Colic and Crying Babies

What evidence is there for conventional or complementary colic treatments?

Crying Baby in Brown and Black Hooded Top

A quick skim over most baby advice forums often throws up the same kinds of queries. “My baby is so unsettled – do they have colic?” In response, we often see helpful parents talking about remedies and medicines, which are often easily available over the counter, and discussing what did or didn’t work for them.

Most babies will have periods of crying. Often these ‘witching hours’ coincide with the early evening. This kind of crying tends to peak at around 6-8 weeks and then starts to subside.

Kellymom talks about fussy evenings here: fussy evenings

So what is “colic”?

NHS defines colic as, “Excessive, frequent crying in a baby who appears to be otherwise healthy.” The criteria for colic is often given as more than 3 hours a day, for more than 3 days a week, for more than 3 weeks.

And that is basically it. Colic is simply a ‘medical’ term for a baby who cries a lot, and sadly colic is one of those mysteries of nature; we still don’t actually know what causes it.

Commonly suggested treatments for colic

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Not quite the shelves of Boots the Chemist these days, but when looking for something to help with baby’s colic it can feel like there are a lot of different options people try to sell you! Crying babies are big business. So let’s look at what the evidence says around commonly suggested remedies to treat colic.

Infacol (simethicone) & Dentinox Drops (Dimethicone):

The active ingredient in Infacol is simethicone. It claims to work by helping the little-trapped gas bubbles join into bigger bubbles which your baby can more easily bring up as wind.

What evidence is there that Infacol is effective? Basically – not much!

“But my Doctor/Health Visitor/Midwife recommended I try Infacol?” I often hear parents ask. “Why do they say this if it doesn’t work?”

Well, for the answer to this question, up until 2017 the NICE guidance suggested a one week trial of the orangey stuff. Crucially though, it was not because it worked: “Although studies of simethicone have not provided evidence of benefit in infantile colic … a 1-week trial as a placebo may still be worth a try because … the simple act of being able to give their baby something may help parents cope better with the crying.” (NICE guidance prior to 2017).

It was prescribed or recommended because was suspected to have a placebo effect on the parent.

Since 2017 there has been new guidance in place which says:

“Do not recommend the following management strategies, as there is insufficient good-quality evidence for their use: Simeticone (such as Infacol®) or lactase (such as Colief®) drops.”

There have also been no longer-term studies of the impact of introducing remedies like Infacol into the infantile gut.

Dentinox drops contain an activated version of simethicone called dimethicone. Again, much like Infacol, there is no good evidence that these actually work.

If your health visitor or GP do recommend Infacol or Dentinox to you it may simply be they haven’t yet come across the relatively new guidelines.

Colief (Lactase Drops):

The BfN statement on assessing the evidence for colic treatments shows lactase enzymes like Colief were shown to be largely ineffective.

One small study claimed to show that lactase drops, if mixed with the milk and left for 24 hours before feeding, reduced colic in one randomised trial, but other studies have not shown this. Meanwhile, the positive study was criticised for being small and biased, because it was not independent of industry.

Again, the revised 2017 NICE guidelines have stated that lactase drops should no longer be recommended or perscribed.

Gripe water:

Gripe water is an old-fashioned remedy which has changed substantially in formulation since it was invented. The original ‘Woodward’s Gripe Water’ contained 3.6% alcohol and sugar water! These days the sugar and the alcohol have been removed for obvious reasons, but it is worth thinking about why that original formula may have been effective and therefore why this ‘treatment’ has been passed down through the generations.

A 2000 review found that most of the ingredients in modern gripe water are of little value in relieving discomfort. It is worth bearing in mind that the WHO says receiving any liquid other the breastmilk in the early months can have a detrimental impact on establishing breastfeeding as it can replace breastmilk intake.

