Treating Kids with Colic- Ferrill DSA Flashcards
Colic defined
Scientific-defined for research efforts
- Wessel criteria (1954):
- – Crying and fussing more than
- ——– 3 hours per day, 3 days a week, For more than 3 weeks
Inconsolable, excessive crying associated with hypertonicity, perceived pain, borborygmus, wakefulness
Cyclic
Onset 2-6 weeks old and lasts typically 3 months
colic - The Differential
Infection – meningitis, encephalitis, sepsis, pneumonia, UTI, osteomyelitis, septic, toxic synovitis, AOM, herpes stomatitis, oral thrush, gastroenteritis, herpangina, insect bites, cellulitis, infectious arthritis
Trauma – non-accidental trauma (skull fracture, intracranial bleed, rib fracture, pneumothorax, long bone fracture, intra-abdominal blunt trauma), accidental trauma (falls), corneal abrasion, hair tourniquets (digits, penis, clitoris)
Metabolic – inborn error of metabolism, electrolyte abnormality, acid/base derangement, hypoglycemia
Foreign body – oral, nasal, ear, pharynx, eye
GI – intussusception dehydration constipation, GERD, hernia
CV – SVT, congenital heart disease
Environmental: neglect, hunger
Current thoughts on the pathophysiology and etiology of Colic
Dietary Psychological Gastrointestinal Hormonal Neurological immaturity
Food sensitivities and colic
RCT conducted among exclusively breastfed infants with colic (90 completed the trial)
Average cry-fuss time over 48 hours was 630-690 minutes
Active arm: mother’s excluded cow’s milk, eggs, peanuts, tree nuts, wheat, soy, and fish. Control arm: mothers continued to consume these foods
Outcomes assessed after 7 days as the duration of cry-fuss behavior over 48 hours using charts
End point 25% reduction in cry-fuss behavior over 48 hour period after 7 days of dietary intervention
Result: objective 21% of babies in the low allergen diet group had less cry-fuss time
psychological etiology of colic
The relationship between maternal post-partum depression and colic
Ante-partum stress and depression and colic
Association is clear—what is not clear is if there is an etiological relationship
- Maternal/familial stress and depression anxiety causes colic?
- Colic causes maternal/familial stress, depression and anxiety?
- Or they just exist together?
physiological etiology of colic
GI related
- Gut motility and neurological immaturity
- Intestinal flora imbalance
Neurobiological
- HPA axis and adrenergic system feedback loops activated as a result of perceived danger or discomfort (on the part of the infant)
- Epigenetic modulation in the limbic system may explain correlations between regulatory problems in the first months of life and behavioral/feeding problems later in life
H. Pylori and Infantile Colic
Case control study (Saudi Arabia)
Used H. Pylori stool antigen testing
Case population:
55 infants with colic per Wessel criteria
2-4 months age
45 (81.8%) tested positive for H. Pylori infection
Control population:
30 infants without colic
Age, country of origin, gender and ethnicity matched
7 (23.3%) tested positive for H. Pylori infection
Treatment of colic
Rule out organic disease Reassurance, reassurance, reassurance Dietary interventions -- Maternal diet restriction (big 5: gluten, dairy, egg, citrus, soy) -- Formula changes -- Herbal teas -- Sugar water
Supplements
- High fat diet per mother or fats added to infant diet
- Pro- and pre-biotics
Medication
- Simethicone
- Dicyclomine
- Methylscopalamine
Behavioral
- Quiet area/decreased stimulation
- Vibration (car ride, sitting on the dryer, etc)
- Intensive parental training
Manual treatment/therapy
- OMT
- Chiropractic
- Massage
What may work (according to the literature)
Fennel extract tea
Chamomile, vervain, licorice, fennel, balm mint
Fennel has analgesic effect
Sucrose/glucose solutions
Sweetness may induce analgesic effect
Manipulation (of any sort)
Several showed benefit, but lack of blinding, small ‘n’ limited usefulness of the studies
Studies not well funded or of good trial design
Need better studies
Probiotics
L reuteri has been found to be helpful in several studies
OMT for the colicky baby
Indications
Somatic dysfunction
Organic disease ruled out and “functional” cause is suspected
Contraindications
??
Rule out organic disease
Follow contraindications for modalities
The theory behind why we even try
Lies within the concept of facilitation and the long term effects it has on the nervous system
Facilitation
Nociceptive information comes in from a peripheral source (outside the CNS). This could be from viscera, muscle, bones, peripheral nervous tissue….anything outside the CNS.
- This information bombards the CNS and decreases the firing threshold of those neurons (side dynamic range neurons). In effects, these neurons are facilitated—they are activated more quickly than neurons that have not been exposed to excessive nociceptive information.
- These irritated (facilitated) neurons activate and facilitate neighboring neurons.
The gut as the pain generator:
The gut sends nociceptive information to the central nervous system via the visceral afferents (CN VII, IX and X) whose nucleus resides in the brainstem. This area gets facilitated. Notice that the nuclei for the visceral efferents (CN X) and motor efferents of CN IX and X are right next to the visceral afferents. Now these get facilitated and send protective information to those areas. We get reflex irritation as well as spasm in those areas. The stomach pain causes more stomach pain.
the mediator of headache
Note also that the dorsal rootlets of C1 and C2, which carry motor efferents to the upper cervical spine, are right there and they also get facilitated causing muscular hypertonicity. Stiff neck.
Note also that the nucleus of the trigeminal nerve is also right there. The trigeminal nerve is the primary sensory nerve to the cranium—it is the mediator of headache. When this nucleus gets facilitated, headache is the result.
The Head and neck as the pain generator:
When babies are born, a lot of force is placed through the system. The uterus generates up to 80 psi during the birth process. To absorb those forces properly, the baby’s body must be aligned well. It must be a vertex presentation with the head and neck aligned in such a way so that the forces are absorbed and dispersed through the cervical spine axially. When the head is turned or the body is in any other position, those forces get absorbed and dispersed into tissues not designed to tolerate those kinds of forces. Most commonly, these forces are taken up in the upper cervical spine and cranial base. What would the facilitation picture look like then?
Muscular tensions and pain from the upper cervical spine sends nociceptive information to the upper cord via C1 and C2 rootlets. The upper cord area gets facilitated, irritating the nuclei of the motor and visceral efferents which then send a volley to the gut causing increased gastric secretions, increased or decreased peristalsis and pain. The trigeminal nucleus also gets facilitated and causes headache.
This facilitation is why stiff necks cause headache (a clinical entity known as cervicogenic headache).
It is also part of why people with migraines also have nausea and vomiting.
It is the close physical relationship and interconnectedness of the central nervous system that makes it so that symptoms that appear to be unrelated may, in fact, be related.
Colic and other childhood problems
Prospective study comparing infants with and without severe colic during infancy and 10 years later.
- Significantly increased incidence of
Recurrent abdominal pain (abdominal migraine) - Allergic diseases (asthmatic bronchitis, rhinitis, conjunctivitis, atopic eczema, food allergy)
- Psychological disorders (sleep disorders, aggressiveness, fussiness, ‘supremacy’)
