AN OSTEOPATHIC APPROACH TO

COLIC Heather Ferrill DO, MS

Associate Professor OPP

Rocky Vista University College of Osteopathic Medicine

OUR GOALS TODAY

The current research on the pathophysiological

mechanisms underlying colic

The current research on the treatment for the

infant with colic

Anatomical and physiological relationships

important in the osteopathic evaluation of the

infant with colic

Indications and contraindications to OMT in the

infant with colic

Fast and easy OMT for the busy PCP to use with

the colicky infant

COLIC

DEFINED

Scientific-defined for research efforts Wessel criteria (1954)

Crying and fussing more than

3 hours per day

3 days a week

For more than 3 weeks

Inconsolable, excessive crying associated with hypertonicity, perceived pain, borborygmus, wakefulness

Cyclic

Onset 2-6 weeks old and lasts typically 3 months

DIFFERENTIAL DIAGNOSIS INCLUDES:

Infection – meningitis, encephalitis, sepsis, pneumonia, UTI, osteomyelitis, septic, toxic synovitis, AOM, herpes stomatitis, oral thrush, gastroenteritis, herpangina, insect bites, cellulitis, infectious arthritis

Trauma – non-accidental trauma (skull fracture, intracranial bleed, rib fracture, pneumothorax, long bone fracture, intra-abdominal blunt trauma), accidental trauma (falls), corneal abrasion, hair tourniquets (digits, penis, clitoris)

Metabolic – inborn error of metabolism, electrolyte abnormality, acid/base derangement, hypoglycemia

Foreign body – oral, nasal, ear, pharynx, eye

GI – intussusception dehydration constipation, GERD, hernia

CV – SVT, congenital heart disease

Environmental: neglect, hunger

CURRENT RESEARCH ON PATHOPHYSIOLOGY

AND ETIOLOGY OF COLIC

Dietary

Psychological

Gastrointestinal

Hormonal

Neurological

immaturity

ETIOLOGY

Dietary

Breastfeeding:

Clifford TJ, Campbell MK, Speechley KN, Gorodzinsky F.

Infant colic: empirical evidence of the absence of an

association with source of early infant nutrition. Arch

Pediatr Adolesc Med. 2002 Nov;156(11):1123-8.

Prospective cohort study of 856 mother infant dyads

Maternal questionnaires at 1 and 6 weeks regarding

feeding sources, presence of colicky behavior, maternal

anxiety and alcohol consumption

Breastfeeding did not have a protective effect on the

development of colic

Maternal anxiety was positively correlated with colic

ETIOLOGY

Dietary

Food sensitivities

Hill D, et al. Effect of a Low-Allergen Maternal Diet on Colic Among Breastfed Infants: A Randomized, Controlled Trial. Pediatrics Vol. 116 No. 5 November 1, 2005; pp. e709 -e715 (doi: 10.1542/peds.2005-0147)

RCT conducted among exclusively breastfed infants with colic (90 completed the trial)

Average cry-fuss time over 48 hours was 630-690 minutes

Active arm: mother’s excluded cow's milk, eggs, peanuts, tree nuts, wheat, soy, and fish. Control arm: mothers continued to consume these foods

Outcomes assessed after 7 days as the duration of cry-fuss behavior over 48 hours using charts

End point 25% reduction in cry-fuss behavior over 48 hour period after 7 days of dietary intervention

Result: objective 21% less cry-fuss time in the low allergen diet group.

ETIOLOGY

Psychological

The relationship between maternal post-partum

depression and colic

Ante-partum stress and depression and colic

Association is clear—what is not clear is if there is an

etiological relationship

Maternal/familial stress and depression anxiety causes

colic?

Colic causes maternal/familial stress, depression and

anxiety?

Or they just exist together?

ETIOLOGY

Physiological

GI related

Gut motility and neurological immaturity

Intestinal flora imbalance

Neurobiological

HPA axis and adrenergic system feedback loops activated

as a result of perceived danger or discomfort (on the part of

the infant)

Epigenetic modulation in the limbic system may explain

correlations between regulatory problems in the first

months of life and behavioral/feeding problems later in life Douglas PS, Hill PS. A neurobiological model for cry-fuss problems in the first three to

four months of life. Med Hyp 2013. DOI:

http://www.sciencedirect.com/science/article/pii/S0306987713004386 (abstract

only)

ETIOLOGY

H. Pylori and Infantile Colic Case control study (Saudi Arabia)

Used H. Pylori stool antigen testing

Case population

55 infants with colic per Wessel criteria

2-4 months age

45 (81.8%) tested positive for H. Pylori infection

Control population

30 infants without colic

Age, country of origin, gender and ethnicity matched

7 (23.3%) tested positive for H. Pylori infection

Ali, AM. Helicobactor Pylori and Infantile Colic. Arch Pediatr Adolesc Med. 2012 Jul 1;166(7):648-50.

COLIC AND MIGRAINE

Children with personal history of migraine

208 kids aged 6-18 with headache history; 471 without

72.6% of children with migraine also had infantile colic

26.5% of children without headache had infantile colic

Romanello S, et al. Association between childhood migraine and history of infantile colic. JAMA 2013;309(15):1607-1612

Parents with migraine and their kids

Maternal migraine was associated with a more than 2-fold increase in prevalence of infantile colic

Gelfand AA, et al. Before the headache: Infant colic as an early life expression of migraine. Neurology 2013;79;1392-1396.

COLIC AND OTHER CHILDHOOD PROBLEMS

Prospective study comparing infants with and

without severe colic during infancy and 10 years

later.

Significantly increased incidence of

Recurrent abdominal pain (abdominal migraine)

Allergic diseases (asthmatic bronchitis, rhinitis,

conjunctivitis, atopic eczema, food allergy)

Psychological disorders (sleep disorders, aggressiveness,

fussiness, ‘supremacy’)

Savino F, et al. A prospective 10-year study on children who had severe

infantile colic. Acta Paediatrica, 2005; 94(suppl 449):129-132.

FACILITATION

Floyd Henry Allport. "The Physiological Basis of Human Behavior." Chapter

2 in Social Psychology. Boston: Houghton Mifflin Company (1924): 17-41.

Adapted from: Nolte, John. The Human Brain An Introduction to its

Functional Anatomy,6th ed. Philidelphia: Mosby Elsevier, 2009. Print.

Spinal Trigeminal

nucleus

C1 Rootlets

Visceral Afferents

(VII, IX, X)

Visceral Efferents (X)

Motor Efferents (IX, X)

TREATMENT OF COLIC

Rule out organic disease

Reassurance, reassurance, reassurance

Dietary interventions

Maternal diet restriction (big 5: gluten, dairy, egg, citrus, soy)

Formula changes

Herbal teas

Sugar water

Supplements

High fat diet per mother or fats added to infant diet

Pro- and pre-biotics

Medication

Simethicone

Dicyclomine

Methylscopalamine

Behavioral

Quiet area/decreased stimulation

Vibration (car ride, sitting on the dryer, etc)

Intensive parental training

Manual treatment/therapy

OMT

Chiropractic

Massage

WHAT MAY WORK

(ACCORDING TO THE LITERATURE)

Fennel extract tea

Chamomile, vervain, licorice, fennel, balm mint

Fennel has analgesic effect

Sucrose/glucose solutions

Sweetness may induce analgesic effect

Manipulation (of any sort)

Several showed benefit, but lack of blinding, small ‘n’ limited usefulness of the studies

Studies not well funded or of good trial design

Need better studies

Probiotics

L reuteri has been found to be helpful in several studies

QUICK OMT FOR THE COLICKY BABY

High yield areas to

evaluate and treat as

necessary

OA

Suboccipital inhibition/soft

tissue

Mid thoracic

Rib raising

Thoracolumbar junction

Myofascial release

Lumbar spine

Myofascial, especially upper

lumbars

Pelvic diaphragm

Myofascial release

Allie

Indications

Somatic dysfunction

Organic disease ruled out and “functional” cause is

suspected

Contraindications

??

Rule out organic disease

Follow contraindications for modalities

How often to treat?

Depends-weekly is most often, usually

Gauge how much help parents need

Treat parents as well if necessary

PELVIC DIAPHRAGM Myofascial release

LUMBAR SPINE

Myofascial release

Gra

y's

An

ato

my o

f th

e H

um

an

Bod

y s

ubje

ct #

256 1

157

THORACOLUMBAR JUNCTION

Myofascial release

MID-THORACIC SPINE AND RIBS

Rib raising

Gray's Anatomy of the Human Body Plate # 839

OCCIPITOATLANTAL JOINT

Soft tissue/inhibition

Also addresses upper

cervical spine

WHAT WE LEARNED

Colic is tough

There are no answers, lots of questions, lots of interesting research going on

Focus on helping parents cope

OMT for colic is focused on

Augmenting circulatory motion in the abdomen

Treating viscero-somatic and/or somato-visceral reflexes

Areas to focus on in the busy practice Look at diaphragms

pelvic, thoracic diaphragm

Mesenteric root

Mid-thoracic region

OA/upper cervicals

THANK YOU!

