by Anne Eglash MD, IBCLC, FABM
What interventions are proven to be helpful for breastfed infants with colic? Colic is typically defined by the Wessel rule of ‘3’s, occurring in infants who are growing well, healthy, but have episodes of irritability and who cry inconsolably for at least 3 hours a day, at least 3 days a week, for a period of 3 weeks or longer. Evidence has shown that colic starts before or at 3 weeks of age, peaks at 6-8 weeks of age, and diminishes by 3-4 months of age.
Studies on the causes of colic indicate the association with several factors, including maternal diet, infant sensory processing capacity, environmental exposures such as cigarette smoke, and infant gut microbiome. A recent study indicates that colic may be related to insufficient development of the melatonin and cortisol circadian rhythms, both of which emerge by 3 months of age.
There are several different products marketed for colic such as probiotics, teas, gas drops, and special infant formulas. Many families are advised to consider a maternal elimination diet, medications for gastroesophageal reflux, acupuncture, chiropractor visits, massage, driving the infant in a car seat, among other recommendations.
The most recent systematic review of interventions for managing colic in breastfed infants was published in December 2015. The review included 17 studies on the following categories of interventions: maternal diet, pharmacotherapies, plant-based therapies, and probiotics.
What do you think the authors found to be true regarding the evidence of colic management interventions for breastfed infants (choose 1 or more):
- The probiotic lactobacillus reuteri reduces crying time.
- Gas drops with simethicone are effective for colic.
- There is insufficient evidence on the effect of maternal diet on colic.
- Fennel appears to be helpful but the strength of evidence is somewhat weak.
- All of the above.
See the Answer
The answers are A, C and D. Simethicone is not effective for colic
Infant Colic-What works: A Systematic Review of Interventions for Breast-fed Infants.
Harb T, Matsuyama M, David M, Hill RJ.
OBJECTIVES:
To determine the strength of evidence for commonly used interventions for colic in breast-fed and mixed-fed infants younger than 6 months.
METHODS:
Searches of PubMed, CINAHL, Embase, AMED, and Web of Science databases were conducted from July 2014 to July 2015. Included studies were randomised controlled trials involving mothers and their colicky infants younger than 6 months; assessed colic against the Wessel or modified Wessel criteria; and included phytotherapies, prescription medicines, and maternal dietary interventions. Studies with <16 participants were excluded. Meta-analyses were conducted where data were sufficient to enable pooling. Quality was assessed against the Cochrane Risk Bias Assessment Tool.
RESULTS:
A total of 17 articles met the inclusion criteria for this review. The 6 studies included for subgroup meta-analysis on probiotic treatment, notably Lactobacillus reuteri, demonstrated that probiotics appear an effective treatment, with an overall mean difference in crying time at day 21 of -55.8 min/day (95% CI -64.4 to -47.3, P = 0.001). The 3 studies included for subgroup meta-analysis on preparations containing fennel suggest it to be effective, with an overall mean difference of -72.1 min/day (95% CI -126.4 to -17.7, P < 0.001).
CONCLUSIONS:
Probiotics, in particular L reuteri, and preparations containing fennel oil appear effective for reducing colic, although there are limitations to these findings. The evidence for maternal dietary manipulation, lactase, sucrose, glucose, and simethicone is weak. Further well-designed clinical trials are required to strengthen the evidence for all of these interventions.
Milk Mob Comment by Anne Eglash MD, IBCLC, FABM
Approximately 20% of infants suffer from colic according to various studies, but I think colic is a spectrum that occurs in at least 50% of infants. Infants with severe colic may cry for 3 hours, but I believe that the average infant aged 3 weeks to 3 months has some degree of colic, whether it is just restlessness, popping on and off the breast, or feeding more frequently.
It appears that supplementation with Lactobacillus reuteri DSM 17938 has the strongest evidence for its effectiveness in controlling infant colic. A more recent meta-analysis on lactobacillus reuteri published in 2017 verified the probiotic’s reduction in crying time in infantile colic. In addition, there have been several studies that have found a difference in the gut microflora between infants with and without colic.
Several companies market infant probiotic drops for colic containing lactobacillus reuteri, but not every infant needs probiotics. I would suggest reserving its use for infants with severe relentless crying. Because the probiotics don’t appear to eliminate crying, but rather reduce crying time, families still need counseling on managing the fussy infant. Family need to understand that the infant’s behavior is self -limited and will improve by 3 months. They should be encouraged to ask their friends and family for help with respite time, and to reduce expectations for social plans such as dinners out or parties with friends. Parents will experience more sleep time if they keep their babies up in the evening, so that the colic happens in the evening and not between 11 pm and 4 am. Fresh air can do wonders for a crying infant. Even in northern winters, a baby hat, jacket, and a snuggle under a parent’s coat with the nose in fresh air is plenty protective from the elements. Discourage mom from an elimination diet, since that has not been shown to be helpful. Congratulate parents on their patience and understanding as their infant journeys through this tough yet short-lived stage.
Pat Bucknell
I have been an IBCLC since 1992. I’m finding that soy is becoming more & more of a problem with breastfeeding babies. I do a weekly hospital-sponsored breastfeeding support group and am finding babies reacting to soy is increasing. If you look at food labels, soy seems to be in “everything”. I have no science to back this up, but I think that genetically modifying soy might be the reason for this. Fifteen to twenty years ago soy issues weren’t even on the radar. Be interested in knowing if you or others are also seeing this?
Teresa Kovarik
Thank you for this lovely synopsis of a topic that is often managed clinically with anecdotal-based, rather than evidence-based, approaches. If I may add to Dr Eglash’ compassionate comments, I also suggest to parents that a tag-team approach is often vital to parent survival in these “short” 2.5 mos or so. Not all families have two care-givers sadly. But, if possible, it does help to have one parent with the raging infant and the other use sound-blocking ear plugs and try to sleep/ get outside on their own for a peaceful walk/meditate/ do yoga/listen to music etc. Hovering together over your crying infant just keeps both parents tense and we all know that a baby can calm more easily on a more relaxed body.
My husband and I survived our first child’s classic colic in this fashion. Our rule: If the person with our beloved “Jekyll/Hyde” daughter was at the end of their rope, then “tag, you’re it” with no regulations/expectations for length of time or equity etc. Our daughter was better cared for and we supported each other through this marathon. Yes, they DO outgrow it within 3 months. But those 3 months seem like an eternity to new parents and will forever be etched into their memories. No wonder so many managements of colic proliferate all over this country that do not help and are not evidence-based. Many parents are sure that something horrible is happening to their new baby and something is being missed. Another great example of when the best clinical help we can offer is not from a prescription pad but rather from first listening to and then reassuring/supporting this new family.
Mary polk
What are the statistics on gripe water or craniosacral therapy?
MilkMob
There is not enough good evidence on either gripe water or craniosacral therapy to say definitely that these are helpful.However, gripewater tends to have fennel, and fennel has been shown in low quality studies to be somewhat effective for colic. The concern with gripewater is introducing something other than breastmilk, increasing the risk of electrolyte imbalances if homemade gripewater is given in large volumes, or risk of infection if it is made with contaminated water or herbs.
Nancy Comello
I don’t see that the article addressed sensitivities to milk products via breastmilk. If the mother has a history of dairy sensitivity as an infant and child, what kind of evidence exists that dairy elimination when breastfeeding helps?
Milk Mob
Colic, by definition, is fussiness not related to other known medical problem. If a baby cries due to milk intolerance, the crying is due to milk intolerance and not colic.