Infantile Colic: Diagnosis, management and role of the FODMAP diet

We discussed the importance of receiving adequate nutrients for lactating mothers in an earlier blog last month. Now let’s take a look at what role nutritional management plays in infantile colic in babies.

Infantile colic - what has changed and what is the same?

Infantile colic is known as excessive and frequent crying of unknown cause in otherwise healthy infants (1). It is a condition that affects approximately 1 in 5 infants globally (2). 

Infantile colic was previously defined by the Wessel’s Criteria of ‘crying or fussing more than three hours of the day for more than three days of the week’ (3), hence its name of the ‘rule of three’. However, the definition has recently shifted to the newer Rome IV criteria (4), which defines the condition as per below:

Signs and symptoms of a colicky baby may include:

• Excessive and frequent crying

• Appearing unsettled, irritated and fussy without a definite explanation

• Signs of fatigue and perceived pain, such as fist clenching, drawing up knees and wrinkling eyebrows

Fortunately, infantile colic is a benign condition that is usually resolved by the time a baby turns 3-4 months old. 

How should infantile colic be managed? (5)

The first step of managing infantile colic is to rule out any red flags and medical cause of excessive crying by a paediatrician, to ensure the baby isn’t in fact affected by any other clinical conditions. These include, but are not limited to, the following:

It is essential that healthcare professionals and parents are involved in the treatment of infantile colic. These strategies may be useful in helping and encouraging the parents to care for their baby during this period of excessive crying:

• Allow parents to talk about any emotional concerns or stress they have been experiencing and acknowledge their feelings

• Reassuring that this is a benign and self-resolving condition when other causes of excessive crying are excluded

• Discussing with parents to see if other caregivers or family members are able to help with taking care of the baby 

Physical touch and manipulating the ambience of the environment are often practical to help soothe and settle the infant. Examples include:

The probiotic strain L Reuteri DSM17938 may be effective in reducing excessive crying in exclusively breastfed babies aged under 3 months (6). 

Regular check-ups and follow-ups are also essential to ensure the infant is growing well.

What role does a low FODMAP diet play in managing infantile colic?

Preliminary research from Monash University indicates that a maternal low FODMAP diet may play a role in reducing crying times. In a 2015 study, mothers of exclusively breastfed infants aged 9 weeks or less received a low FODMAP diet or typical Australian diet then swapped over. Crying times decreased by a greater extent on the low FODMAP diet than the latter (7). Another 2018 open-label study found that a 7-day maternal low FODMAP diet resulted in shortened crying and fussing duration (8).

The mechanisms behind this theory are not yet exactly understood. 

As per a systematic review published by the Cochrane Database (9), there is yet to be sufficient evidence to recommend any modification of formulas or maternal diet to treat infantile colic at this stage. Moreover, as nutrient requirements increase during lactation, caution should be applied to the use of dietary modifications amongst breastfeeding mothers. 

What does not work or has not been proven to be safe? (5)

• Gripe water or herbal tea - although a treatment often recommended by relatives and friends with good intentions, no high-quality clinical trials have ascertained their effects on colicky babies. Moreover, consumption of these beverages may prevent babies from consuming breast milk or formula milk, which are sources of nutrients that support their optimal growth. 
• Medications - although emerging studies are available, there is still a lack of high-quality studies to prove their safety or effectiveness in this population. 
• Formula changes or weaning from breast milk - despite beliefs that changing formulas or switching from breastfeeding to formula feeding may reduce crying in babies, no high-quality scientific evidence has been found to ascertain this theory in babies without diagnosed cows milk allergy. In fact, it is recommended that babies are exclusively breastfed until 6 months of age, before introducing solid foods. 
• Shaking a baby - this attempt to settle colic symptoms is a behaviour that can come with dangerous, irreversible and long-term clinical consequences (known as shaken baby syndrome).

References:

1. Sung V. Infantile colic. Australian Prescriber. 2018;41(4):105-110.

2. Indrio F, Miqdady M, Al Aql F, Haddad J, Karima B, Khatami K et al. Knowledge, attitudes, and practices of pediatricians on infantile colic in the Middle East and North Africa region. BMC Pediatrics. 2017;17(1).

3. Wessel M, Cobb J, Jackson E, Harris G, Detwiler A. Paroxysmal Fussing In Infancy, Sometimes Called "Colic". Pediatrics. 1954;14(5):421-435.

4. Zeevenhooven J, Koppen I, Benninga M. The New Rome IV Criteria for Functional Gastrointestinal Disorders in Infants and Toddlers. Pediatric Gastroenterology, Hepatology & Nutrition. 2017;20(1):1.

5. The Royal Children's Hospital. Clinical Practice Guidelines : Unsettled or crying babies [Internet]. 2019 [cited 25 November 2021]. Available from: https://www.rch.org.au/clinicalguide/guideline_index/Crying_Baby_Infant_Distress/

6. Sung V, D’Amico F, Cabana M, Chau K, Koren G, Savino F et al. Lactobacillus reuteri to Treat Infant Colic: A Meta-analysis. Pediatrics. 2018;141(1).

7. Iacovou M, Craig S, Yelland G, Barrett J, Gibson P, Muir J. Randomised clinical trial: reducing the intake of dietary FODMAPs of breastfeeding mothers is associated with a greater improvement of the symptoms of infantile colic than for a typical diet. Alimentary Pharmacology & Therapeutics. 2018;48(10):1061-1073.

8. Iacovou M, Mulcahy E, Truby H, Barrett J, Gibson P, Muir J. Reducing the maternal dietary intake of indigestible and slowly absorbed short-chain carbohydrates is associated with improved infantile colic: a proof-of-concept study. Journal of Human Nutrition and Dietetics. 2017;31(2):256-265.

9. Gordon M, Biagioli E, Sorrenti M, et al. Dietary modifications for infantile colic. Cochrane Database of Systematic Reviews. 2018(10).