Background: Infantile colic is a severe irritable or crying which bothers babies and parents. The etiology of infantile colic is not known until now and nutritional intervention is often used as a treatment for colic symptom.

Objective: To determine the role of nutrition in the management of infantile colics.

Method: This review article on infantile colic used several electronic databases such as Google, Pubmed, Ebscohost, American Academy of Pediatrics Publications and Cochrane databases

Results: Three studies of infantile colic on breast-fed infants and six studies of infantile colic on infants who consumed formula milk were found.

Conclusion: Low-allergen diet consumption in mothers who breast-fed infants or infants who consumed extensive hydrolyzed casein-based formula can improve symptom of infantile colic. There is no strong evidence for now to recommend the use of soy protein-based formulas and low-lactose formula as the management of infantile colic in infants.

Keywords: infantile colic, nutritional intervention.

Infantile colic is a symptomatic disorder characterized by paroxysms of fussing, agitation or crying, lasting more than three hours a day and occurring more than three days a week for at least three weeks.¹ In addition to this definition, diagnostic criteria of Rome III for functional gastrointestinal disorder defines infantile colic as a condition that includes all of the following symptoms in infants aged less than 4 months, such as (1) paroxysms of irritability, fussing or crying that start and stop without obvious cause, (2) episodes lasting for three or more hours per day and occurring at least three days per week for at least one week, and (3) there is no failure to thrive.² The main symptoms are excessive and persistent crying which tend to occur at night. During each episodes, the child appears distress, irritable, fussy, becomes red faces, contracted legs, and frequent borborygmi.³ This condition occurs in 10-40% of infants worldwide and peaks at around 6 weeks, then disappears by 3-6 months. The incidence of infantile colic is similar in both male and female infants. There are also no relationships between infantile colic and feeding types (breast-fed or formula), gestational age, or socioeconomic status. The definite cause of infantile colic is unknown. Several causes of infantile colic have been proposed such as microfloral changes in faecal content, cow’s milk or lactose intolerance, gastrointestinal immaturity or inflammation, increased serotonin secretion, inappropriate breast-feeding techniques, and maternal smoking or nicotine replacement therapy.⁴

Infantile colic is a diagnosis of exclusion; established only after careful history and physical examination have excluded some dangerous causes including morbus hirschprung, incarcerated hernia, testicular torsion, child abuse, gastroesophageal reflux disease, pyloric stenosis, anal fissures, etc. Parental support and reassurance are key components of colic management.⁵ Various studies have analyzed the management of infantile colic with mixed results. These include: (1) probiotic Lactobacillus reuteri (strain DSM 17938), drugs such as simethicone, dicyclomine, and proton pump inhibitors, (3) dietary modification, (4) physical therapy including chiropractic and osteopathic manipulation, massage, and acupuncture, (5) herbal therapy including Mentha piperita (peppermint) and various other herbal teas such as fennel, chamomile, vervain, lemon balm, and licorice, and (6) other modalities including 12% sucrose solution, “Gripe water” which consists of dill seed oil, bicarbonate, and hydrogenated glucose, the use of a vented bottle or swaddling.⁴ This review only discusses the role of nutrition in the management of infantile colic.

This review used Google, Pubmed, Ebscohost, American Academy of Pediatrics Publications and Cochrane databases with infant and colic as the keywords. The inclusion criteria in this review were studies which involved infant as the subject’s research and had been published during 1980 - 2016. The studies included in this review were studies that met the inclusion criteria and focuses only on infants who were breast-fed and infants receiving hydrolyzed protein-based formula, soy protein-based formula, and low-lactose formula.

There were 3 studies on infants with infantile colic who were breast-fed and 6 studies on infants with infantile colic who received formula milk (Tables 1 & 2). Studies on nutritional intervention as the management of infantile colic in breast-fed infants showed various results (Table 1). Jakobsson et al.,⁵ Hill et al.,⁶ and Hill et al.⁷ showed that there were improvements of colic symptoms in breast-fed infants if mother avoided cow’s milk, eggs, peanuts, wheat, soy, and fish in their diet (low-allergen diet). Several studies which used infant formula as nutritional intervention in infants suffering from infantile

colic also gave varying results (Table 2). Studies by Lothe et al.,⁸ Lothe et al.,⁹ Lucassen et al.,¹⁰ and Savino et al.¹¹ that used hydrolyzed casein-based formula (Nutramigen) or hydrolyzed whey-based formula showed improvements of colic symptoms and crying duration. However, the administration of capsules containing whey powder extracted from cow’s milk caused colic symptoms to reappear in 75% of infants who showed improvement of colic symptoms after consumption of hydrolyzed casein-based formula (Nutramigen).⁹ Consumption of soy protein-based formula either resulted in improvement of colic symptoms in 18% of infants with colics⁸ or reduced duration of colic symptoms,¹² whereas Infante et al.¹³ showed in their study improvement in excessive gas production, abnormal feeding pattern, and crying duration in infants with colics who received low lactose-based formula for 15 days.

Dietary modification is one of the most frequently used management strategies of infantile colic. Infants should be exclusively breast-fed for the first six months of life to achieve optimal growth, development, and health. In situations where infants can’t suckle, expressed breast milk (mother own milk) or donor milk that meet safety requirement can be considered.^14,15 If breast milk is not available, infants may be given formula milk which fulfills the Codex Alimentarius regulation with proper preparation of formula milk.¹⁴

The pathogenesis of infantile colic remains partly unknown. Several main factors are considered to cause colic symptoms, such as immaturity of nervous/digestive system, cow’s milk proteins allergy and atopy, altered gut microflora such low Lactobacilli or increased E. coli), and gut hormones such as increased ghrelin and motilin). ¹⁶From Tables 1 & 2, the colic symptoms improved in breast-fed infants whose mothers consumed low-allergen diet (free of cow’s milk, eggs, wheat, and nuts), and infants who received hydrolyzed casein/whey-based formula. This suggests that infantile colic can be triggered by food allergies, such as cow’s milk allergy. The possible relationship between food allergy and infantile colic is based on two evidences, (1) the presence of dysmotility with visceral neuronal hypersensitivity and dysbiosis, and (2) the clinical response to dietary intervention. Although the etiology of infantile colic remains controversial, dysmotility and gut neuronal hyperexcitability have been advocated as pivotal pathogenetic factors. Food allergy induces gut neuronal hyperexcitability which lead to altered perception of physiological stimuli, such as intestinal distention and peristalsis, being perceived as painful events.¹⁷

Hypoallergenic maternal diet may be suggested in breast-fed infants. Meanwhile, partially hydrolyzed whey protein is the first line-approach and extensive hydrolyzed formula based on casein or whey could be useful in children with severe infantile colic or additional atopic symptoms.^16,18,19 The use of hydrolyzed casein or whey-based formula led to the improvement of colic symptoms in infants, but Lothe et al.⁹ found that colic symptoms recurred in 75% of infants who received capsules containing whey protein powders extracted from cow’s milk. This may be due to β-lactoglobulin which is the largest cow’s milk allergen. In fact, β-lactoglobulin is the major component of whey protein in cow’s milk, but it is not found in breast milk.²⁰ In the confusion of using partially or extensive hydrolyzed formula, American Academy of Pediatrics(AAP) statedthat partially hydrolyzed formulas are not hypoallergenic and should not be used for the dietary management of colic due to cow’s milk protein allergy.²¹ Therefore, we suggest that low allergen maternal diet is effective in breast-fed colicky infants and extensive hydrolyzed formula based on casein or whey are effective in formula-fed infants due to the possibility of cow’s milk allergy as the cause of infantile colic. Because some infants may still have colic symptoms after the consumption of whey protein, extensive hydrolyzed casein-based formula is preferably to manage infantile colic in formula-fed infants.

Campbell¹² found that colic symptoms were significantly reduced during the consumption of soy protein-based formula, but only 5 (17%) out of 19 subjects experienced spontaneous improvement. Cow’s milk protein-based formula is the first choice for healthy and term infant who are not exclusively breast-fed,²² whereas soy protein-based formula is indicated for infants with galactosemia, congenital lactase deficiency, or conditions in which parents prefer the vegetarian diet.²³ European Society for Paediatric Gastroenterology Hepatology and Nutrition (EPSGHAN)²² and AAP ²³ suggest that the use of soy protein-based formula is not proven to prevent or manage infantile colic or fussiness in infants. Moreover, soy is an important allergen in infants because approximately 10-14% infants with cow’s milk allergy will also have soy protein allergy.²³ In 2009, the Canadian Paediatric Society also stated that “physician should consider limiting the use of soy-based formulas to those infants with galactosemia or those who cannot consume dairy-based products for cultural or religious reasons.²⁴ The use of low-lactose formula in the study by Infante et al.¹³ caused a significant reduction in the number of infants with excessive gas production, abnormal feeding pattern, and duration of crying, due to the inadequate study design. In contrary, there was no evidence of but those results should be considered carefully effect on excessive crying of lowering the lactose content of the formula milk.^25-27

Various studies have shown that nutritional intervention is one of the managements which can reduce the symptoms of colics in infants. Breast-fed mothers are advised to consume low-allergen diet, such as free of cow’s milk, eggs, wheat and nuts to reduce the symptoms of infantile colic. In the other hand, infants who consume formula milk should be best given extensive hydrolyzed casein-based formula because colic symptoms may still persist after the consumption of whey protein. The use of soy protein-based formula and low-lactose formula does not have a strong evidence to reduce infantile colic symptoms in infants.

None.

Author declares that there is no conflict of interest.

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