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Masters of Pediatrics - Module 3

  • Authors: Authors: Basil J. Zitelli, MD; Barton Schmitt, MD
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Target Audience and Goal Statement

The target audience for this presentation is pediatric physicians.

On completion of this continuing medical education offering, participants will be able to:

  1. Differentiate chronic cough due to pulmonary conditions from that of other organ systems.
  2. Know how to evaluate and manage chronic cough.
  3. Decide when chronic cough is due to nonorganic causes.
  4. Prescribe the appropriate treatment modalities to control colic.
  5. Explore other treatment alternatives in the management of colic.
  6. Identify parents at risk for intolerance of colic.

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    For Physicians

  • The University of Miami School of Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to sponsor continuing medical education for physicians. This activity was planned and produced in accordance with ACCME Essentials.

    The University of Miami School of Medicine designates this continuing medical education activity for a maximum of 1.5 credit hours in Category 1 of the Physician's Recognition Award of the American Medical Association.

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Masters of Pediatrics - Module 3: Colic: Surviving 100 Days of Excessive Crying


Colic: Surviving 100 Days of Excessive Crying , Presented by Barton Schmitt, MD

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Even normal crying is pretty stressful, and if you get a screaming baby, it totally disrupts the family unit. Hardly anything else can happen while a baby is screaming and everybody is panicking and trying to fix it. And if you get a child, a young child with inconsolable crying, you can really drive some parents to the very brink of doing something they later regret. So I want to submit to you at the beginning, and I will come back to it, that this is an urgent symptom. Crying babies. Bad crying is an urgent symptom. We need to treat it that way, evaluate it in a very serious way. See these people. Don't try to manage it by telephone. Do a physical exam and provide close follow-up.

Looks familiar. We don't even like these babies in our offices.

So what do I mean by colic. Colic -- we're going to talk about all kinds of crying -- but colic is the name that's used for the crying we can't figure out a cause for. It's the unexplained crying. It's clearly not crying due to hunger, which is the majority of crying seen in young babies. It's not painful crying. We'll come back to how to recognize the children who are crying in pain. It's intermittent crying and when the children are not crying, they're happy between bouts of crying. And that is so discriminating in contrast to the kids who are in true pain who seem to be never happy. They're usually under four weeks of age when it begins and some of them are recognized by newborn nursery nurses as being a future colicky baby in the very near future. And resolution, spontaneous resolution of this physiological kind of excessive crying is almost always by three months, occasionally four months. And the parents are concerned about it, and I don't have any research criteria on here for colic. There's tons of research on colic, and they pretty much adhere to the criteria of having more than three hours per day of crying. Some of these kids, according to their parents, have fifteen hours a day, and more than three days a week. But I submit to you, all these babies that parents are complaining about and concerned about are crying every day.

What causes colic? It's clearly multifactorial, but the more research that comes back, I think it convinces all of us that it's mainly biological, it's mainly this specific baby. This baby with a very sensitive temperament to changes and external stimuli. The child has an intense kind of reaction with high-pitched crying, louder crying than other babies. A child who has great difficulty self-comforting and self-soothing. Are there environmental factors. Well, sure, you need stimuli to turn this process on, so the louder the environment, the more lights and things going on in the environment, the more rough handling, the more likely this baby is going to really get into a crying jag. Is the mother a factor? I think we've all seen severe crying and colic in families that are very stable, where the mother is well put together, and in many cases, she has had previous babies and not had to deal with this. So, in general, we need to be reassuring parents and especially mothers that they're not the cause, not the primary cause. If a mother's life is going badly, that can certainly intensify the frequency and severity of the crying. Some of these mothers, inexperienced at soothing a baby, and you have to know how to soothe a baby to survive colic. Some of them have been very successful in life, are having babies in the second half of the third decade or later and have some performance anxiety. I should have said fourth decade. And certainly if they become sleep deprived themselves, they aren't themselves and aren't going to do a good job and aren't going to be able to comfort their baby when they're feeling their own life falling apart.