Homeopathy or herbal treatments – colic granules e.g. Nelson’s granules, Colocynth Crystals, Fennel Tea, Star Anise:

There is only low-quality evidence to suggest homeopathic and herbal remedies are an effective treatment for colic.  It is also important to consider the possible impact of such treatments on your breastfeeding relationship and on your baby’s developing gut biome. As with gripe water, concerns have been raised about the possibility of these liquids reducing baby’s intake of breast-milk.

Some herbal treatments such as star anise are not recommended, because some studies have indicated they can be harmful to the baby.

Dairy-free diets

At any given time, on any breastfeeding forum, you will see recommendations for parents to cut out dairy (and sometimes soy) from their diet to resolve colic.

There is some limited evidence to suggest a dairy-free or low-allergen diet can help reduce the symptoms of colic, and this is certainly true if your little one has a cows milk protein allergy.

However, it is important to remember that the current evidence for rates of cows’ milk protein allergy in exclusively breastfed babies suggests it affects only a tiny percentage. If you are concerned about this your clinician should take an allergy-focused clinical history- it is a more likely scenario if you or baby’s other parent have any atopic conditions such as eczema, asthma or other allergies.

I cannot stress enough how it’s important not to jump to conclusions and start cutting out food groups without guidance from a dietician and without ruling out other causes of baby’s distress first. Going to see a breastfeeding counsellor might be a good first step.

Probiotics 

An emerging area in the treatment of infant colic is the use of probiotics, particularly ones containing the strain L reuteri.

Over recent years there have been several studies with conflicting outcomes, and a recent meta-analysis concluded that they may help with colic. However, more recent studies have suggested probiotics need to be personally tailored to the individual to be effective. Concerns have also been raised about adding bacterial strains into a baby’s developing gut without having a clear understanding of what the baby’s gut bacteria may or may not be missing. We just do not have any research into the long-term safety of using probiotics in young babies. The good news is if you breastfeed your breastmilk contains the absolute best probiotics for your baby.

We are expanding our knowledge all the time in this area, so it is always worth keeping up to date with the research as things can change quickly! I wrote this blog originally in 2016, and I have updated this section three times now.

Cranial Osteopathy

Research looking at the effects of cranial osteopathy on infants is mixed, with some trials showing a benefit and others showing no benefit when compared with ‘sham’ manipulation.

While some parents will say they found osteopathic treatment useful, unfortunately, the evidence around these therapies is fairly inconclusive and it isn’t available on the NHS. On the positive side, cranial osteopathy is a gentle and non-invasive intervention, it doesn’t involve introducing new things into a baby’s delicate gut, and many parents report their babies to enjoy it.

Baby Massage

Baby massage is another common suggestion for help with colic and if I was recommending any intervention to help with colic, this would be it. In terms of its use as a colic treatment, more research needs to be done as the results have been a mixed bag, however, what has been shown is that baby massage is a great way to promote parent-child bonding. This means, even if it doesn’t help the colic, it will help you to cope with it better. Signing up for a baby massage course has the added advantage of getting you out of the house and talking to other sympathetic parents and making friends. All very positive things for your own mental health. It is also a gentle and non-invasive way to soothe a baby, with the added bonus that it gets all that oxytocin flowing!

Block Feeding

One thing most breastfeeding supporters wish they could stop people recommending willy-nilly is the suggestion that “oversupply” is the cause of a baby’s colic, wind or reflux.

Block feeding – where a mother offers baby the same breast for a set number of hours – is an effective technique used to reduce supply in mothers who have an over-abundance of milk. Where oversupply has been identified by a breastfeeding professional, this may help with an unsettled baby.

However, the problem is that the symptoms of oversupply are remarkably similar to the symptoms of shallow attachment. If the baby isn’t attached to the breast deeply enough, they may struggle to handle the flow and splutter, cough, gag and take in lots of air.

Parents who block feed in this situation may start out with a perfect milk supply for their baby’s needs but end up with a low milk supply, simply because the breasts are not being stimulated enough. If you are concerned about oversupply, your best course of action is to seek out an experienced breastfeeding professional to observe a feed and take things from there.

So what works?

