Infant paroxysmal gastro-intestinal upsets – is it Colic? Or what is it?

The three most commonly accepted states to consider are:

(a)  Colic

(b) Lactose Intolerance

(c) Gastro Oesophageal Reflux (GOR)

Colic is the popular term used almost universally to describe unsettled behaviour in infants. This usually refers to bouts of seemingly inconsolable crying due to gastro-intestinal pain, which may be accompanied by abdominal distention (with flatus), vomiting, copious and loose stools and a tendency to draw up the legs. Severe cases also see other signs such as arching of the back and severe difficulty in settling.  It usually resolves spontaneously at about 3 months of age.  Parents need reassurance and practical suggestions on how to plan around the sessions of periodic crying which usually have a set time; the most characteristic being in the early evening.

Lactose intolerance, (often diagnosed in the clinical setting by virtue of testing faecal pH and faecal reducing sugars or by the breath hydrogen test; but only truly diagnosed through a biopsy of the small intestine) manifests with chronic diarrhoea and a failure to thrive. In this situation the stool is characteristically frothy, watery and passed with much flatus. It is due to an inability to digest lactose, which is the primary carbohydrate in milk. The lactose levels in human milk are higher than in most other mammalian milks, the sugar being hydrolysed by lactase- phlorizin hydrolase, an enzyme in the small intestine. This enzyme develops in the neonatal gut mainly throughout the last trimester of the pregnancy. By 34 weeks gestation, lactase activity is approximately one third that of the full-term infant reaching 70% of full-term level by 38 weeks’ gestation. Congenital lactase deficiency is extremely rare and is inherited as an autosomal recessive gene. Symptoms, therefore, are most likely to occur in premature infants or in those who have had undergone a bout of excessive peristaltic activity.

With either of these two conditions, a Lactation Consultant can offer assistance by suggesting feeding protocols such as timed and/or evenly spaced feeds designed to reduce excessive intake of milk and upright feeding positions. Encouraging the mother to allow the baby to ‘finish the first breast first’ increases the fat intake, which tends to reduce gut motility.  This management technique is most effective when accompanied by dietary advice aimed at increasing the intake of mono and poly-unsaturated fats. Similarly increasing protein and complex carbohydrates at the expense of simple carbohydrates has been shown to decrease the lactose levels in human milk and, along with that, the common symptoms of lactose intolerance.

Parents appreciate also the practical advice and support offered by community groups such as:

• Australian Breastfeeding Association (ABA) – www.breastfeeding.asn.au. Hotline 1800686268
• Reflux Infants Support Association (RISA) – www.reflux.org.au
• Bubs Australia – www.bubsaustralia.com

They can call upon them for a wealth of experience to share with parents thus assisting them to survive those early difficult weeks.

Gastro-oesophageal reflux is described as a pattern of consistent regurgitation leading to distress after feeds. In severe cases it may lead to apnoea, pneumonia, failure to thrive and anaemia.  Oesophagitis has been associated with candida and herpes. Mapping of a gene for severe paediatric gastro oesophageal reflux to chromosome 13q14 was published in the July 19, 2000 issue of The Journal of the American Medical Association where it was described as a common medical problem affecting one in 20 babies.  

JAMA The Journal of the American Medical Association 284(3):325 · July 2000

In the general population oesophageal reflux has been assessed as being prevalent in 4% of the population. Notionally it shouldn’t occur because of the presence of the lower oesophageal sphincter. Strictly speaking this is not so much a physiological entity as a zone of high pressure, which is maintained just above the gastro-intestinal junction. Normally this area has a high resting tension, which prevents or inhibits reflux. The sphincter usually relaxes once the peristaltic wave arrives. It is controlled by nervous and hormonal mechanisms. In adults this oesophageal pressure may be lowered due to cigarettes, alcohol, fat, stress, caffeine and obesity.

However, it is acknowledged that a persistent pattern may occur in the first year of life due to a functional immaturity of the lower oesophageal sphincter leading to episodes of inappropriate relaxation. 