Some would say that colic resolves when a child reaches an age where they can entertain themselves, and the case you can make for that is that around three months, children can start playing with objects, transferring objects, and can do some self-entertainment.

So, what are the main myths about colic. I think the biggest one is that colic is caused by gas, and there are studies, even back in the '60s, dispelling that myth. Namely, the myth is that there is a bad bubble and air gets stuck. Where did that come from? That came from veterinary medicine, in animal species that are unable to vomit and can't get their bowels locked, like horses. But that doesn't apply to kids. They have an open GI system. They can pass a lot of gas, north or south, without any problem, and the business that these kids are so gassy, of course, relates to crying and gulping air, and this is an interesting study done in the '60s again. This is a baby who, in this doctor's office had a flat plate of the abdomen done before they got wound up and cried, has this normal kind of gas bubble. They cried for an hour and a half in the office, finally went to sleep and they have acute gastric distention from all the air they pumped in there.

Consequential, not causal. Why do people get misdirected and into this idea that it's an abdominal problem and abdominal pain? I think it's because when kids cry, they increase their muscle tone everywhere, and the position of discomfort is increased flexor tone, not increased extensor tone. Just like the position of comfort in utero. And kids, when they cry, no matter what the cause, they sort of double up. Some would say it's due to intestinal spasms or such, but again these kids in general don't have diarrhea. That would lead us down another diagnostic pathway. There is no evidence that they have true constipation, and yet some of these kids, because that is diagnosed by the parents, are given suppositories and some laxatives. We should be aware of that because maybe you saw a report last year on a young baby about four weeks of age who was brought in semi-comatose with hypermagnesium -- magnesium toxicity from Milk of Magnesia because the parents had self-diagnosed constipation in a colicky baby. Iron in the formula has been disproven in at least three studies -- at least prophylactic iron does not cause symptoms of diarrhea or constipation or abdominal pain, unlike therapeutic iron. And the lactose intolerance idea that these children would have difficulty in contrast to non-colicky babies in digesting lactose did not stand up to good research by Ronald Barr back in the '80s. In fact, all babies in the first month or so of life have some diminished lactose digestion.

So, I would like to switch to the medical evaluation of the crying baby, starting with just that symptom alone, excessive crying, crying of concern. What's our job? What's our responsibility? It's clearly -- because nobody else is going to do that -- clearly it's ruling out organic causes for excessive crying.

And in the history, we want to be sure that this child isn't crying excessively because they're not gaining weight well and they are receiving inadequate calories. I think most of us would agree that in a breastfed baby, especially in a preemie, that until we have the weights back, this is the cause of the crying until proven otherwise. There is a 10% or so rate of inadequate weight gain in breastfed babies. There could be a reaction to some medications, something the mother is taking. There are some breastfeeding mothers who avoid caffeine in their mind, but a lot of iced tea, especially in the Southeast, maybe in Florida, and are drinking eight or 10 glasses of iced tea per day. There are babies who are at risk for physical abuse, and certainly we know that can be one of the very severe outcomes of interminable crying, if that child is left with somebody with poor impulse control, that baby may be shaken, and we certainly want to look at those children, examine these children for fingerprint bruises, range of motion, some of the corner fractures that we can pick up and localize, tenderness, etc. Broken ribs that you can find when you try to compress the chest in this young crying baby and the crying intensifies. And that has to be on our mind.

Of the many, many babies who are crying, which ones should we look at closely and say this is painful crying? This baby has a cause of pain and we just have to be smart enough to figure out what it is and if we're not, we need to refer the baby. I submit to you, it's the clues to the painful crying are the ones who have recent onset. The child who, in the second month of life or the third month of life, has a new onset of crying. That is not ever going to be colic. The ones who have continuous crying is the best clue, and that can even be the case in the first months of life -- that we tumble onto the leading diagnosis that way. That they're crying almost non-stop every day, in the parent's mind, at least. And in our office. If they're not crying in our office, I think they're not going to end up in this category of painful crying. If they have nonstop crying, it goes on two hours or longer and many times a day, and there are studies looking at the voice printouts and the types of cries, the higher pitch cries, etc., that identify painful crying.

In your syllabus, there is a list of probably 30 or 40 etiologies for painful crying from something I wrote a good many years ago. I want to talk about two in particular that I find most commonly, probably in 20% of the children I see, -- but I see a very skewed group. I would submit to you, though, that 10% of your kids with colic, of the 15%, so 1 or 2% of kids that you see overall have one of these two causes and that's reflux esophagitis or cow's milk protein hypersensitivity, usually colitis. Not always.

It can be a cow's milk allergy gastritis. What would lead us to suspect cow's milk allergy? First of all, I want to submit to you this isn't the dominant cause of colic. Look at the frequency difference. Cow's milk protein allergies are 1 or 2% of children. Fifteen percent of children have colic or more. The duration is different, but again I told you that if you've got a kid at four months you're carrying in your practice with a diagnosis of colic and it's not resolved, you have to go back and reconsider this diagnosis or the other one. But a general cow's milk protein allergy lasts 12 months. In fact, a third of them go on to two years and 10% go beyond that time. The frequency is different. In general, with cow's milk protein reactions, they scream bloody murder during every feeding, or at the latest, at the end of every feeding. And it goes on for a half hour or an hour and then it resolves, and then it recurs with the next cow's milk protein exposure. In general, these children have the other symptoms we all look for. Everybody in the room has seen children with the allergic colitis, with at least very, very mucusy stools and often bloody stools with an onset at two or three or four weeks of age. But some of these kids don't have that as a marker and some of them have vomiting as their predominant symptom in association with their screaming and crying. Rare, though. Some of them have difficult-to-control eczema, but some of them just have the crying. What's helpful is getting the family history of a cow's milk sensitivity. But diagnosis rests in putting these children on elemental formula, and there is a remarkable decrease in the amount of crying. They can go from eight hours a day -- I've had parents say there is no crying anymore. It's totally gone. And this response is within two or three days. So it's very striking when it happens. There are a few studies showing that soy formula can't, in general, doesn't bring about this change. If you really want to do the diagnostic test, you will want to use an elemental formula. Something that people in academic medicine, of course, dismissed for a long, long time. But there's a great deal of research in the last two years, including the gastroenterology -- pediatric gastroenterology journals support this.

The other subject I would like to bring to your attention is reflux esophagitis. Parents often tell us that these children cry 50% of waking hours. They wake up crying. They rarely if ever are happy. They are very sour kids in our office. They're grumpy. The father is often pacing, holding them in sort of either a football hold or a vertical hold. Usually, they're spitting up constantly. A clue is if they cry less in a vertical position, some of them -- it's a very interesting diagnosis -- have silent reflux, but enough reflux to get it half-way up the esophagus, but it's not visible reflux, but everything else fits the pattern except they are a non-spitter.

That is a really interesting child to nail down diagnostically and to treat. Because again, with the treatment, Zantac 2 mg per kg per dose every 12 hours, usually for about a month unless you've got a relapse, and then you put them on for another two months for a total of about three months. Other anti-reflux measures we can come back to which are almost as important as the Zantac, but again striking response.

Again, I am in a type of a setting where I get end-stage sort of conditions, and every year I have three or four kids who have both of these diagnoses and normal colic. They have three diagnoses. So after we treat their reflux, which in many cases has resulted because they've been overfed as one of the measures to treat their colic, remove the reflux, get them on an elemental formula, counteract the cow's milk protein sensitivity, they're still left with physiological excessive crying and need all of the management that I'm going to talk about now, to really bring them under control.

So, we're going to talk about managing true colic. Let's assume we've done the evaluation, we are convinced the child has non-organic crying.

