is the valve between the stomach and the food pipe coming from the mouth), so it can easily get up and out.
Bottle fed babies can most easily suffer from trapped wind, often because air is incorporated into the milk or drawn through the teat. After adding the powder to the extremely hot water, we should swirl, rather than shake the bottle to incorporate the powder into the water: if you have shaken it, let it stand for 20 minutes to allow any bubbles to disperse. Babies are often less colicky on liquid ready-to-feed formulas, although these are considerably more expensive.
Frequently we find that using a similar feeding position to the breastfed baby, works: the bottle should follow the same line as the breast would, so aim the teat at the pointy part at the back of your baby’s head rather than his ears. This is what the baby expects, naturally. It’s how his anatomy works best. Keep the teat full and try to maintain this angle as the bottle empties. You may need to start the feed with your baby relatively upright, before reclining him a little so that the bottle and his head stay in a straight line.
A range of bottles is available featuring different valves, vents, air systems and shaped or angled teats which claim variously to mimic breastfeeding and prevent colic by reducing the air transferred. What we know is the best advice is to buy a bottle and teat which are easy to thoroughly clean and sterilise, and make sure the milk is made up with the very hot water (70degC minimum) because one of the biggest contributors to baby’s crying is gastroenteritis, which is from bacterial infection via the bottle or milk.
As the baby grows and develops, parents may choose to switch to a different size or shape of teat or bottle to help feeding be more effective.
Too much milk, too fast, can give your baby a bloated, colicky feeling. It’s a tendency with bottle feeding, whether with breast or formula milk, but can be avoided if you try to respond to your baby’s demands. Paced or responsive feeding means offering baby a break from the bottle after every ounce or two, rather than trying to be efficient with time, or with the milk.
Milk in a bottle is homogenised (all mixed together), unlike that fed from the breast, so the way the baby suckles will make no difference to the consistency of milk he receives. He can drink too quickly – and he won’t be getting the natural cues that tell him he is full. It’s tempting to want to use every last drop, but take the lead from the baby if it appears that he’s had enough.
During the feed, breastmilk changes from a more watery type to a thicker, fattier substance, as the baby drains more from the breast. If his positioning, attachment and latch are good, he will be getting the nourishment he needs and will be less prone to digestive troubles. The watery milk is thirst-quenching but high in lactose and low in protein. While it may temporarily fill the baby, it won’t satisfy him for long and can also ferment in his gut and cause tummy pain.
These different stages are sometimes called ‘foremilk’ and ‘hindmilk’, although many feeding experts feel that these terms are misleading as they suggest a cut-off point where consistency switches. In reality, the change is more gradual.
You may find that if you improve the effectiveness of attachment and baby draws more of the richer, fattier milk, he will be more contented. It’s normal to use just to use one breast per feed, but mum should let the baby decide: if he comes off the breast and doesn’t look finished, try the same one again. If he objects, mum can try the other breast. You’ll know if he has had his fill of richer milk as he’ll look ‘milk drunk’, with a bit of a loll and perhaps some creamy liquid trickling from the side of his mouth. And he’ll be satisfied – you won’t hear from him for an hour or so.
If you feel that your baby is not receiving the milk he needs, a breastfeeding counsellor of IBCLC (lactation consultant) can provide support to enable more effective feeding. What’s in baby’s nappy will give further clues – a young baby (under six weeks) should poo at least twice a day, so speak to their midwife or health visitor if he’s not doing this.
Sometimes families of babies with digestive issues wonder whether the so-called ‘baby probiotics’ might be helpful with babies who seem to have some gut issues. Certainly, given what we know about the microbial flora and fauna of humans in general and babies in particular, and the big trend over recent years to supplement the diet of adults with so called ‘healthy bacteria’, might lead us to draw the two together.
Personally I am not keen on the idea of giving live bacteria to new babies, especially when we would only be speculating about whether the gut was deficient in those specific species of bacteria, or not. If the mother is breastfeeding and is keen on the idea of probiotics, perhaps because baby was born by caesarean section, or either mum or baby have had antibiotics since the birth, then the mum could take them – a good broad spectrum multi strain one is probably best – and her milk will then transfer this better blend of probiotics to the baby as needed. There is evidence that probiotics work to prevent colic in healthy babies, although we know that certain premature and sick babies might be effectively treated with them.