COMMUNITY PHARMACY LECTURE NO.20 PAEDIATRICS COLIC COMMUNITY PHARMACY LECTURE NO.20

BACKGROUND 1- RULE OF THREES An infant could be considered to have colic if it cries for more than 3 hours a day for more than 3 days a week for more than 3 weeks. OR 2- Crying for as little as 90 minutes per day as excessive. Regardless of which definition is used, persistent crying is a cause of stress and anxiety to parents. Colic starts in the first few weeks of life and usually resolves by the age of 3 to 5 months.

AETIOLOGY Linked to a disorder of the GI tract, where spasmodic contraction of smooth muscle causes pain and discomfort, which might be caused by allergy to cow's milk or lactose intolerance. It might stem from emotional, behavioral and social problems that include underdeveloped parenting skills, postpartum depression, and parental anxiety and stress.

ARRIVING AT A DIFFERENTIAL DIAGNOSIS It can be difficult to determine if the baby has colic or is just excessively crying. The term colic is often wrongly applied to any infant who cries more than usual.

CLINICAL FEATURES OF COLIC Excessive crying is obvious clinical features. Pain may be mild, merely causing the child to be restless in the evenings or severe resulting in rhythmical screaming attacks lasting a few minutes at a time, alternating with equally long quiet periods in which the child almost goes to sleep, before another attack starts. Attacks appear to be more common in the early evening.

CONDITIONS TO ELIMINATE Acute infection. Intolerance to cows' milk protein. Gastro-oesophageal reflux disease (GORD)

1- Acute Infection Colic and acute infections of the ear or urinary tract can present with almost identical symptoms. In acute infection the child should have no previous history of excessive crying and have signs of systemic infection such as fever.

2- Intolerance To Cows' Milk Protein Colicky pain in infants is sometimes due to intolerance to cows' milk protein. This is far less common than generally believed but should be considered if the infant is failing to thrive.

3- Gastro-oesophageal Reflux Disease (GORD) Infants frequently have regurgitation that is accompanied with excessive crying. A diagnosis of GORD is usually made if regurgitation happens more than f1ve times a day and is associated with failure to gain weight and refusal to feed.

TRIGGER POINTS Indicative Of Referral: Infants that are failing to put on weight. Medication failure. Over anxious parents.

Evidence Base For Over-the-counter Medication Treatments include: 1- lactase enzymes 2- Simeticone 3- Low-lactose milk formulas 4-Gripe mixtures. None have a credible evidence base.

1- Lactase Enzymes Lactase breaks down lactose present in milk to glucose and galactose. The reduction in lactose concentration is reported to improve colic symptoms

2- Simeticone (e.g. lnfacol and Dentinox) Simeticone is reported to have antifoaming properties, reducing surface tension and allowing easier elimination of gas from the gut by passing flatus or belching. Pharmacologically inert. Has no side effects, drug interactions or precautions in its use and can be safely prescribed to all infants. It should be given with or just after each feed.

3- Low-lactose Formulas Low-lactose formulas should not be recommended as studies conducted to date have been of poor methodological quality. No trial data exists for gripe mixtures and therefore should be avoided

4- Gripe Water Original formulations of Woodward’s gripe water included the ingredients: Alcohol, sodium bicarbonate, dill seed oil, and sugar. The current formulation includes:  Sodium bicarbonate, glycerol, and dill seed oil, but no longer contains alcohol or sugar.

4- Gripe Water (continued) Mommy’s Bliss Apple Gripe Water: Deionized Water, Vegetable Glycerin, Sodium Bicarbonate, Citrus Bioflavonoid Extract, Citric Acid, Potassium Sorbate, Natural Apple Flavor.

4- Gripe Water (continued) Wellements: Organic Ingredients: Agave Fructose, Citric Acid, Chamomilla Recutita (Chamomile) (flower), Ginger Extract (root), Fennel (Foeniculum Vulgare) Extract (seed). Additional Ingredients: Glycerin, Sodium Bicarbonate (Baking Soda), Water (Purified).

4- Gripe Water (continued) Little Remedies:  Purified Water, Sugar, Glycerin, Propylene Glycol, Sodium Citrate, Natural Ginger Flavor, Potassium Sorbate, Citric Acid, Xanthan Gum, Disodium EDTA