Those were the exact words spoken to me
by my oral examiner for my Pediatrics certification in 1984. We were "discussing" the use of medications of possible use in infantile colic, and I was sticking to my guns not wanting to prescribe a certain drug the examiner had suggested, metaclopromide, more commonly known as reglan. My major reason for refusing was that I was not absolutely certain how the drug worked, or what its major side effects were, and I was absolutely certain that if, in the course of this examination, I prescribed a drug with which I was unfamiliar I could fail.
So I stuck to my guns, and told the examiner that I was hopeful I would have developed a strong enough relationship with the mother by then that the mother would feel comfortable to call me if she felt so frustrated that she wanted to throw the baby out the window or harm him in some other way. I suggested that if I felt the need to prescribe this medication, I might obtain a pediatric GI consult to be sure something else was not wrong. I also told him that most infants "outgrow" their colic over the course of weeks to a few months, that parents needed support during this period of time, and a bit of handholding from their primary care physician. And, I passed my oral exam in Pediatrics. PHEW
Today, more than 25 years later, there is still no clear cut treatment for infantile colic, a problem that continues to frustrate parents and physicians both.
It may surprise readers to learn that the definition of infantile colic currently used by most pediatric practitioners was first proposed by Dr. Morris Wessel in an article he wrote in 1954. At that time, no one knew what caused colic, and therefore no treatment strategy could be proven to work well.
He described colic occurring in otherwise healthy infants less than 4 months of age as "paroxysms of irritability, fussing or crying lasting for a total of more than three hours a day and occurring on more than three days in any one week."
Its as good a definition as any. Possible causes were thought to be "congenital hypertonicity", "allergy", "physiologic immaturity of the intestinal tract" and "parental influence" (having very anxious parents).
In 2011, we still don't know what causes colic,
and our traditional medical therapies are imperfect. Countless children undergo multiple changes in formula, or their mothers embark on elimination diets in order to try to ease the distress presumed to be caused by an allergy or sensitivity to certain foods. Others are put on medication to treat intestinal gas, since many children with colic are noted to pass a lot of gas. Still others take daily doses of anti-reflux medicine, which may include the drug my examiner tried to get me to prescribe, but has never been proven of direct benefit to infants with colic.
Because of the failure of prescribed medical regimens to work conclusively, many parents have turned to complementary and alternative medicine (CAM). I was therefore happy to see an article in Pediatrics this month which reviewed multiple published studies of nutritional supplements and other complementary medicine approaches for infantile colic.
The lead author, Rachel Perry, from a medical school in the UK, did an exhaustive search for relevant articles, and ended up looking in detail at 15 studies which met certain requirements indicative of high-quality research. There is good news and bad news here, The good news is they found over 1700 articles in the medical literature that purported to study CAM for colic. The bad news is that very few met the criteria for a high-quality study. Even within the 15 that made it into this paper, very few can be considered as definitive. These articles covered multiple types of CAM. Ranging from herbal and probiotic supplements, to massage, reflexology and manipulation, or a combination of approaches. Here again, some good news and bad news.
The good news is that in general these approaches did not seem to cause any specific adverse events; the bad news is that it is difficult to draw conclusions that might lead to specific recommendations from any of the studies, due to some problems with statistical analysis, sample size, or other problems in research design. As you might imagine, some of the outcomes are very subjective, and if you rely upon parents' impressions, especially if they are not "blinded" from knowing what group their child is in, outcomes can be difficult to rely upon.
The bottom line from her evaluation is that:
- Three of 4 studies on spinal manipulation (chiropractic or osteopathic) seemed to show some benefit; but most reliable of the 4 showed no improvements.
- All 3 studies that looked at herbal supplements showed positive results; one with fennel extract alone, the other two looked at herbal teas or combination supplements that contained fennel extract in addition to other substances, such as chamomile.
- Sugar solutions (concentrated sucrose or glucose--which are often used as pain relievers in infants undergoing procedures) showed effectiveness, but there were questions about the validity of the statistical methods used in the five studies that looked at these solutions
- Massage therapy was evaluated in one study, and the results were equivocal, since the placebo group started out with more severe colic at the onset of the study
- One study compared targeted reflexology, non-targeted reflexology and standard care. It showed improvement in the non-targeted group compared to standard care, but could not find a statistical difference between the targeted and non-targeted groups, calling the whole determination of outcome into question.
- One study looked at four groups, the author of this paper only discussed the three related to CAM; sucrose vs. fennel tea vs. massage and found that each of these was independently better than doing nothing.
- One of two studies on probiotics showed improvement in crying time when probiotic was compared to simethicone, and anti-gas treatment often used to treat colic, although without proven benefit.
In the end, Rachel Perry suggests that supplements containing fennel extract have the strongest evidence for positive benefit in infants with colic. She does not negate the possibility of the other studied approaches in helping infants with colic, but believes the studies were too flawed to really appropriately guide our treatment of this disorder. We are still looking for an absolute etiology of colic, but fennel has been noted to be an antispasmodic and probably increases intestinal motility. It would therefore work on both possible reflux as well as intestinal cramping.
Is it time to run out and buy fennel tea or essential oils for your baby with colic?
I would say, "talk to your health-care provider" but I suspect he or she may not really know the answer to this question. If you have a baby with colic you know how miserable the infant is, and how stressful the home can become with a child who cries seemingly all day. If you have never had a baby with colic, you can commiserate but not quite understand the feeling of wanting to "throw your baby out the window". Colic may contribute to child abuse, and so, even though it is what we term a "self-limited" problem and will go away within a few weeks or a few months even if you do nothing, the long-term impact may be significant. So, I am happy that all possible treatment modalities are being studied. In another 50 years we may have THE answer, or at least AN answer. As usual, looking for your comments