Infant Colic

Dear Lisa,

My 6 week old son is very fussy. He has changed formulas 3 times and now is onNutramigen. He is also on Axid for reflux. However he seems to be in pain. He will cry and scream for hours and won’t settle down until he has a bowel movement. Sometimes he can’t go and I have to use a thermometer with jelly to get him to go. He doesn’t like to lay flat on his back, isn't sleeping much, holds his breath when he gets going and seems to always be hungry. It breaks my heart when he’s like this. It's usually between the hours of 6pm and 3am, but also during the day sometimes. Any advice????

“SLB80”

Dear “SLB80”

It looks like you and your baby have had a rough time for the last 6 weeks. It also looks like you and your Physician have tried many avenues to help your son find some comfort. Nutramigen is one of the recommended formulas for children allergic to milk protein. (1) The switch to this formula should have addressed a possible milk sensitivity. Your son’s Gastroesophageal Reflux Disease (GERD) is also being addressed with the use of the medication Axid that he is taking.

Axid is an H2 receptor antagonist which works by blocking stomach acid secreted by histamine. H2 receptor antagonists are the first line treatment for children with GERD. H2 receptor antagonists typically need to be administered twice per day because the medication’s effectiveness runs out approximately 9 to 11 hours after the morning dose. Infants who are prescribed this type of medications only once per day tend to have a return of their symptoms in the evening hours when the medication is no longer working.

H2 antagonists also tend to gradually lose their efficacy with long-term administration.(2) Because of this children treated with H2 antagonists for a length of time can experience a return of their GER symptoms. Therefore it is common for children on H2 antagonists to be stepped up to the next treatment option, such as a Proton Pump Inhibitor (PPI) when GER symptoms occur.(3)

Proton pump inhibitors (PPIs) are superior to H2 receptor antagonists as acid suppressors.(4) Proton pump inhibitors prevent acid secretion stimulated by histamine as well as acetylcholine and gastrin.(5) In addition, the use of PPIs results in faster and higher rates of erosive esophagitis healing compared with H2 receptor antagonists.(4) Prevacid is one of the Proton pump Inhibitor that is approved in the pediatric population.(5) Even though it is recommended for children from 1-11 years old, it is prescribed by many Doctors and Nurse Practitioners to children less than 1 year old.(6)

Typical GER symptoms experienced by infants include vomiting, regurgitating, back arching, excessive hiccoughing and irritability. Some children with Silent Reflux will experience irritability with no obvious signs of vomiting.(3) You did not mention if your son’s GER symptoms improved with the institution of Axid or if he is presently experiencing GER symptoms. If this is the case, the approach to the treatment of his GERD may need to be re-evaluated.

In some cases medications need to be adjusted, non-medical treatments need to be initiated or further diagnostic testing needs to be performed. One of the non-medical treatmtnets for GER includes thickening the infant formula. Many doctors have moved away from the practice of thickening baby formula with rice cereal as a treatment for GER. It is true that it will not cure the disease, but it has been shown to decrease the amount of times per day that a baby spits up and has brought relief to many children.(3,7) You might want to discuss this option with your Doctor if your son is having vomiting with his GERD.

Another non-medical treatment is positioning. Babies with GER tend to experience less symptoms when they are elevated at a 30 degree angle.(3) Since your son has GER, it is not surprising that he has discomfort when he lies flat. You may want to purchase a bouncy seat that is made to maintain an infant in an elevated position. Placing a child in an infant car seat is usually not effective. Infant car seats cause the baby’s hips to flex which places pressure on the stomach and increases reflux. (5)

Babies with gas also have a lot of abdominal discomfort, abdominal pain and crying. Some infants entrap a lot of air with their vigorous sucking which causes air to be trapped in their stomach. In addition certain bottles allow more air to enter the baby’s stomach during a feeding than others. If your son is having a lot of burping you may want to consider adjusting your feeding technique. From my experience many parents have found success with the use of a Dr. Brown’s bottle which is designed to prevent air from entering the baby’s stomach.

Once all of these areas have been addressed and your baby’s Doctor determines that there is no other medical cause for your son’s crying, Colic should be considered. Colic usually begins in the first three weeks of life and typically lasts up until a child is three months old. In rare cases it may persist up until 6 month of age.

