• Frequent, intense, prolonged crying/fussiness in an otherwise healthy infant
• Etiology unknown
• incidence 700k infants/yr affected in U.S.
• prevalence 9%-26% of all infants
  
• Spontaneous resolution
  
• Very frustrating for parents due to:
  
• lack of  appearent reason for crying
  
• inability to console child
• episodes typically occur in the evening
• lack of effictive treatment or therapy
  

• Rule of 3's
• Episodes start after 3wks and resolve by 3mo
  
• Episodes lasting 3+hrs/day
• Episodes occuring 3+days/wk
• Episodes occur in late afternoon or evenings
• Appearance suggests GI symptoms which can lead to misdiagnosis
• Intense crying that may seem more like screaming or an expression of pain
• Crying for no apparent reason, unlike crying to express hunger or the need for a diaper change
• Extreme fussiness even after crying has diminished
• Predictable timing, with episodes often occurring in the evening
• Facial discoloring, such as reddening of the face or paler skin around the mouth
• Bodily tension, such as pulled up or stiffened legs, stiffened arms, clenched fists, arched back, or tense abdomen

• Foreceful or Bilious Vomiting
• GI Bleeding (hemetemesis, hematochezia)
• Failure to thrive (FTT)
• Diarrhea
• Constipation
• Fever
• Lethargy
• Hepatosplenomegaly (HSM)
• Bulging fontanelle
• Micro/macrocephaly
• Seizures
• Abd tenderness or distension

• The Rome III diagnostic criteria for infantile colic include all of the following in infants from birth to 4 months of age:
  
• paroxysms of irritability, fussing, or crying that stop and start without obvious cause
• episodes lasting three or more hours per day
• episodes occurring at least three days per week for at least one week and no failure to thrive.
  

• early discontinuation of breast feeding
• frequent formula changes
• maternal distress and irritability
• suboptimal father-infant interactions
• increased risk for abuse
• potential for increased impulsivity, hyperactivity, academic problems later in life
• BEWARE of potential for shaken baby syndrome and abuse/neglect
  

• *Excess flatulence secondary to colonic fermentation of malabsorbed dietary carbs
• trial of simethicone in colic shows no efficacy
• Breath hydrogen tests do not support theory
• excess flatulence is likely due to crying and aerophagia
• Mode of feeding
• Prevalence, pattern, amount of crying during episodes are similar in both breast and bottle fed infants
• Protein Allergy/Intolerance
• Some data suggests switch to hydrolyzed formula may improve crying behavior
• Consider short trial of hydrolyzed formula in infants already being fed formula, esp if blood noted in stool
• Abnormal motility
• No data to support this proposed mechanism
• GERD
• Study of 24 infants with colic <3mo revealed only 1 infant with GER
• no difference between PPI and placebo in Colic symptoms during controlled study
• consider limited empiric trial of antireflux meds in infant with colic and emesis
• Gut Hormones
• Motilin-basal levels elevated in infants with colic independent of diet
• Higher motilin levels observed in infants who later go on to develop colic
• Non-GI Pathology
• Study showed 2-fold increase prevalence of colic in infants of mothers who smoke
• Study showed increase in colic symptoms in infants of mothers with
•  high anxiety
• maternal EtOH consuption at 6wks
• shift work during pregnancy
• Lower risk in infants of mothers with stable partners, full time employment

• randomly assigned to L reuteri or placebo for 21 days
• measured reduction in crying time to < 3hrs/day on day 21
• measured number of infants with 50% reduction in crying time by days: 7, 14, 21
• Greater reduction in crying time in probiotic group
• similar results seen in earlier study comparing L reuteri to simethicone
  
• interestingly similar results were not seen in an earlier study where formula containing α-lactalbumin enriched with L. rhamnosus and B. infantis versus placebo was used
• more studies needed to determine effectiveness (limited and low power)
  

Study design: Fifty exclusively breastfed colicky infants, diagnosed according to modified Wessel's criteria, were randomly assigned to receive either L reuteri DSM 17 938 (10(8) colony-forming units) or placebo daily for 21 days. Parental questionnaires monitored daily crying time and adverse effects. Stool samples were collected for microbiologic analysis.

Results: Forty-six infants (L reuteri group: 25; placebo group: 21) completed the trial. Daily crying times in minutes/day (median [interquartile range]) were 370 (120) vs 300 (150) (P=.127) on day 0 and 35.0 (85) vs 90.0 (148) (P=.022) on day 21, in the L reuteri and placebo groups, respectively. Responders (50% reduction in crying time from baseline) were significantly higher in the L reuteri group versus placebo group on days 7 (20 vs 8; P=.006), 14 (24 vs 13; P=.007), and 21 (24 vs 15; P=.036). During the study, there was a significant increase in fecal lactobacilli (P=.002) and a reduction in fecal Escherichia coli and ammonia in the L reuteri group only (P=.001). There were no differences in weight gain, stooling frequency, or incidence of constipation or regurgitation between groups, and no adverse events related to the supplementation were observed.

Conclusion: L. reuteri DSM 17 938 at a dose of 10(8) colony-forming units per day in early breastfed infants improved symptoms of infantile colic and was well tolerated and safe. Gut microbiota changes induced by the probiotic could be involved in the observed clinical improvement.

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