A 6-week-old male came to clinic for his health supervision visit. His mother was concerned because he seemed to have excessive crying more in the evenings but also during the day. The episodes would last 30-60 minutes and were intractable with no soothing techniques helping. The episodes could occur once or more times/day and occurred 5-7 days a week. Between episodes he was a happy baby who was breastfeeding well. He had soft bowel movements 1-2 times per day and the mother did not think he was particularly gassy. His mother denied any rashes. She said that she, her husband and a close friend took turns watching him and they were all very good at handing him over to another person, or putting him down and walking away for a few minutes when they became frustrated with the crying. The past medical history showed a full-term infant with mild jaundice perinatally who did not need phototherapy. The family history was positive for atopic dermatitis in the mother, but no other allergic, immunological or gastrointestinal diseases. The review of systems was negative.
The pertinent physical exam showed a healthy male with weight and head circumference at the 25%, and height at the 75%. His examination was normal and he was happy and playful during the visit. The diagnosis of a healthy male was made who had colic. The physician recommended to continue some of the soothing techniques and reiterated the need for breaks from the crying. He also said that there were some studies that reported crying improvement with probiotics and that the mother could try it if she wanted to. The patient’s clinical course over the next two months showed that the mother had tried the probiotics with the infant for 1 months and didn’t really see much difference. She felt that the child overall was just generally improving and he was having fewer crying episodes. “When he has them though, they are still just as intense,” she told the physician. However they were only occurring 2-3 days/week. At his 6 month check up, the episodes continued to decrease and were occurring 1-2 days/week.
Colic is often defined by Wessel’s rule of threes: crying 3 or more hours/per day, 3 or more days per week, for 3 weeks or more. Colic is a diagnosis of exclusion based upon through history and physical examination in a healthy growing child being fed properly. It usually starts at 1-2 weeks of age, stops around 3-4 months and has no predictable long-term outcomes such as behavioral, tempermental or psychological problems.
Parental and caregiver support is the most important treatment for excessive crying and colic as these infants can be very intense individuals who require a great deal of attention. For more information about crying and colic, see What Should I Do? I Just Can’t Get Him to Stop Crying?
“Probiotics are foods that are composed of the same live bacteria that are present in the gut microflora.” They should not be confused with prebiotics which are “…specific nondigestible oligosaccharides that stimulate the growth of certain types of bacteria in the colon…. prebiotics assist the survival of the microflora of the colon, whereas probiotics contribute to the intestinal flora.” Probiotics work by colonizing the bowel, secreting antibacterial substances, competing with other organisms for nutrients and preventing adhesion to the intestinal epithelium and regulation of the immune system.
According to the current clinical practice guideline of the North American Society of Pediatric Gastroenterology, Hepatology and Nutrition society from 2006, probiotic efficacy is supported for acute infectious diarrhea, antibiotic-associated diarrhea, and atopic dermatitis.
For acute gastroenteritis, Lactobacillus rhamnosus GG (LGG) started as soon as possible at a dose of 10 billion colony forming units/day (1010 CFU) for 5-7 days is recommended by Cincinnati Children’s Hospital. One product that is available is Culturelle® packets, capsules or chewable tablets. Capsules can be opened and placed into a cool-beverage (not warm or hot). LGG has been effective for prevention of atopic dermatitis when used by the child and the mother. A recent metaanalysis found that Lactobacillus reuteri (108 CFU) may be effective for treatment of colic in exclusively breastfed infants.
Questions for Further Discussion
1. How common is probiotic or other complementary and alternative medicine use among your patients?
2. What other potential uses could probiotics have?
- Symptom/Presentation:Crying and Colic
- Age: Infant
To Learn More
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NASPGHAN Clinical Practice Guideline. Clinical Efficacy of Probiotics: Review of the Evidence With Focus on Children. Journal of Pediatric Gastroenterology and Nutrition
Cincinnati Children’s Hospital Medical Center. Best evidence statement (BESt). Use of Lactobacillus rhamnosus GG in children with acute gastroenteritis. Cincinnati (OH): Cincinnati Children’s Hospital Medical Center; 2011 Apr 15. 6 p.
Foolad N, Brezinski EA, Chase EP, Armstrong AW. Effect of nutrient supplementation on atopic dermatitis in children: a systematic review of probiotics, prebiotics, formula, and fatty acids. JAMA Dermatol. 2013 Mar;149(3):350-5.
Freedman SB, Ali S, Oleszczuk M, Gouin S, Hartling L. Treatment of acute gastroenteritis in children: an overview of systematic reviews of interventions commonly used in developed countries. Evid Based Child Health. 2013 Jul;8(4):1123-37.
Bernaola Aponte G, Bada Mancilla CA, Carreazo NY, Rojas Galarza RA. Probiotics for treating persistent diarrhoea in children. Cochrane Database Syst Rev. 2013 Aug 20;8:CD007401.
Sung V, Collett S, de Gooyer T, Hiscock H, Tang M, Wake M. Probiotics to prevent or treat excessive infant crying: systematic review and meta-analysis. JAMA Pediatr. 2013 Dec;167(12):1150-7.
ACGME Competencies Highlighted by Case
1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients’ is gathered.
3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
4. Patient management plans are developed and carried out.
5. Patients and their families are counseled and educated.
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.
12. Evidence from scientific studies related to the patients’ health problems is located, appraised and assimilated.
13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital