COLIC, GER 2022-2023

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INSTRUCTIONAL OBJECTIVES

By the end of this lecture, the student will

 Define infantile colic?

 Criticize the causes of infantile colic?
 Distinguish the clinical features of infantile colic
 Analyze the differential diagnosis of infantile colic
 Demonstrate the treatment of infantile colic
 Illustrate the Techniques for calming infants of Dr. Harvey
Karp
 Review the prognosis of colic
 Define gastroesophageal reflux (GER)?
 Distinguish the factors that involved in physiologic GER?
 Identify the criteria for physiologic GER?
 Identify the criteria for pathological GER?
 Illustrate how do you diagnose a physiologic GER?
 Manage uncomplicated GER
 Manage complicated GER
 Discuss surgical treatment of complicated GER
 Recognize the prognosis of physiologic GER

Further reading is required from

Nelson ESSENTIALS OF PEDIATRICS 9th edition (2023)

Page 41-42 and page 500-502

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Colic
Definition

Infantile colic is defined as episodes of uncontrollable crying in an

otherwise healthy infant

Varying diagnostic criteria for the actual medical definition for colic
exist

Colic often is diagnosed using Wessel’s rule of threes :

Crying for more than 3 hours per day, at least 3 days per week, for
more than 3 weeks and resolves by 3 or 4 mo of age.

Wessel’s rule has been replaced by the 2016 ROME IV criteria, which
include the following:

1. Age <5 months when the symptoms start and stop

2. Recurrent and prolonged periods of crying, fussing ‫تهيج‬, or
irritability that start and stop without obvious cause and cannot
be prevented or resolved by caregivers
3. No evidence of poor weight gain, fever, or illness
4. Caregiver reports of crying/fussing for ≥ 3 hours per day on ≥ 3
days/week
5. Total daily crying confirmed to be ≥3 hours when measured by at
least one prospectively kept 24-hour diary

Epidemiology

 Incidence rates of colic vary from 10–40%.

 It appears to peak at approximately 6 weeks of age.
 There is no known association with gender, gestational age, breast
versus bottle feeding, season of year, or socioeconomic status

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Etiology
The etiology of colic is unknown and is likely a multifactorial
No single factor consistently accounts for colic. Usually the cause is
not apparent.
 In some infants, the attacks seem to be associated with hunger or
with swallowed air that has passed into the intestine.
 Overfeeding may cause discomfort and distention
 Breastfeeding mothers may try elimination of milk, beans, and
cruciferous vegetables.
 In allergic Families, mothers may try a stricter elimination of food
allergens (milk, egg, Wheat, nuts, soy, and fish), although nutritional
status should be monitored.
 For Formula-fed infants, changing from milk-based to soy-based or
other lactose-free Formulas had no effect in most studies. A protein
hydrolysate formula may moderately improve symptoms.
 Some studies have found differences in fecal microflora between
babies with excess crying and controls. Results include fewer
bifidobacteria and lactobacilli and more coliform bacteria such as
Escherichia coli. None of these studies were conclusive
 Attacks commonly occur in the late afternoon or early evening,
suggesting that events in the household routine may be involved.
 Higher levels of fecal protectin, a marker of colonic inflammation,
have been reported
 Increase in serotonin secretion
 Maternal smoking may be associated.

The clinical manifestations are characteristic:

- The attack usually begins suddenly, with a loud, sometimes
continuous cry. The paroxysms may persist for several hours.
- The infant's face may be flushed, or there may be circumoral pallor.
- The abdomen is usually distended and tense.
- The legs may be extended for short periods, but are usually drawn
up on the abdomen.
- The feet are often cold, and the hands are usually clenched.
- The attack may not terminate until the infant is completely
exhausted.

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- Sometimes, however, the passage of feces or flatus appears to

provide relief.
- Attacks commonly occur in the late afternoon or early evening.

