Mark Sykes explains how pharmacists should advise parents whose babies are in distress
• Infant colic is a common condition and often pharmacists are the first port of call
• The symptoms of incessant and inconsolable crying are distressing for the parents. Advice and support are the key ways the pharmacist can help
• Colic is self-limiting, appearing in the first few weeks of life and usually resolving by six months of age
Colic is a common condition affecting up to one-fifth of babies. NHS England recently launched Stay Well Pharmacy, a campaign encouraging people to first use a pharmacy for minor health problems. Infant colic also falls into the NHS England consultation on restricting the prescription of over-the-counter (OTC) items for common conditions.
NHS Choices provides the simple definition of infant colic as ‘excessive, frequent crying in a baby who appears to
be otherwise healthy’. For research purposes, colic is described as periods of inconsolable, unexplained and incessant crying in a seemingly healthy infant that leads to concerned parents seeking advice to comfort their child.
Causes and symptoms
The cause of infant colic is still not clear. Possible causes include abnormal gastrointestinal motility and pain signals from sensitised nerves in the gut; an imbalance in gut bacteria that results in changes in gut motor function and excess gas production or behavioural factors such as family tension, parental anxiety or misreading the infant’s needs. A further suggestion is that colic may well just fall within the normal range for crying in babies, though it may be unhelpful to suggest this to the parents.
Colic typically presents early on in the first few weeks of life and usually improves over time to resolve at around six months. It occurs equally in breast fed and bottle fed infants and affects both boys and girls. It is mainly characterised by excessive, inconsolable crying, often occurring mostly in the late afternoon or early evening. The infant will also tend to draw their knees up to their abdomen or arch their back while crying.
These symptoms (see box 1) are quite distressing for the parent, especially as there is no obvious cause. This will be a stressful time, so it is important that the parents’ experiences are taken into account and that they are supported alongside the infant. It has been said that ‘colic overshadows everything’, leaving both parents feeling powerless and overwhelmed.
Is it colic?
Diagnosis of colic is based on excluding other causes. Generally speaking, if the infant has difficulty sleeping, is drawing its knees to its chest, having repeated episodes of inconsolable and excessive crying (three hours a day, on three days a week for more than three weeks as a guide), is showing signs of stomach cramps, and has a flushed face, this is indicative of colic.
Severe colic that doesn’t seem to be responding to treatment may be due to cows’ milk allergy. Symptoms that don’t fit into the list above need to be considered as potentially more serious. Differential diagnosis includes: meningitis, urinary tract infection, otitis media, constipation, gastro-oesophegeal reflux disease (GORD) and pyloric stensosis. If there is concern that it is not a simple case of colic, you may consider referring the infant to the GP.
How to help
Treatment is centred around providing reassurance to the parents and advising on coping strategies. A systematic review of pain-relieving agents for infantile colic found that there was no evidence to support the use of simethicone as a pain reliever as it did not reduce crying time or relieve other symptoms when compared against placebo, and that evidence covering use of herbal remedies was of low quality.
A further systematic review that considered manipulative strategies such as cranial manipulation, and osteopathy concluded that the apparently statistically significant improvement in symptoms may be down to performance bias on the part of the parents keeping the record of effectiveness. The use of lactase drops similarly fails to show sufficient evidence of effectiveness.
NICE guidance on postnatal care up to eight weeks after birth says that ‘healthcare professionals should reassure parents of babies with colic that the baby is not rejecting them and that colic is usually a phase that will pass. Parents should be advised that holding the baby through the crying episode and accessing peer support may be helpful’. It goes on to advise that the ‘use of hypoallergenic formula in bottle-fed babies should be considered for treating colic, but only under medical guidance’.
The Infant Formula and Follow-on Formula (England) Regulations 2007 require that only a healthcare professional may recommend infant formula. It may be appropriate to suggest a special formula milk for colic from the products available, but counter assistants will need to refer patients to either the pharmacist or a pharmacy technician to make the recommendation.