Bad babies don't come with directions, especially. These babies -- what are these babies trying to do? They're crying because they can't talk, and the parents job is to learn how to interpret why they are crying. And in your syllabus you will find a crying diary, and its really helpful when you're not sure what the main triggers are, to have a parent keep that and help them discover what quieted your baby. What was the last thing you did when they stopped crying. Every time they cry each day, see if there is a pattern. If they're uncomfortable, pinched nerve, tight clothing, change their position, loosen their clothing. Some kids cry if they're hot or too cold. They ought to have about the same number of layers we do for the environmental temperature. Some kids are very sensitive. Its amazing how sensitive colicky babies can be to external stimuli, including crying every time they urinate or defecate or both. Many are sensory overloaded, and in general, we want to help parents decrease sensory stimulation. Because its often excessive in colicky babies who aren't in good control in their homes. Some are lonely for human contact, mainly for human touch. We'll come back to that. Best common pathway for helping a colicky baby is with holding. Some want to suck and need a pacifier. They're not hungry, but they have equal number of minutes per day of non-nutritive sucking they need to meet. To spend more than two hours, and you might say for an hour and a half for breast fed, that means its time to feed them. If its been more than three hours and they haven't been asleep, they need to sleep. Taubman in several studies, Bruce Taubman, by rotating his responses to the crying every five minutes for a max, I believe it was about 15 or 20 minutes, reduced crying in three days by 70%. We'll come back to that.

This is a baby sling. Holding babies is the final best way to intervene for a screaming, crying baby who doesn't have a disease. The big question, I think for many parents, should be for many parents, is how to hold them. And there's a lot of mistaken intervention in this department, and I hope all of you have parents who, when you bring up the idea of holding and rocking the baby, and they say they tried that It doesn't help at all, that you have them demonstrate the manner in which they hold the baby. And you will see elevator rides, as I call them. You will see rock and roll. You will see bouncing the baby in different positions. You will see somebody hold their baby upside down, if you ask enough times. And the thought that keeps going through my mind when I see these things is what would I do if this was happening to me. My adrenergic nervous system would just be going full blast, and I think some of the parents believe this helps, temporarily. Nobody says it works or they wouldn't be in our office, but it helps temporarily because the kids in a state of shellshock or he's extremely distracted by this. Keep in mind that in several studies now we know that 80% of children who are in the midst of a crying episode, that episode ends with going to sleep. So I just work on a premise that almost all babies who are screaming and crying and wound up like this, somebody needs to help them go to sleep i.e., whoever is with the child. So we should try to help the parent come up with interventions that are soothing, calming, so this baby can get into that state of mind and go to sleep. So look at it that way instead of trying to find a quick fix. A warm bath with the parent is not a bad idea, if you keep in mind that they've spent the last nine months in a constant temperature water bath, namely amniotic fluid. I had a parent a few years ago say this. I thought it was a great example of a parent being sort of not aware of what was really going on around them. - He won't stop crying unless I hold him - which allowed me to say - well, that's colic. If holding works, its colic, its not a disease. And then the parent went on to say something like they didn't have time to hold the baby this much. Well, it is a lot of crying and it is a lot of time and a lot of holding time and most parents have that time. What comes in handy are some of the slings and front packs for these babies This parent was asking for a gizmo, and I think you will find that the upright swings, they may prevent reflux esophagitis But that these can be soothing, and there are some newer ones -- not that new, but the ones that are out there now are very, very quiet, unlike the older wind-up swings. So keep that in mind when push comes to shove and they need a gadget. How long to hold, some parents ask, because they'll say "I've held him, and I've held him exactly the way you told me to, and I've done it for hours and it doesn't stop crying." If you keep in mind this baby is trying to go to sleep, I would say if you're holding the baby for twenty minutes or thirty minutes max and they're not asleep, put them in their crib and let them fuss themselves to sleep. And you'll be amazed when you get parents to stop breastfeeding or holding or different things and just put the baby down and accept the fact that the baby on their back is going to fuss and cry, twenty seconds later, they're asleep. Just like magic. And if the crying continues another fifteen minutes, its time to pick them up again and go through some of these things. But if there was one way to soothe a baby, it really is prone. And I know back is best, but prone is best in terms of sleep onset. Shorter sleep onset, deeper sleep prone than supine, longer sleep without awakenings, so to get the baby to sleep, do it prone. Put the baby on a cushion, on your thighs, prone, hand on the baby, some touch, maybe some massage of the feet or legs or head and very little movement. I submit to you that babies fall asleep, at least in my office, better, at least in my office, with no movement, just being held in a horizontal prone position. When asleep, you put them in their crib on their back, or when calm. Better yet, put them in there when they calm down.