Differential Diagnosis
Colic is a diagnosis of exclusion following a careful history and
physical examination.
Any condition that can cause pain or discomfort in the infant
1. It is important to evaluate for emergency conditions such as
• Intracranial involvement
• Infectious disease
• Non accidental trauma (child abuse)
• Acute abdomen
2. Others
• Cow’s milk protein intolerance
• Gastroesophageal reflux disease (GERD)
• Other causes of excessive crying as UTI, otitis media, and irritated
skin lesions ,corneal abrasions, hair tourniquets

 Treatment:
 Education about the natural history of colic. The fact that the
condition rarely persists beyond 3 months of age should be
reassuring.
 Techniques for calming infants
 Techniques for calming infants include Dr. Harvey Karp’s “5 Ss ”
1. Swaddling
2. Side or stomach holding
3. Soothing noises (such as shushing, singing, or white noise)
4. Swinging or slow rhythmic movement (such as rocking, walking,
or riding in a car)
5. Sucking on a pacifier.
 Dietary changes
In most circumstances, dietary changes are not effective in reducing colic
but should be considered in certain specific circumstances such as
when there is concern for cow’s milk protein allergy/intolerance or
lactose deficiency

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 Medications:
Including phenobarbital, diphenhydramine, alcohol, simethicone,
dicyclomine, and lactase, have no benefit and may cause serious side
effects.
Passage of flatus or fecal material spontaneously or with expulsion of a
suppository or enema sometimes affords relief.
Anticholinergic medications should not be used in infants younger than 6
months
Simethicone and other carminatives before feedings are ineffective in
preventing the attacks.
Sedation is occasionally indicated for a prolonged attack
Some studies have suggested that probiotics may be useful. The use of
probiotics such as lactobacillus reuteri has been shown to decrease
crying time in the infant with colic without adverse effects
 Herbal medications :
Some herbal medications (such as chamomile, fennel, vervain, licorice,
and balm-mint teas) have been suggested, there is no evidence of
effectiveness and they may result in side effects such as hyponatremia
and anemia
 Others:
Chiropractic manipulation and acupuncture have insuffient evidence
to support their use.
Prognosis:
 Three is no evidence that infants with colic have adverse long term
outcomes
 It has been associated with postpartum depression, parental guilt.
Infantile colic does not have untoward long term effcts on maternal
mental health, as parental distress tends to resolve as colic subsides.
 The most serious complication of colic is nonaccidental
trauma(shaken baby syndrome)

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Gastroesophageal reflux (GER)

GER is the most common esophageal disorder in children of all ages
Definition
GER is defined as: the effortless retrograde movement of gastric contents upward
into the esophagus or oropharynx.
It is passive regurgitation of gastric contents into the esophagus and should not be
confused with vomiting, which is an active process and requires the contraction of the
diaphragm and abdominal muscles to initiate the event.
 Virtually all newborns have GER,
 Nearly half of all infants are reported to spit up between 2 and 4
months of age.
 Peaking at about 4 mo and resolving in most by 12 mo
Criteria for physiologic GER Infants who regurgitate stomach contents and:
1. Normal weight gain
2. The absence of esophagitis
3. Have no signs of respiratory complications.
Factors involved in physiologic GER include
1. Short, narrow esophagus.
2. Immature lower esophageal sphincter (LES).
3. Small, noncompliant stomach;
4. Liquid diet.
5. Frequent, relatively large volume feedings.
6. Horizontal body position;
As infants grow
1. Develop a longer and larger diameter esophagus
2. Have a larger and more compliant stomach,
3. Eat more solid foods,
4. Experience lower caloric needs per unit of body weight
5. They spend more time upright,
As a result, most infants stop spitting up by 9 to 12 months of age.

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Pathologic GER: Gastroesophageal reflux disease (GERD) is diagnosed