 A short intra-abdominal length of oesophagus as occurs in babies, probably also contributes to the problem. Also increased abdominal pressure resulting from fermentation in the small intestine due to problems coping with the daily lactose load in the still maturing gut can be a significant factor. This tends to be exacerbated by the tendency for the baby to draw up the legs in response to pain. It is recognised that lying down also enhances intra-abdominal pressure. This becomes somewhat of an occupational hazard for pre-ambulatory infants. In those cases where the mother has a problem with copious supply and/or a vigorous letdown, the peristaltic wave tends to be enhanced giving little time for the sphincter to self-regulate appropriately.

By 12 months nearly all symptomatic reflux resolves spontaneously probably due to a combination of maturation of the lower oesophageal sphincter, assumption of an upright posture as the baby is no longer lying down all the time and is starting to mobilise upright, and the inclusion of solids in the diet.

 Current paediatric protocols include:

• reassurance and support   
• avoidance of over-feeding    
• maintenance of a 30 degree head up prone position after feeds   
• placing baby on the L side (in a sling) with mattress raised for sleeping   
• antacids such as Gaviscon. Such alginate preparations form a gel on the surface of the gastric contents thus preventing reflux in the upright position.
• feed thickeners containing rice starch, corn starch or bean gum. This is somewhat controversial in some communities and results are mixed – for some babies, it is a miracle, a panacea. For others it causes diarrhoea and or constipation.    
• early solids
• histamine receptor antagonists which lower production of acid and pepsin such as Cimetidine.                
• Dopamine receptor antagonist drugs which increase the contraction of the lower oesophageal sphincter as well as promote gastric emptying, such as Metoclopramide. Metoclopramide does not promote gastric secretions.
• Cisapride stimulates acetycholine release in the myenteric plexus in the upper GI tract. This raises oesophageal sphincter pressure and increases gut motility. Side effects may include diarrhoea, abdominal cramps and tachycardia.

It has been suggested that the successful use of Metoclopramide in alleviating the symptoms of oesophageal reflux can be considered as being equally confirmatory [as an endoscopy] for the condition.  However, most paediatric texts advise 24 Hr ambulatory oesophageal pH monitoring, endoscopy and barium studies to rule out underlying anatomical abnormalities in the oesophagus, stomach and duodenum.

There are various hands-on modalities, which can offer another type of assistance to babies in distress. These include: Massage (perhaps with Aromatherapy oils); Bowen technique; Chiropractic or Osteopathy. If the birth has been, in any way, traumatic, any of these modalities are worthy of consideration. 

SO, WHAT CAN THE NATUROPATH DO?

A naturopathic approach to GOR would be to concentrate on improving digestion. A grand elimination diet wouldn’t be suggested during lactation. However, removal of cow’s milk and/or soy proteins from the maternal diet does much to improve the clinical picture. Increasingly wheat is also seen to be problematical and a naturopathic approach would consider using a blood type diet. Without going into too much detail this dietary approach is based on the notion that blood types O and A are the earliest recorded blood types. Type O is referred to as the cave man blood type, while type A evolved during the period of settlement along the Tigrus and Euphrates rivers. Neither of these blood types tolerates dairy or wheat.

Treatment of colic also warrants the use of probiotic strains for the infant gut as well as using herbal carminatives and anti-spasmodics to relax smooth muscle spasm and assist in expelling excess wind from the gut.  

The naturopathic approach to settling gut inflammation is with the use of Ulmus Rubra or Slippery Elm Bark, which may be administered quite safely to the baby. In King’s Medical Dispensary (the pharmacopoeia of the American Eclectic Physicians from the last century), Slippery Elm is described as “a nutritive, expectorant, diuretic, demulcent and emollient which is a very valuable remedial agent in mucous inflammations of the lungs, bowels, stomach, bladder or kidneys when used freely in the form of a mucilaginous drink”.

 Its’ use today is relegated primarily to treating the gut because of its mucilaginous properties. It enjoys much success as a method of treatment for worms and dysentery when used aggressively as a gruel. However, for babies it can safely be given in the form of a thin paste mixed with EBM and administered by spoon from an eggcup. In those cases where familial eczema is a feature and salicylate sensitivity may be a problem, it is best to first mix a good pinch of the powder to a firm paste with boiling water and then add EBM when cooled. It tastes like dirt and tubercular babies tend to like it. It goes straight through the system and renders the characteristically watery stool of a baby with GIT disturbance, markedly thicker.