In conclusion, the word on the street from Cochrane is, “At the present time, evidence of the effectiveness of pain-relieving agents for the treatment of infantile colic is sparse and prone to bias. The few available studies included small sample sizes, and most had serious limitations. Benefits, when reported, were inconsistent.”

So, if you think your baby has colic what can you do?

1. Look at breastfeeding management, attachment, and positioning

There is some evidence to suggest that making sure a baby is well positioned during breastfeeding may lead to a reduction in colic-type symptoms. There is also evidence for allowing the baby to finish feeding on the first breast before offering them the second breast. So there’s no need to time feeds per breast, and it’s best not to remove the baby from the breast before they decide they are done themselves.

Sometimes a little chat and some work on attachment and positioning with a peer supporter or breastfeeding counsellor can really help.

2. Find experienced breastfeeding support from a breastfeeding counsellor or IBCLC

If simple adjustments do not help, this is when skilled help to assess your baby feeding can be really useful. A breastfeeding counsellor or IBCLC who is skilled enough to look at baby’s suck/swallow/breathe technique, and who can do an examination of baby’s mouth, will be able to talk to you in detail and may be able to pinpoint some things for you to try.

3. The Comfort Cycle

This is my list for dealing with cranky babies in helpful meme form!

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Even if none of these things work, the action of just doing something can help make you feel better about the situation.

4. Talk to somebody

When you have a baby who is unsettled and cries a lot, it can be incredibly hard. It can really shake your confidence in your ability as a parent and affect how you view your breastfeeding relationship.

Talking to somebody about the situation can go a long way towards helping you feel better about the situation, even if the colic doesn’t improve instantly.

So if your baby has colic, and if you just take one thing away from this blog, remember this too will pass. Remember, you are doing a GREAT JOB. Time is the number one treatment for infant colic, and it is nearly always a cure.

If you are struggling with a crying baby and really need to talk to somebody urgently, the breastfeeding helplines will be happy to talk to you.

This blog is not intended to replace the advice of a medical professional, simply to give information for further discussion. Please make sure if you are concerned about your baby to discuss this with a medical professional or a health visitor.

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*This blog has been substantially updated from an article I wrote for Breastfeeding Support and Information UK‘s blog “Through the Eyes of a Breastfeeding Support Group” if you like you can still read the original here *

Breastfeeding with CMPA

Identifying CMPA and how to cope if your baby is diagnosed with it

Cows Milk Protein Allergy is a hot topic. Hop onto any online breastfeeding support group, on any given day, and you will find someone asking about whether their baby could have a dairy allergy, or being told their baby might have a dairy allergy. When it comes to colic, reflux, general grumpiness, or a bit of green poo, it seems to be one of the go-to suggestions.

So this is my personal story, and some information about CMPA, covering diagnosis, how to live with it, what it is, and what it isn’t.

What is CMPA?

CMPA stands for “cow’s milk protein allergy” and it is the most common infant allergy in the world. If you look at what the guidance, and some of the research, says it is less common than seems.

Some research suggests:

  • Formula feeding increases the risk of CMPA.
  • 2-7% of formula infants and 0.5% of exclusively breastfed babies are thought to suffer from the condition.

Many people feel these numbers are conservative and research is ongoing. However, I include these figures here to make an important point- often what is going on is a lot more basic, and resolving the issue won’t involve you making huge changes to your diet.  If you are concerned that your breastfed baby may have CMPA, as well as speaking to a healthcare professional, it’s probably a good idea to have a chat with an IBCLC or breastfeeding specialist. This would be in order to rule out other, more common breastfeeding issues, for example, tongue tie, or a shallow attachment.

There are two kinds of allergy response to consider:

  • ‘IGE allergy’ is what people commonly identify as an allergy- in its most severe form it includes anaphylactic shock. Symptoms of IgE allergies include hives, wheezing, swelling, and projectile vomiting.
  • ‘Non-IgE allergy’ used to be called ‘intolerance’ or ‘CMPI’. Non-IgE allergies are delayed response allergies, meaning they can occur up to 72 hours after exposure. Symptoms of Non-IGE allergies include reflux (GORD), eczema and ear infections.