If there are troublesome symptoms or complications such as
a)Esophagitis.
i. This may present clinically as blood in the vomit or
ii. More insidiously with the development of anemia or stricture.
iii. Older children may complain of heartburn with reflux
While smaller infants may develop feeding difficulties due to
esophageal discomfort
b) Respiratory symptoms (Aspiration): wheezing, aspiration pneumonia,
hoarse voice chronic cough, or apneic spells without overt emesis may
have occult GER.
c)Failure to thrive
Diagnosis:
A clinical diagnosis is often sufficient in children with classic effortless
regurgitation and no complications (physiologic GER).
Diagnostic studies are indicated for pathological GER (GERD)
1. A barium upper GI series:
 To exclude anatomic obstruction such as pyloric stenosis, hiatus hernia,
gastric antral web, duodenal stenosis, annular pancreas, and malrotation).
 Because of the brief nature of the examination, a negative barium study does
not rule out GER.
2. A 24-hour esophageal probe monitoring: uses a pH electrode placed
transnasally into the distal esophagus, with continuous recording of
esophageal PH
Data typically are gathered for 24 hours, following which the number and
temporal pattern of acid reflux events are analyzed.
Measurement of lower esophageal pH shows that in normal individuals there is
acidity (pH < 4) from reflux of stomach contents for less than 5-8% of the total
monitored time of a 24-hour period. If there is reflux it will occur more
frequently than this time.

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3. Esophageal impedance monitoring: records the migration of electrolyte-

rich gastric fluid in the esophagus.

4. Endoscopy is useful to rule out esophagitis, esophageal stricture, and

anatomic abnormalities. .

Treatment of uncomplicated GER

In otherwise healthy young infants ("well-nourished, happy spitters"), the
mother should be reassured and advised of simple measures to help with the
problem, such as:
1. Towel on caregiver's shoulder cheap, effective. Useful only for
physiologic reflux
2. Thickened feedings:
 Thickening of feeds
 Use of commercially prethickened formulas: reduces number of episodes,
and enhances nutrition
 Thickening of formula with a tablespoon of rice cereal per ounce of
formula results in fewer regurgitation episodes, greater caloric density
(30kcal/oz), and reduced crying time.
3. Smaller, more frequent feedings: Can help some infants. Be careful not to
underfeed child
4. Positional therapy:
 The head should be elevated by elevating the head of the bed, rather than
using excess pillows, to avoid abdominal flexion and compression that might
worsen reflux
 Prone positioning with head of crib or bed up is helpful, but not for young
infants because of risk of SIDS

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Evidence that the supine position reduces the risk of sudden infant death
syndrome has led the American Academy of Pediatrics and the North
American Society of Pediatric Gastroenterology and Nutrition to recommend
supine positioning during sleep.
 When the infant is awake and observed, prone position and upright carried
position can be used to minimize reflux.
 Lying in the flat supine position and semi-seated positions (e.g., car seats,
infant carriers) in the postprandial period are considered provocative
positions for GER and therefore should be avoided
 Seated position worsens infant reflux and should be avoided in infants with
GERD
 Left lateral positioning resulted in reduction in the total number of
reflux episodes.
5. A short trial of a hypoallergenic diet in infants may be used to exclude milk
or soy protein allergy before pharmacotherapy
Treatment of complicated GER:
Medical Therapy
a) Proton-pump inhibitor Effective medical therapy for heartburn and
esophagitis
b) H2 receptor antagonist(H2RAs): cimetidine, famotidine, nizatidine, and
ranitidine reduces heartburn, less effective for healing esophagitis
c) Metoclopramide Enhances stomach emptying and LES tone. Real
benefit is often minimal. In 2009, the FDA announced a black box
warning for metoclopramide, linking its chronic use (>3 mo) with
tardive dyskinesia, the rarely reversible movement disorder
Surgical Therapy:
a) Esophagitis unresponsive to medical therapy (refractory esophagitis)
b) Esophageal stricture

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c) Chronic pulmonary disease

Nissen or other fundoplication procedure for life-threatening or medically
unresponsive cases Fundoplication procedures may be performed as open
operations, by laparoscopy, or by endoluminal (gastroplication) techniques.
Feeding jejunostomy: placement of a feeding jejunostomy may be considered as
an alternative to fundoplication.
Prognosis:
In 85% of infants with gastroesophageal reflux, the condition is self-limited,
disappearing between ages 6 and 12 months, coincident with assumption of:
d) Erect posture and
e) Initiation of solid feedings.
Treatment in older children:
 Lifestyle changes should be discussed, including cessation of smoking,
weight loss, not eating or exercising before bed, and limiting intake of
caffine, carbonation, and high-fat foods.
 If lifestyle changes are ineffctive in reducing symptoms, proton pump
inhibitor therapy is effctive in reducing symptoms and supports healing

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