St. Mary’s Glacier, Colorado

REFERENCES

Wessel, MA, et al. Paroxysmal fussing in infancy, sometimes called colic. Pediatrics 1954;14;421.

Carreiro, Jane E. An osteopathic approach to children. Churchill Livingstone, 2003.

Sergueef, Nicette. Cranial osteopathy for infants, children and adolescents: a practical handbook. Elsevier Health Sciences, 2007.

Clifford TJ, Campbell MK, Speechley KN, Gorodzinsky F. Infant colic: empirical evidence of the absence of an association with source of early infant nutrition. Arch Pediatr Adolesc Med. 2002 Nov;156(11):1123-8.

Ali, AM. Helicobactor Pylori and Infantile Colic. Arch Pediatr Adolesc Med. 2012 Jul 1;166(7):648-50

Nolte, John. The Human Brain An Introduction to its Functional Anatomy,6th ed. Philidelphia: Mosby Elsevier, 2009. Print.

Garrison MM, Christakis DA. A Systematic Review of Treatments for Infant Colic. Pediatrics 2000;106(1):184-190.

Sung, V, et al. Probiotics to improve outcomes of colic in the community: Protocol for the Baby Biotics randomised controlled trial. BMC Pediatrics 2012; 12:135.

Szajewska H, Gyrczuk E, Horvath A. Lactobacillus reuteri DSM 17938 for the management of infantile colic in breastfed infants: a randomized, double-blind, placebo-controlled trial. J Pediatr. 2013 Feb;162(2):257-62. doi: 10.1016/j.jpeds.2012.08.004. Epub 2012 Sep 14.

Savino F, et al. A prospective 10-year study on children who had severe infantile colic. Acta Paediatrica, 2005; 94(suppl 449):129-132.

Hill D, et al. Effect of a Low-Allergen Maternal Diet on Colic Among Breastfed Infants: A Randomized, Controlled Trial. Pediatrics Vol. 116 No. 5 November 1, 2005; pp. e709 -e715 (doi: 10.1542/peds.2005-0147)

REFERENCES

Miller JE, Phillips HL. Long-tern effects of infant colic: A survey comparison of chiropractic treatment and non-treatment groups. J Manipulative Physiol Ther. 2009 Oct;32(8):635-8. doi: 10.1016/j.jmpt.2009.08.017.

Dobson D, et al. Manipulative therapies for infantile colic. Cochrane Database Syst Rev. 2012 Dec 12;12: CD004796. doi:10.1002/14651858.CD004796.pub2.

Bronfort G, et al. Effectiveness of manual therapies: the UK evidence report. Chiropr Osteopat. 2010 Feb 25;18:3. doi: 10.1186/1746-1340-18-3.

Perry R, Hunt K, Ernst E. Nutritional Supplements and Other Complementary Medicines for Infantile Colic: A Systematic Review. Pediatrics. 2011 Apr;127(4):720-33. doi: 10.1542/peds.2010-2098. Epub 2011 Mar 28.

Hayden C, Mullinger B. A preliminary assessment of the impact of cranial osteopathy for the releif of infantile colic. Complement Ther Clin Pract. 2006 May;12(2):83-90. Epub 2006 Feb 8.

Akman I, et al. Mothers' postpartum psychological adjustment and infantile colic. Arch Dis Child. 2006 May;91(5):417-9. Epub 2006 Feb 1.

Kheir, AEM. Infantile colic: facts and fiction. Ital J Pediatr 38 (2012): 34.

Radesky, JS, et al. Inconsolable infant crying and maternal postpartum depressive symptoms. Pediatrics. 2013 Jun;131(6):e1857-64. doi: 10.1542/peds.2012-3316. Epub 2013 May 6.

Gelfand AA, Thomas KC, Goadsby PJ. Before the headache: Infant colic as an early life expression of migraine. Neurology 2013;79;1392-1396.

Carson L et al. Abdominal Migraine: An underdiagnosed cause of recurrent abdominal pain in children. Headache 2011;51(5):707-712.

Romanello S, et al. Association between childhood migraine and history of infantile colic. JAMA 2013;309(15):1607-1612.

Roos S, et al. 454 Pyrosequencing analysis on faecal samples from a randomized DBPC trial of colicky infants treated with lactobacillus reuteri DSM 17938. PLoS One 2013; 8(2): e56710. doi: 10.1371/journal.pone.0056710.

Szajewska H, et al. Lactobacillus reuteri DSM 17938 for the management of infnatile colic in breastfed infnats: a randomized, double-blind, placebo controlled trial. J Pediatr 2013 Feb; 162(2):257-62. doi: 10.1016/j.peds.2012.08.004. Epub 2012 Sep 14.