It’s possible for a child to have a combination of IGE and Non-IGE symptoms.

The Breastfeeding Network has a great fact sheet on CMPA here which talks about the symptoms.

CMPA symptoms

BfN CMPA symptoms list

Is CMPA the same as Lactose Intolerance?

I want to shout this from the rooftops. CMPA is NOT lactose intolerance! (more here).

Lactose intolerance is fairly common in adults. It is caused by the body not producing enough lactase to digest sugars in milk. Lactase production declines as we get older, and in some adults, it declines to a level where it is a problem.

Babies and infants normally produce plenty of lactase, which would make sense since their diet is entirely milk. Lactose intolerance from birth is a different condition. It is a very rare enzyme disorder, not an allergy. Lactose-free products are not suitable for anyone dealing with a cows milk protein allergy.

Diagnosing CMPA

My daughter has both CMPA and a soy protein allergy, which was diagnosed late on. Unfortunately, no-one involved in our care took an allergy-focused clinical history which might have speeded up the diagnosis. A’s Dad suffers from a few allergies. We have extensive food allergies on my mother’s side of the family. My daughter suffered from silent reflux, mild- but difficult to treat- eczema, and recurring ear infections. She was congested a lot of the time, so she snored loudly, slept with her mouth open, and had a persistently shallow latch (due to a blocked nose). It was an IBCLC who suggested CMPA to us after I visited her. She was 12 months old. I was slightly desperate at the time due to the fact she also woke up around once an hour (or more) so I was up for trying anything that might help. My husband and I were also concerned we were still medicating her for reflux, and as her eczema only seemed to be getting worse, we decided it was worth investigating it further. I went to talk to my GP.

To confirm whether or not A had CMPA I followed the NICE guidelines which meant removing all milk products from my diet for at least 4 weeks. An elimination diet like this is considered the best way to confirm allergies in infants. The reason for this is that tests to confirm allergies in babies are unreliable, and they will not identify Non-IgE allergies.

I also avoided soya milk, yoghurt, and cheese as replacements for cows milk products. I had learned a large percentage (somewhere between 20 and 60%) of babies with CMPA will also have a soy allergy and I was keen to not confuse things with the elimination trial. This was my personal choice, it certainly isn’t a blanket recommendation, but it is something to bear in mind and discuss further with your health care team.

I carried on breastfeeding while I followed the elimination diet, it’s rare for a mum to have to stop breastfeeding if CMPA is suspected.

We saw an improvement in A’s symptoms within a few weeks. After six weeks I “challenged” to be sure we had an issue with CMPA- this involved simply having a glass of milk and watching for 72 hours to see if her symptoms returned, which they did.

In cases of children with severe allergies, this process must be managed under medical guidance My daughter didn’t have a severe allergy so we could do this at home without supervision- do check with a health care professional if you are unsure.

Once you have confirmed CMPA it is important to have some input from a dietitian (especially if the baby is on solids). It is also really important to consider how you will replace essential nutrients which may be lost from your diet if you eliminate milk longer term. More on this here.

“What do you mean there’s milk in the pickled onions?”- Living with CMPA

I quickly had to get to grips with checking labels! I’ve found milk in wine, crisps, chorizo, bread and yes- pickled onions! I quickly learned you cannot assume something will be okay.

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This wine reduced me to tears one Friday. Proof– wine can contain milk! So check the labels on everything!

In the UK we have strict labelling requirements and common allergens need to be highlighted on the label in bold, which makes things easier for sleep-deprived parents!

Sticking to chain restaurants when eating out made our lives easier. Big chains tend to take allergies seriously, and often have a special folder or menu for people with allergies. All places which serve food have to be able to tell you (at least verbally) what allergens their food contains. Zizzi, Pizza Express and Pizza Hut all now offer vegan cheese and have dairy free pizza bases. Who would have thought you can still go out for pizza and be dairy free?