The symptoms include crying episodes accompanied by pulling the knees to the chest as if the baby is in pain. The crying episodes typically last 30 minutes to 2 hours and occur one to two times per day, usually concentrated in the evening hours. In between the crying spells the babies with colic are quite content and happy.

Taking care of a baby with colic can be extremely exhausting and can have a strong emotional impact on the whole family. It is very difficult to watch your baby cry, especially when measures taken to provide comfort do not seem to help. This stress can profoundly affect the primary caregiver who needs some time away from the baby.

When a baby has colic it is a good idea to have a friend or relative take care of the baby on a regular basis in order to give the major caretaker a break. In addition to parental breaks, there are some measures that may help soothe the baby’s symptoms. Parents may need to experiment with these interventions because each baby is different and different techniques work for different babies.

Some infants respond favorably to gentle pressure over the abdominal area. Walking with the infant held over your arm can provide the gentle pressure that is needed.(8) Other babies find relief if their position is changed frequently. Measures to distract the baby may work for some families. Music with a varied rhythm or a beating heartbeat in the background may stop the baby from crying.(8) Other babies find comfort from loud humming sounds such as the noise made by a clothes dryer, motor of a car or vacuum cleaner.

Swaddling an infant may also reduce the amount of crying and fussiness. The swaddled position replicates the position of comfort that neonates experienced in the womb. Swaddling promotes restful sleep, reduces scratching of the infant’s face and diminishes frequency, intensity and duration of crying episodes.(9) You can ask the Nurse in your Doctor’s office to show you how to swaddle your baby and practice on a doll or stuffed animal if necessary.

I hope this information helps because I understand how heart wrenching it can be to see your baby cry. Just be assured that many times it is normal for a baby to cry because it is their way of communicating. Also be assured that colic, and GER improve with age and this period will soon come to an end.

Signs that a crying baby needs medical attention include a baby with a fever, continuous crying, abdominal distention, bilious vomiting (foamy yellowish green vomit), projectile vomiting, lethargy, muscle weakness, a baby with improper head circumference growth, ineffective voiding and/or blood in the stool. These situations require medical attention and a further workup in order to determine the cause of the vomiting.

If you are interested in reading other Pediatric Advice Stories about topics discussed:

Swaddling

Infant Vomiting

Gastroesophageal Reflux

Infant Back Arching

Gassy Baby

References:
(1)Rudolph CD, Mazur L, Liptak GS. North American Society for Pediatric Gastroenterology and Nutrition Guidelines for evaluation and treatment of Gastroesophageal reflux in infants and children: recommendations of the North American Society for Pediatric Gastroenterology and Nutrition J Pediatr Gastroenterol Nutr 2001;32(Suppl 2 ):S1-31.
(2)Gillen D, McColl Ke. Problems related to acid rebound and tachyphylaxis. Best Pratct Res Clin Gastroenterol. 2001.15:487-95.
(3)Suwandhi E, Ton M, Schwarz S. Gastroesophageal Reflux in Infancy and Childhood. Pediatric Annals. 2006.35(4):259-266.
(4)Edmunds A. Gastroesophageal Reflux Disease in the Pediatric Patient. Therapeutic Spotlight. 2005. August:4-13.
(5)Christensen M, Gold B. Clinical Management of Infants and Children with Gastroesophageal Reflux Disease: Disease Recognition and Therapeutic Options. Presented at: ASHP Midyear Clinical Meeting; Dec 9, 2002:Atlanta.
(6)Schwartz R, Guthrie K. GERD: the lessons my new grandchild taught me. Infectious Diseases in Children. 2006. April:14.
(7)Wenzi TG, Schneider S, Scheele F. Effects of the thickened feeding on Gastroesophageal reflux in infants. A placebo-controlled crossover study using intraluminal impedance. Pediatrics. 2003; 11:355-359.
(8)Betz C, Hunsberger M, Wright S. Family-Centered Nursing Care of Children. 2nd ed. Philadelphia, PA:W.B.Saunders Company. 1994: 1486-1487.
(9)Schwarz R, Guthrie K. Musings on infant swaddling. Infectious Diseases in Children. 2006. June:14.


Lisa-ann Kelly R.N., P.N.P.,C.
Certified Pediatric Nurse Practitioner

Pediatric Advice For Parents with Infants