Introduction
Etiopathogenesis
Main factors | Related factors |
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Immaturity of nervous/digestive system | Family tension |
Cow’s milk proteins allergy and atopy | Maternal smoking |
Altered gut microflora (low Lactobacilli, increased E.coli) | Increased maternal age |
Gut hormones (increased ghrelin and motilin) | Firstborn status |
Diagnosis
Frequent | Infrequent |
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Infantile colic | Bowel intussusception |
Otitis | Inguinal hernia |
Gastro-oesophageal reflux | Fracture |
Urinary tract infection | |
Constipation | |
Pyloric stenosis |
Treatments
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Dietary advices may be distinguished according the type of feeding as follow [18, 19]:
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breast-fed infants: a monitored low allergen maternal diet avoiding cow’s milk and dairy food with appropriate intake of vitamins and minerals may be suggested. A period of at least two weeks is necessary to check the effectiveness of the diet and dietary intervention in mother has to be continued only if effective [1, 20]. Evidence show that nocturnal breast milk contains melatonin, which could be useful in improving infant’s sleep and reducing colic [21] Figure 1.
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bottle-fed infants: first-line approach is represented by formulas based on partially hydrolyzed whey proteins with prebiotic oligosaccharides that have been tested to be effective [22], while the efficacy of other formulas, for instance containing probiotics, need to be further documented [23]. Extensively hydrolyzed formulas based on casein or whey could be useful in children with severe infantile colic or additional atopic symptoms. However, it is crucial that any dietary changes or therapies are performed only under the supervision of the pediatrician [24] Figure 2.
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Pharmacological treatments: simethicone, which reduces gas production, may be helpful for some infants, although several randomized controlled trials noted no difference in reducing colic episodes compared with placebo [1, 15]. A RCT evaluated the use of a symptomatic anticholinergic agent, cimetropium bromide, in reducing crying during colic episodes in breast-fed infants [25]. Current literature does not recommend the use of any other drugs because of reported side effects [1]. A new pharmacological agent (Nepadutant) acting on intestinal motility and sensitivity is under investigation with multi-centre, multinational, randomised, double-blind, placebo controlled study at phase IIa [26]. A Cochrane Review on pain relieving agents is in progress [27].
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Probiotics: the use of probiotics in infantile colic is based upon the hypothesis that aberrant intestinal microflora could cause gut dysfunction and gas production, contributing to symptoms. Some studies have shown that administration of Lactobacillus reuteri ATCC 55730 and its daughter strain Lactobacillus reuteri DSM 17938 to breastfed infants is well tolerated and improves symptoms of infantile colic compared with simenthicone or placebo [28‐30]. The possible mechanism of action of Lactobacillus reuteri include improvement in gut function and motility as well as a possible effect on visceral pain. We could speculate that the improvement of colic effect may be related to induced changes in the fecal microbiota, since a reduction of E. coli colonization has been observed. At present, growing data are available on the role of probiotics in colic [31], and there is a great interest within medical research in the understanding of the mechanisms by which probiotic bacterial strains antagonize pathogenic gastrointestinal microorganisms or exert other beneficial effects in vivo [32]. Recently the use of 454-pyrosequencing analysis has been shown an increased value of Bacteroides in infants responding to probiotics [33]. A recent meta-analysis underlines that L. reuteri may be effective as treatment for crying in exclusively breastfed infants with colic, but there is still insufficient evidence to support probiotic use to manage colic, especially in formula-fed infants, or to prevent infant crying [23].Indrio et al. have performed a RCT that shows the efficacy of L. reuteri in preventing infantile colic and other functional gastrointestinal disorders [34].Recently, Sung et al. have described another RCT that shows no effect of L. reuteri in treating infantile colic, but this study has been conducted in a really heterogeneous population of infants with many confounding factors (such as treatment with proton pump inhibitors, types of infant formulas, recruitment at emergency department and outcomes including fussing, that is not an objective parameter). However, the meta-analysis reported by Sung in the same article confirms the positive effect of L. reuteri in reducing symptoms due to infantile colic [35].
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Complementary and Alternative Therapies: in the absence of safe and effective pharmacological interventions, complementary therapies have assumed an increasingly important role in the management of infantile colic.
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Herbal supplements: herbs such as fennel (Foeniculum vulgare), chamomile (Matricariae recutita) and lemon balm (Melissa officinalis) may help calming the infant and reducing abdominal distension [36, 37]. However, the administration of herbal products in infants with colic raises some concerns about the potential nutritional effects (these treatments provided for a long time could lead to a decreased intake of milk), the lack of standard dosages and the possible content of sugar and alcohol. In conclusion, parents have to use them with attention and under medical control.
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Manipulative therapies: Cochrane Database Systematic Reviews and randomized trials published in last years focused on this kind of intervention for infantile colic. Chiropractic treatment may offer short-term relief (reduction of daily hours of crying compared with no treatment or placebo), but long-term benefits are not demonstrated. The controversial nature of these interventions, their popularity among caregivers and the presence of weak supportive evidence underline how further rigorous researches are needed [38].
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Acupuncture: standardized light stimulation of the acupuncture point LI4 twice a week for 3 weeks has shown reduction in the duration and intensity of crying, with no serious reported side effects [39]. However, a recent study has reported no significant efficacy of acupuncture in the treatment of infantile colic and the Authors suggest to use it only in clinical trials [40]. Future researches are needed in order to clarify this issue and to investigate the efficacy of other acupuncture points and modes of stimulation for the treatment of infantile colic.
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Behavioral interventions: parents’ responsiveness should be stimulated but with recommendations not to exhaust themselves and underlying that they can leave their infant with others when necessary. Many studies have proposed “infant massage”, although it does not significantly improve symptoms. A recent Cochrane Database Systematic Review acknowledges that “there is some evidence of benefits on mother–infant interaction, sleeping and crying, and on hormones influencing stress levels. Further research is needed”. A more recent study describes an approach based on regularity in infant’s daily care and feeding, accompanied by instructions to swaddle during sleep. The aim consists in helping the infant to establish a regular sleep–wake rhythm that can reduce parental distress and improve quality of interaction between parents and child [41, 42].
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Conclusive remarks
Title | Prot/Rev n | Authors |
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Manipulative therapy for infantile colic | E0017 | Dobson D, Lucassen PLBJ, Miller JJ, Vlieger AM, Prescott P, Lewith G |
Pain relieving agents for infant colic1
| K0015 | Savino F, Tarasco V, Sorrenti M, Lingua C, Moja L, Ricceri F, Biagioli E |
Dietary modifications for infantile colic2
| M0015 | Savino F, Tarasco V, Sorrenti M, Lingua C, Moja L, Gordon M, Biagioli E |
Oral probiotics for infantile colic1
| L0018 | Praveen V, Praveen S, Deshpande G, Patole SK |