Let's assume we've answered the parents' main question, which is "what do I do when he's screaming and crying." And we come back to the Q&A, if you like. Its time to look after the parents, and reassurance goes a long way. Without educating people, either live or with an educational handout, many parents continue in their sort of panic mode and unable to be calm enough to calm the baby. So, we need to tell them all babies cry. That some crying is normal crying, physiological crying. Babies are different. Yours has a sensitive temperament. You didn't cause this. Its not caused by pain, because if we say its caused by pain or disease and its not, this parent is going to want a medication. There are some medications who used to prescribe Demerol for these children. It worked, but it was also walking the edge in terms of toxic therapeutic ratio. Babies need to be held and carried, and the promise we need to make to parents is that if they come up with the right soothing behavior, comforting behavior, they can in a matter of two days reduce the amount of crying to one hour to 1 1/2 hours per day. You can make that promise, and that's held up by Taubman's research. There is an end point, colic resolves by three months, and we need to promise we will stay involved, and these are the kind of parents who need a phone call from somebody in your office, every day, for two or three days, until they get a technique that works, and they need to be seen weekly until they've mastered it.

And that's not enough, because what happens in these cases, if we don't go out of our way to help the mother, the mother becomes deprived, exhausted, and unable to pull her own life together, and, therefore, unable to help her baby since we haven't helped her. So we need to urge some of these moms, especially the super moms who come out of a very, very successful high-powered career and want to prove they can do this on their own, we need to convince them that they need help, that this is a two-person job. And if they have another child who is two or three, we tell them to take a nap every day. We're telling them something that's nearly impossible to do, so we need to be sure somebody else comes in, helps them out, spells them. We need to be sure at naptime that they have a sign on the door so nobody rings the doorbell. Mom is sleeping. New baby. That the phone is taken off the hook. We need to urge them to get time away from the baby. Need to consider a home visit by a public health nurse if you're dealing with somebody who needs that sort of help. And follow closely again until improved. There are some nonefficacious interventions, maybe not Bentyl was efficacious, but it also caused apnea and coma and some deaths. It's been taken out of the PDR since about 1984, I think, as it can't be used for this. Barbiturates, atropine, alcohol, first of all they have risk, but in the article by O'Donovan around 1980, it was not effective. There are three huge studies looking at simethicone, scores based on the bad bubble myth. That's why it doesn't work. Controlled studies, no efficacy. Changing formulas, if they're not allergic to cow's milk protein. Changing formulas just waste a lot of time since we do have an intervention that works. Extra burping is not the answer. Special bottles, special nipples, not the answer. It's not air. It's not gas. And there are some harmful techniques including sheepskin pads, waterbeds, things like that. I've already talked about Milk of Magnesia, laxatives being harmful. So in summary, if we don't have a child with cow's milk protein allergy, we don't want to get sidetracked into formulas. They've been studied. They're not the answer. Medications have been studied. They're not the answer. We need to encourage parents to hold babies. We need to help them come up with ways to calm babies and soothe babies. Less rocking. Rocking doesn't have to be part of the intervention. Respond quickly before the baby becomes wound tightly up. Encourage the mother to share her colic duty with spouse, relatives, and friends. And set a realistic goal of reducing screaming and crying down to about an hour, but not eliminating normal colicky behavior. Thank you very much.

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