In those instances when early solids or feed thickeners are being considered, Slippery Elm Bark is a safe, effective alternative based on over 100 years of proven clinical experience. In those instances where gut problems arise after antibiotic use, a pinch of Slippery Elm Bark mixed with boiling water and then thinned out with EBM, three times a day for three days followed by a few doses to which a pinch of bifidus powder (a probiotic)  has been added can be most beneficial. .

In addition the following herbs:   

• aniseed,
• fennel,
• caraway seed,
• peppermint leaves,
• ginger,
• chamomile flowers 
• dill seeds

possess significant and effective anti-spasmodic qualities and can be administered to baby. For an added benefit the breast feeding mum can also drink two to three cups of Herbal tea  of chamomile, peppermint and fennel to help the anti-spasmodic effects on baby. Meadowsweet is another herb used if there is the presence of GOR.

In keeping with Hering’s Law of Cure, which states that disease symptoms have a tendency to move from the top down and from the inside to the outside, as gut inflammation begins to settle, often the skin aggravates. It is often useful to consider the removal of salicylates from either the maternal diet if baby is not yet on solids and from the baby’s diet when treating an older baby. Mothers who consume large amounts of tea can find it may aggravate a baby’s skin. Common salicylates include: oranges; pineapples; grapes; berries; melons; dried fruits; apricots; plums; tomato products; capsicum; zucchini; almonds; honey; liquorice; vegemite; herbs and spices; wine and some spirits; tea and peppermint tea.

Amines may also have to be removed from the diet. These include: cheese; banana; avocado; nuts; soy sauce; miso; herrings; smoked foods; sausages; offal; spinach; chocolate and wine (particularly red). 

 Likewise, preservatives and artificial colourings may also need to be eliminated in some very sensitive individuals. There is a comprehensive Food Additives list available on www.foodstandards.gov.au available to download to help you to understand and recognise these additives and their effects.

 If candida is a complicating or causative factor, a low sugar/yeast free diet by the mother is recommended until the clinical picture clears. If herpes’ outbreaks are a common problem for the mother, low arginine/high lysine diets with appropriate l-Lysine supplementation is indicated. Foods high in arginine include: all nuts and seeds (especially peanuts); chocolate; corn; sugar; alcohol; coffee and tea. Foods high in lysine include fish and seafood; milk (including human milk!); cheese and yoghurt; eggs; liver; soybeans; peas and beans; wheatgerm and brewer’s yeast.

So in summary:

Colic affects one in five children and is notoriously hard to define, usually presenting as prolonged restless and uncontrolled crying, that is different from that of fussing. It often occurs after feeding, at similar times of the day, usually in the late afternoon and evening. Relief to the infant can often be in passing gas or have bowel motions, which often are runny, pungent and profuse. It usually settles by 14 to 16 weeks of age.

Naturopathic treatment involves slippery elm, given as a paste mixed with EBM or water, and given to the infant via a spoon. Herbs can be used and administered to the infant via bottle two or three times a day to help the infant’s gut to be less spasmodic and calmer. Probiotics can also help with smooth muscle relaxation and assist in expelling gas from the gut. The use of massage using essential oils is also beneficial to the colicky infant. The herbs mentioned above can be added to a carrier oil such as coconut or almond oil and used as a massage oil, for the abdomen ((in clockwise motions) and in the legs and feet massaging upward towards the heart.  

The breastfeeding mother should observe a diet that is high in protein and fat and moderate in complex carbohydrates. Avoid Simple carbohydrates. Be mindful of foods that you have come to realise may not agree with your child, this often revolves around certain foods such as cabbage, broccoli, cauliflower, onions and other spicy foods.  If there is an eczema symptom present, avoidance of salicylates may also need to be incorporated into the mother’s diet.

Above all, do not cope with this alone! It can be a very stressful, sleep-deprived chronic situation that you find yourself in. There is lots of help out there at your doctor, specialist, complementary health practitioner or from various associations and community groups. and for the majority of babies, it is a passing trait that will settle as their bodies mature.