Infantile colic is a major gastrointestinal disorder that affects infants during the initial stages of their lives. Fussing and crying are normal aspects of development during the first months of a baby’s life. However, long periods of inconsolable crying and patent distress can be extremely upsetting and worrisome to parents, especially because these behaviours don’t appear to be linked to a specific cause (Barr et al, 2001).
Infants and children frequently suffer from difficulties in defecation, which are associated with infrequent bowel movements, hard stools, and painful defecation. In the vast majority of cases, such symptoms of constipation are functional and not of organic origin. They can be treated successfully with pharmacological agents, or also with more gentle and natural non-pharmacological measures.
A common gastrointestinal problem for many babies and toddlers is experiencing loose or liquid stool and an increased frequency of evacuation. These symptoms of diarrhoea – which may also occur together with vomiting – could come from a variety of sources. Nutrition should be adapted accordingly in order to avoid severe consequences.
Although reflux and regurgitation are often used as synonyms, they are not the same. While reflux only refers to a movement of stomach content into the oesophagus, regurgitation describes the spitting up of such contents. In infants, both reflux and regurgitation are common processes and are not necessarily a reason to worry.
Food allergies and food intolerances can be distinguished by their causes: While food allergy is induced by an immunological overreaction against protein, food intolerances are caused by a (potentially non-immunological) reaction against other food components. Cow’s milk proteins allergy, as well as lactose intolerance, are common examples. Frequently, food allergies and intolerances entail gastrointestinal symptoms such as colic and constipation, diarrhoea and vomiting, and reflux and regurgitation.
The term colic is usually used to describe an infant with excessive crying, irritability or fussiness, and is usually associated with unexplained and acute abdominal pain (Zeevenhooven et al, 2017).
The most commonly accepted definition of colic was the “rule of three”, thought to originate in 1954 (Wessel’s criteria). According to this rule, crying more than three hours per day, for more than three days per week, and for more than three weeks (for an infant who is otherwise well-fed and healthy) is considered colic (Roberts et al, 2004). Throughout the years new insights have been gained on infantile colic and also other functional gastrointestinal disorders. Consequently, diagnostic criteria became very broad and were largely based on compiled experience as opposed to empirical data. This led to the generation of more refined criteria for research purposes specific to neonates and toddlers, as well as children and adolescents. These have been published by Benninga and Hyams in 2016 (Benninga et al 2016; Hyams et al, 2016) and can be accessed through the Rome Foundation.
Infantile colic affects up to 25% of infants under 3 months of age (Nocerino et al, 2015). The pathophysiology of infantile colic is not fully understood and is assumed to be of multifactorial genesis. It has been postulated that infantile colic is caused by various factors, which include: i) disturbance or immaturity in the central nervous system or digestive system; ii) psychosocial causes; iii) gastrointestinal related causes (e.g. cow’s milk allergy); iv) altered gut microflora (e.g. increased E.Coli); and v) altered gut hormones (e.g. increased ghrelin and motilin) (Zeevenhooven et al, 2017; Savino et al, 2014).
One of the most important goals of the treatment of infantile colic is to help caregivers cope with the infant’s symptoms (which sometimes lead to frustration and insecurity), and to strengthen the infant-family relationship (Vik et al, 2009). It is essential for healthcare professionals to recognise this and offer the family continuous support. Some treatment options are available to help manage infantile colic, such as: i) specific dietary advice; ii) pharmacological treatments to reduce gas production or to balance intestinal flora (e.g. pharmacological agents or probiotics); and iii) complementary and alternative therapies (e.g. herbal based extracts, and manipulative or behavioural therapies) (Savino et al, 2014).
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Constipation is usually described as a delay or difficulty in defecation, which is present for 2 or more weeks and sufficient to cause significant distress (Biggs and Dery, 2006). It is a common health problem in infants and children, which decreases their quality of life and generally leads to paediatrician visits or – in severe cases – even hospital treatments. The disorder is characterised by infrequent bowel movements, hard and/or large stools, painful defecation, and faecal incontinence, and is often accompanied by abdominal pain (Koppen et al, 2015).
Constipation is defined as functional (Functional Constipation, FC) if there is no underlying organic cause, which is the case for up to 95% of children (Tabbers et al, 2014). The remaining 5% are related to organic causes, which include metabolic or endocrine disorders, anorectal anomalies, neuromuscular diseases, and Hirschsprung's disease (Castiglia, 2001).
The pathophysiology of FC is still not completely understood but is likely to be multifactorial. One important etiological factor, especially for young children, is withholding behaviour – which frequently occurs after a negative experience such as hard and painful bowel movements. This can lead to faecal impaction – the presence of a large faecal mass in the rectum or abdomen that often causes overflow faecal incontinence, i.e. the involuntary loss of soft stools (Mugie et al, 2011).
The reported prevalence of FC in infants and toddlers varies between studies but usually ranges between 5 and 27%. Frequency in toddlers is reported as higher than in infants (Zeevenhooven et al, 2017).
