Most young infants eat and sleep, pass normal regular bowel movements, and cry only when they are hungry or need a fresh diaper. There are, however, many infants who cry for a large part of the day and night. They scream in pain after feedings, before bowel movements, or even right in the middle of good sleep. These babies can be thriving and healthy, but crying is a real problem. The infant is tired and miserable, the parents are frustrated and exhausted, and the siblings are annoyed and resent the amount of attention they lose to this screamer. Over the years this problem was called infant colic. The general impression was that it had no cause, no treatment, and it went away by about three months of age.
An incredible amount of nonsense has been published in Pediatric journals trying to prove that the babies are only crying to relieve tension and that is just neurological immaturity. Parents have been blamed for being too tense around the baby, not holding or feeding the baby properly, and many other unfounded improprieties. The most ridiculous premise was that there was no physical basis for the crying and that the infants were not in pain.
About ten years ago, physicians started to look more carefully at the problem and found that some of the infants actually have digestive difficulties. A small percentage of the babies seemed to have true colic. This consists of pain in the abdomen from cramping and gaseous ballooning of the bowel. Uncoordinated contractions of the intestinal muscles were noted. The condition seems to be an infant form of Irritable Bowel Syndrome.
At the same time, it was noted that a significant number of these children actually had acid reflux that caused the crying. Since that time, pediatricians have been analyzing the behavior of these screaming babies to prescribe specific treatments that alleviate the pain. There is a difference between colicky babies and babies who have reflux. Here is a discussion of the two entities.
An infant who has pure colicky pains can scream for hours, often even when held in his parents’ arms. He often folds forward, draws up his legs, and kicks while he is crying. His belly feels tense like a basketball and tapping on it produces a hollow sound. Burping or passing stool and gas sometimes stops the crying. Warm baths, swaddling, rocking or being walked in the stroller sometimes help.
Some colicky babies seem to improve when riding around in a car. To take advantage of this, a device was even invented to simulate a car ride by vibrating the crib and having the sound of a car motor and the wind noises of an open car window.
There are several specific problems that can be addressed before we give up and start driving all night.
1. All babies swallow air while feeding. Sometimes excess air is swallowed if the mother’s milk is flowing too fast and the baby has to gulp to keep from choking. Bottle nipples can also be a source of excess air swallowing. It is important to remember that any air that is swallowed and not burped up will have to travel all the way through the intestines until it gets passed from below.
2. We often recommend that nursing babies who are gulping should be stopped after every 2 or 3 minutes and burped. Bottle-fed infants often benefit from bottles that are designed to minimize air swallowing. Dr. Brown’s bottle is a good example.
3. Stool frequency can be a problem. Most babies pass stools with every feeding in the first couple of weeks of life. As time goes by, the frequency of stools decreases. If a baby is uncomfortable, it is important to note how often he passes stools. If days are going by without a bowel movement, and the baby is colicky, it is wise to induce bowel movements at least once a day. This can be done by using a glycerine suppository or a Baby Lax. Giving small amounts of prune juice sometimes helps. If the baby is really straining and not passing stools easily, he should be brought to the doctor. Sometimes the anal opening is too tight and needs to be stretched. Infrequent bowel movements in a happy, comfortable, not colicky, nursing baby are not a matter of concern.
4. The foods a nursing mother eats can cause problems in some babies. If the infant is colicky, eliminating all juices and a few vegetables can help. These are onions (cooked, fried and raw), broccoli, cauliflower, cabbage (including coleslaw), and green pepper. Fruits and all other vegetables, including yellow and red peppers, are okay. If eliminating these foods does not help, it might be worthwhile to try eliminating cow’s milk and all milk products from the mother’s diet.
5. Infant formulas can be a source of the problem. They are made of either milk or soy protein. Some babies who are colicky improve by switching from one to the other. Hydrolyzed formulas, Nutramigen and Alimentum, are “predigested.” This means that the basic proteins are broken up into small components. Elemental formulas, Neocate and Telecare, are artificial. They are made of amino acids, which are the smallest building blocks of proteins. Some babies, who are colicky on regular formula or who cannot tolerate any of the foods in the mother’s diet, might benefit from a hydrolyzed formula or an elemental one.
6. A recent study showed that probiotics can help infants with colic. Probiotics are germs that are known to be beneficial which are added to the digestive tract. The two probiotics Culturelle (Lactobacillus GG) and Florastor (a beneficial yeast) help the colic in some babies. The dose is half a capsule of Culturelle once a day and half a packet of Florastor twice a day. The formula companies are starting to add probiotics to the formulas in the United States. These newer formulas might be helpful in preventing colic.
7. Herbal colic remedies like “Gripe Water,” Kimmel tea, chamomile tea, and others sometimes help the cramping.
Gastro-Esophageal Reflux Disease (GERD)
This condition occurs when the acidic contents of the stomach travel back up the esophagus, causing damage to the lining of the esophagus, causing a pain known as “heartburn.” Not all reflux babies spit up. The reflux may back up only to the lower part of the esophagus.
GER without the D
It is common for babies to spit up all the time and not have GERD. Even though the food comes back up through the esophagus, it does not cause pain. This is GEReflux, but it does not become GERDisease until it actually causes a problem.
When the reflux causes erosion of the wall of the esophagus, the baby will show painful signs of heartburn.
GERD babies cry intensely after or during feedings. They often gulp during and between feedings. They sometimes wake up screaming after falling sleep contentedly after a feeding. The refluxing baby will often stiffen his legs and body and arch his back, throwing his head back. The upright position seems more comfortable, and many GERD babies are difficult to put down. Here are a few points about the management of this acid reflux:
1. Sleep position can be important in reflux disease. A slight upward angle at the head of the mattress can be helpful. This is done by putting a folded towel under the head of the mattress, creating a 20-degree angle.
2. These infants often sleep better sitting up. It has been noted, however, that infant seats are not the best sleep chairs for reflux infants. This is because the baby is folded in the middle, creating back pressure on the belly. A bouncy seat or swing which allows the baby to keep his abdomen stretched out while seated is better.
3. Thickening feeds can help sometimes. If the baby is bottle-fed, it sometimes helps to add rice cereal to the formula (1 tablespoon to every 4 ounces). Thickened feeds seem to satisfy the baby with fewer ounces, so the stomach is less full. The hole in the nipple has to be opened to accommodate the thicker formula (I have never found that giving cereal after feeding helps a breastfed infant.)
4. Burping, as mentioned before, is very important since the acid-full milk sometimes comes up with a delayed burp.
5. Constipation can add to the problem, probably by delaying the emptying of the stomach contents into the small intestine. The longer the milk stays in the stomach, the greater the chance for reflux. Some babies are still spitting up the last feeding when they start the next feeding. Making sure the GERD baby empties his bowels regularly is important.
6. Antacids can help and are often necessary in order to stop the problem.
There are three types of antacids:
Acid neutralizers like Mylanta or Maalox. These only work for the time they are in the stomach. They can give quick temporary relief from the burning pain. The usual dose is ½ cc per 2 pounds of body weight, given up to 7 times a day.
H2 blockers like Zantac, Axid, and Pepcid. These are acid blockers that actually prevent the acid from being secreted in the stomach. The usual dose is 1cc per 5 pounds body weight, every 8 hours (7 am, 3 pm, and 11 pm). These medications give a lot of relief and can be used for as long as needed (usually a few weeks or months). A recent report in a major Pediatric journal showed no side effects, even after years of use.
Proton Pump Inhibitors (PPIs) These are proton pump inhibitors such as Prilosec and Prevacid. The PPIs are even more potent in blocking acid production than the H2 blockers. The usual baby dose is 7.5 to 15mg, 2 times a day. This is actually the same as an adult dose, but babies need that much in order to get the benefit. The only group that has shown side effects is small premature infants. All the other babies do very well with these medications.
The best way to judge the effectiveness of these treatments is to watch the baby. If there is much less crying, the treatment is working. The spitting up might still persist but it will not cause pain since there is no acid. Silent GERD
It is possible to have the acid contents of the stomach come up to the throat and be swallowed with no symptoms of GI distress. This silent reflux has recently been linked to problems in the throat. Chronic hoarseness is one symptom that often responds to antacid treatment. The ENT specialists can look deep into the throat and find signs of acid burns that lead to this diagnosis. Reflux has also been implicated in apnea in newborn infants, chronic cough, and even sinus disease and ear infections. The research is still being done to determine the validity of these observations.
The medical test for acid reflux is performed in an overnight stay in a hospital. A probe is placed in the baby’s esophagus, and acid levels are recorded over a period of time. This test is not very popular since the reflux can be intermittent and be missed by the probe. Most physicians diagnose reflux by observing the baby’s behavior and by observing the response to medications.
The most important thing is that babies with colic and reflux usually thrive. While it is not necessary to treat them, it is also no longer necessary to leave them in pain until they outgrow the problems. With current medical understanding and the availability of medications, it is possible to relieve many of these infants and their families so they all can enjoy the first few months of his life.