Make your server aware you have a milk allergy so they can take care not to cross contaminate food as they prepare it. It is always worth asking “what’s in that?” rather than just “what is dairy free?” You don’t know what the person serving you understands as dairy. Many people assume eggs are dairy so they may be excluding things from the menu unnecessarily or worse, may assume something isn’t dairy when it is.

I also always make sure I take ‘safe’ snacks with me or a packed lunch for Amy just in case if we are going out now she eats solid foods and a small pot of alternative milk for me.

The thing about cheese and chocolate

Good news- there is amazing dairy free chocolate! Most dark chocolate is dairy-free and many are soy free too. There are also specialised “free from” chocolates like “Moo Free” and “Booja Booja” (who do the most amazing ice cream too)!

I’ve personally found vegan cheese can have a bit of an aftertaste, as well as a strong smell! If you are going directly from eating proper cheese to ‘chease’ it can be a shock! I found after giving up on cheese for a while I was happier with the vegan stuff. The major supermarkets all seem to have a wide variety of dairy and soy free cheeses which makes life a lot easier. Currently, the ASDA cheeses are my favourites, they have a mozzarella alternative (which is also available at their pizza counters!) and a cheddar which are pretty good.

The bad news? I, unfortunately, didn’t lose weight on a dairy-free diet after I discovered loads of biscuits were dairy free…

Cookies on Bowl

May Contains- to eat or not to eat?

One thing which can be confusing when you first go allergen free is the labelling on products like “may contain milk” or “not suitable for milk allergy”.

What may be useful to know is that a ‘may contain’ label isn’t a legal requirement. Any food you buy which is pre-prepared, in a café, or restaurant is a ‘may contain’ even if it doesn’t say this. If you still prepare dairy foods in your own kitchen, this means everything you make is a ‘may contain’! Avoiding ‘may contains’ can make eliminating dairy or other allergens difficult. The risk of reaction from these products is often pretty small, so parents tend to make a risk/benefit based decision, if they have children who do not have life-threatening or very severe reactions some parents will decide not to avoid ‘may contains’.

Adjusting to your new normal

It can feel overwhelming when you first go dairy free. That’s okay. It’s not selfish to feel fed up about not being able to have cheese or to feel upset because OAT MILK IN YOUR TEA IS NOT THE SAME. I get that. It does get an awful lot easier as time passes.

It helps to seek out ongoing support, either in real life or online. There are some fantastic support groups on Facebook where you can get recipe ideas, tip-offs on CMPA friendly treats and generally have a rant if you need to.

It probably took about 6 weeks to come to terms with my new diet, and it was all worth it in the end. The end result was a much happier tot! I’m so grateful I was able to breastfeed her. My milk means I have never worried about my daughter’s nutrition or tricky prescription formulas and for me, that all makes it worth giving up cheese.

This blog is not intended to replace the advice of a medical professional, simply to give information for further discussion. Please make sure before making significant changes to your diet or your child’s diet to discuss this with a medical professional or a health visitor first.

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More information on CMPA (updated 22-10-19)

Finding impartial information on CMPA can be difficult. Unfortunately, this is one area where industry (namely infant formula companies) are very heavily involved. The conflict of interest is clear so I won’t go into too much detail here other than to say the below resources will provide reliable, independent information, fairly free from industry bias.

Further information from:

GPIFN (GP Infant Feeding Network)

Breastfeeding Network

NICE guideline for the diagnosis and management of CMPA

iMAP guideline for the diagnosis and management of CMPA

Useful Facebook groups and pages for support and food swaps/ideas!

https://www.facebook.com/groups/breastfeedingwithallergiesUK/

https://www.facebook.com/Dilanandme/

https://www.facebook.com/groups/CMPASr/permalink/2755097447868350/

“We don’t need to promote breastfeeding in western societies we need to enable it”- Maureen Minchin