The NICE clinical knowledge summary (CKS) for infantile colic advises that parents should be reassured that colic is a common problem that should resolve itself by six months of age. The healthcare professional should advise on strategies that may help to soothe a crying infant (see box 2), and encourage parents and carers to look after their own wellbeing (see box 3), and if the mother is breastfeeding, then encourage her to continue wherever possible.
If parents are struggling to deal with their baby’s symptoms it would be worth signposting them to a support group such as Cry-sis, which runs a national telephone helpline (see box 4) and has a website with information for families who have excessively crying or sleepless children.
Lots of choice, little evidence
Infant colic can be a major source of stress and anxiety for parents of infants from a few weeks after birth up to around six months. Because there is no real understanding of the cause, a lot of different potential treatments have been used or suggested over time, a large proportion of which have low quality or no evidence of efficacy backing them up.
As the NHS looks to encourage parents to use pharmacy as their first port of call for minor conditions such as this, and to stop prescribing OTC medicines on the NHS for the treatment of infant colic, your role is one of providing support. By being aware of the advice you can give and when to refer, you can help make a difference at a difficult time.
At this point, the author will admit to not having the experience of being a parent. This study is a review of the guidelines and evidence. It is only right, therefore, to seek the experience of others. Colleagues and family provide anecdotal evidence of colic drops or lactase enzyme drops helping, along with warmth, and white noise such as the noise of the car while driving, or the hum of the washing machine. As long as you are honest as a professional that the evidence is patchy, you can still offer help.
Mark Sykes is pharmacy qualifications lead for Weldricks Pharmacy in a chain in the north of England
Box 1 Symptoms of infant colic
• Excessive, inconsolable crying that starts in the first weeks of life and resolves by six months of age
• Crying that most often occurs in the late afternoon or evening — over three hours a day on at least three days a week for three weeks
• Infant drawing its knees up to its abdomen or arching its back when crying
Box 2 Strategies that may help to soothe a crying infant
• Hold the baby through the crying episode
• Gentle motion such as pushing the pram or rocking the crib
• White noise such as a vacuum cleaner or washing machine
• Bathing the infant in a warm bath
• Ensuring correct winding technique is used during and after feeds if needed
Box 3 Encourage parents to look after their own wellbeing
•Ask family and friends for support if possible
•Meet with other parents or carers with babies of the same age to share experiences and access peer support
•Rest when the baby is asleep
•Put the baby down in a safe place, such as their cot, if feeling unable to cope with the crying for a few minutes, to take ‘time out’
Box 4 Support for parents
Cry-sis – Support for parents with babies who cry excessively or have sleeping problems. Website: cry-sis.org.uk. Telephone helpline: 08451 288 669 (seven days a week 9am-10pm)
NHS Choices – colic nhs.uk/conditions/colic
NHS Choices, Colic, https://www.nhs.uk/conditions/colic [Accessed February 2018]
2. Landgren K, Hallstrom I, (2011) Parents' experience of living with a baby with infantile colic--a phenomenological hermeneutic study. Scandinavian Journal of Caring Sciences. 25(2), 317-24
3. NICE clinical knowledge summary on Colic – infantile, https://cks.nice.org.uk/colic-infantile#!scenario [Accessed February 2018]
4. Biagioli E, Tarasco V, Lingua C, et al. Pain-relieving agents for infantile colic. Cochrane Database of Systematic Reviews 2016, Issue 9. Art. No.: CD009999. DOI: 10.1002/14651858.CD009999.pub2.
5. Dobson D, Lucassen PLBJ, Miller JJ, et al. Manipulative therapies for infantile colic. Cochrane Database of Systematic Reviews 2012, Issue 12. Art. No.: CD004796. DOI: 10.1002/14651858.CD004796.pub2
6. Drugs and Therapeutics Bulletin (2013) Management of infantile colic. BMJ. 347, 1-5.
7. NICE CG 37, https://www.nice.org.uk/guidance/cg37/chapter/1-Recommendations#maintaining-infant-health [Accessed February 2018]