The evaluation of childhood constipation primarily consists of a thorough medical history and complete physical examination. In specific cases, additional investigation could be needed; including laboratory testing and radiology exams (Koppen et al, 2015). As FC is a common healthcare problem worldwide, several treatment options are available and sectioned into non-pharmacological and pharmacological interventions. Non-pharmacological interventions involve education and demystification, toilet training, diary defecation or additional fibre and fluid intake (Koppen et al, 2015). Note that babies and toddlers have an above-average daily liquid requirement: The younger the child, the higher is the liquid requirement. For a baby, it is 10% of its own body weight, while the percentage for an adolescent only adds up to 5% (Böhles, 2012). Pharmacological management of FC involves three steps: i) disimpaction; ii) maintenance treatment; and iii) weaning. Pharmacological interventions – adjacent to this three-step treatment – have several options ranging from laxatives (osmotic, stimulant or lubricant), enemas, rectal irrigation and additional novel therapies (e.g. Prucalopride) (Tabbers et al, 2014; Koppen et al, 2015).
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Diarrhoea is a common gastrointestinal disorder in infancy, which may be caused by food intolerance, allergies, poisoning, or as a consequence of an antibiotic treatment. The most frequent reason, however, is a viral (e.g. Rotavirus) or bacterial (e.g. Salmonella) infection – an “acute gastroenteritis” (NICE, 2009).
This acute gastroenteritis generally manifests itself as a decrease in stool consistency (loose or liquid) and/or in an increase of evacuation frequency (typically more than 3 times in 24 hours). Acute diarrhoea normally does not exceed 14 days, and typically lasts less than 7 days (Guarino et al, 2014). The symptoms may or may not be accompanied by vomiting. Vomiting is defined as the forceful ejection of stomach contents up to and out of the mouth (NICE, 2009), and must be distinguished from the normal phenomenon of regurgitation (see “Reflux and regurgitation”).
Each year, approximately 1 in 10 children under 5 years is referred to healthcare services due to gastroenteritis (NICE, 2009). Among European children younger than 3 years, Rotavirus is the leading cause. In countries where the rotavirus vaccination rate is high, Norovirus is identified as the main cause of acute gastroenteritis (Guarino et al, 2014).
An inadequate approach to nutrition during a period of diarrhoea can lead to a vicious cycle of malnutrition. It is aggravated, among other factors, by malabsorption (e.g. of lactose and fat), and by impaired immune function and intestinal barrier protection – which, in turn, increase the risk of re-infection (Brandt et al, 2015; Brown, 2003). Another serious consequence of diarrhoea is dehydration; a potentially life-threatening symptom. Symptoms of dehydration include: irritability or lethargy; decreased urine output; sunken eyes; absence of tears; warmth of extremities; dry mucous membranes; and reduced skin turgor (NICE, 2009). If not adequately managed, long-term consequences are: negative impacts on nutritional status; and growth faltering (Brown, 2003). Therefore, maintenance of an adequate diet is a priority for preventing or breaking this cycle and, supporting the healing process instead (Brandt et al, 2015).back
Reflux is the re-entry of stomach content into the oesophagus. It does not necessarily result in regurgitation, which is the re-entry of stomach content into the throat and mouth (i.e. spitting up). Nonetheless, regurgitation is a common symptom of uncomplicated gastro-oesophageal reflux (GOR) (Meunier et al, 2014). Therefore, strict differentiation between reflux and regurgitation or spitting-up is difficult, and these terms are often used as synonyms. However, GOR should be clearly distinguished from gastro-oesophageal reflux disease (GORD), which is associated with severe symptoms and complications, making specific medication necessary (Lightdale et al, 2013).
Reflux is a common and normal physiological process, which is mainly caused by immaturity of the lower oesophageal sphincter. 50% of normally healthy infants regurgitate at least once per day. Reflux usually starts at 2-3 weeks of age (Meunier et al, 2014) and reaches a peak at 4 months (Benninga et al, 2016). Although it is usually harmless and temporary, parents often seek advice about reflux, and therefore it has become a routine topic for healthcare professionals.
In more severe cases, reflux can be associated with an insufficient nutrient intake, a failure to grow properly, and an increased risk of health problems such as respiratory illnesses. However, unlike GORD, GOR is considered to be a normal process and can be managed with a conservative approach (Lightdale et al, 2013).back
Food allergies and intolerances can strongly impair a baby’s digestion, manifesting themselves in various symptoms, some of which have already been described in previous chapters: colic; constipation; diarrhoea and vomiting; as well as reflux and regurgitation (Jochum, 2012).
Food allergies are brought about by an overreaction of the immune system against proteins (antigens), whereas food intolerances can be caused by other food components without immunological reactions.
Cow’s milk proteins allergy (CMPA) is the leading cause of food allergy in infants and children younger than 3 years old (Vandenplas et al, 2014). Globally, up to every 20th baby is affected by CMPA. Between 5 and 15% of infants show symptoms suggesting adverse reactions to cow’s milk proteins. The prevalence of CMPA is estimated to be between 1.9 and 4.9% (Vandenplas et al, 2014; Høst, 2002).
In contrast, lactose intolerance is caused by a lack or reduction of the activity of lactase – the digestive enzyme that breaks down disaccharide lactose into absorbable monosaccharides. Three forms of lactose intolerance are distinguished: Inherent lack of lactase is an extremely rare condition. The common “adult-onset” primary hypolactasia starts approximately at the age of 3 years – with a prevalence of 15% in Europe. In other parts of the world, particularly Asia and Africa, lactose intolerance is even more common than lactose tolerance (80%). Accordingly, lactose intolerance in infancy is mainly not of the primary, but of the secondary type. Secondary lactose intolerance develops due to underlying gastrointestinal conditions like acute gastroenteritis and CMPA (non Immunoglobin E) causing a reduced production of lactase in some infants (Jochum, 2012).back