Other feeding related problems
The subject of infant nutrition and management of feeding problems is much broader and more complex than is possible to cover fully in one module. We have looked in detail at the three principal causes of feeding problems in infants: cow's milk protein allergy, lactose intolerance and gastro-oesophageal reflux. We will now briefly touch on some other feeding-related problems which may present in the pharmacy.
Colic
Colic is a term used to describe rather vague symptoms, possibly related to feeding, that essentially result in excessive and inconsolable crying. The exact causes are not understood, although it could be related to the immature digestive system and problems digesting protein or lactose.19
Under the well-established Wessel criteria,20 colic is defined as crying for at least three hours per day, on three days per week, for three consecutive weeks in an otherwise healthy infant. The crying is high-pitched and usually presents in a pattern, occurring at the same times each day, often late afternoon to early evening. The infant is usually inconsolable and appears to be in distress.
Other signs of colic include:
- Drawing the knees up to the chest
- Cramps and wind
- Flushed face
- Clenched fists
- Difficulty sleeping
The symptoms are distressing for both infant and parents and are likely to result in sleep deprivation for both, compounding the problem and reducing the parent's ability to cope with the crying. A self-help group, Cry-sis, which has a website and telephone helpline, can support parents struggling with a crying baby and lack of sleep.
Parents can be reassured that colic is relatively common, affecting around one in five babies and is self-limiting; symptoms typically present in the first few weeks of life and have usually resolved by four to six months of age.21
Practical tips for management include:
- Continue to comfort the baby during crying episodes.
- Sit the baby upright during feeds.
- Try to avoid excessive intake of air during feeds.
- Use of a fast-flow teat may be required.
- Ensure the bottle is tipped upright with the teat full of milk, not air.
- Wind the baby before and after feeds.
- Rub the baby's back and/or stomach gently.
- A warm bath may help console the baby.
Treatment options have a limited evidence base but include:
- The use of gripe water or simeticone drops e.g. Infacol® cause smaller gas bubbles to coalesce making gas easier to expel.
- Lactase enzyme drops i.e. Colief® help the infant digest lactose.
- Use of specialist infant formulae.
There are a number of specialist formulae designed to alleviate the symptoms and incidence of colic by virtue of being easier to digest. Examples include Aptamil Comfort, Cow & Gate Comfort and SMA Comfort.
Infants who do not respond to a trial of these measures or are failing to thrive should be referred to the GP.
Constipation
Constipation is the abnormally delayed or infrequent passage of dry, hard stools; typically less than three complete stools per week in infants. It is less likely to occur in breastfed infants. It is associated with straining and pain on passing a motion as well as foul smelling stools and flatulence. It can cause poor appetite, a lack of energy and an unhappy or irritable mood. Clearly, the causes and treatment of constipation in children are varied and complex and a full discussion is outside the scope of this module. This may highlight an additional learning need for yourself or the wider team.
Contributory factors could include:
- Dietary and fluid intake
- Insufficient fluid intake
- Incorrectly prepared formula
- Frequent changes of formulae
- Insufficient fibre intake in weaning infants
- Dehydration
- Immature digestive system
- Physiological causes e.g. anal fissure
- Side effects of medicines
When an infant presents in the pharmacy with constipation it is important to try and identify possible underlying causes so that these can be addressed. In formula-fed infants it is important to ensure the feed is being prepared correctly and is not too dilute or concentrated. Simple dietary measures should then be used to return digestive function to normal. Formula-fed infants can be given cooled and boiled water in between feeds to increase fluid intake. Weaned or weaning infants should be offered plenty of fruits and fluids.
A specialist infant formula, such as Aptamil Comfort, can be recommended to try and relieve constipation without pharmacological intervention. The more easily digestible formula can result in softer, more frequent stools. In addition, the inclusion of oligosaccharides provides a substrate for the beneficial microflora with concomitant improvements in digestive health (see previous information).
Constipation in infants can be treated with a laxative. Lactulose is often recommended over the stimulant laxatives, but it does get fermented in the large intestine with the release of gas and concomitant bloating, pain and distension. PEG-based laxatives, such as Movicol Paediatric® are now treatments of choice as they are unaffected by gut bacteria and so do not cause the release of gas. Movicol is unlicensed in children under two years of age and so should only be recommended by an independent prescriber. Laxative treatment may continue for some time and it is important that it is managed under medical supervision, particularly when withdrawing from treatment as the symptoms of constipation may return.