Colic infantile by liaoqinmei

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									Clinical Knowledge Summaries: Previous version – Colic - infantile




Colic — infantile
This PRODIGY guidance topic is obsolete and has been replaced by a CKS Topic Review.
Please visit www.cks.library.nhs.uk to find the latest version.

About this topic
Have I got the right topic?
Age under 6 months
This guidance covers the management of infantile colic.
This guidance does not cover the management of other forms of colic.
The target audience for this guidance is healthcare professionals working within the NHS in
England, and providing first contact or primary health care. Patient information from NHS Direct
is intended to be printed and given to people with this condition, and the Shared decision making
sections are designed to provide a focus for discussion during the consultation about the
treatment options.

Changes
Version 1.0.0, revision planned in 2007.
Last revised in November 2004
October 2005 — minor technical update. Issued in November 2005.

Previous changes
June 2004 — reviewed. Validated in September 2004 and issued in November 2004.
June 2001 — reviewed. Validated in November 2001 and issued in April 2002.
September 1998 — written.

Update
New evidence
Evidence-based guidelines
No new evidence-based guidelines since 1 March 2007.
HTAs (Health Technology Assessments)
No new HTAs since 1 March 2007.
Economic appraisals
No new economic appraisals relevant to England since 1 March 2007.
Systematic reviews and meta-analyses
No new systematic review or meta-analysis since 1 March 2007.
Primary evidence
No new high quality randomized controlled trials since 1 March 2007.

New policies
No new national policies or guidelines since 1 March 2007.

New safety alerts
No new safety alerts since 1 March 2007.

Changes in product availability
No changes in product availability since 1 March 2007.

Concise knowledge for clinical scenarios
Which therapy?
    •    Exclude common causes of excessive crying such as hunger, cold, discomfort, or
         itch.
    •    Reassure parents that infantile colic:
               o  Is a condition that usually resolves within 3–4 months.
               o  Is not due to them doing something wrong.
               o  Does no physical harm even if there is a poor response to treatment (as is
                  often the case).
    •    Advise the parents:

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Clinical Knowledge Summaries: Previous version – Colic - infantile



              o    Simple strategies may help them cope: e.g. checking the baby is not hungry,
                   checking the nappy, establishing a routine to the day, avoiding carrying and
                   holding the baby excessively, and not intervening immediately when the baby
                   cries.
             o     They should schedule 'time out', and should share caring for the baby.
             o     Herbal products are not recommended. Some (e.g. star anise) have poisoned
                   babies. None have been shown to be safe.
             o     Many alternative therapies are promoted, but none have been shown to be
                   effective, and they may be expensive.
    •    Consider the following factors before prescribing any trial of therapy:
             o     Level of distress of the parents — and their response to advice and
                   reassurance
             o     Ability of the parents to cope — assess coping abilities on follow-up
             o     Levels of evidence supporting therapeutic interventions — this is
                   limited
    •    Consider sequential trials of eliminating lactose then cows' milk protein or a trial of
         simeticone (activated dimeticone).

Sequential trials of eliminating lactose then cows' milk protein, or a trial of simeticone
    •    Eliminate lactose with lactase, or low-lactose milk formula; reassess after about
         a week.
    •    Sustained response to lactose elimination:
              o     Continue until about 12 weeks of age.
              o     Wean on to usual milk over 1 week.
    •    No sustained response to lactose elimination:
              o     Eliminate cows' milk protein; reassess after about a week.
                         ▪     Breastfed infants: mother eliminates all dairy products from her
                               diet.
                         ▪     Formula fed infants: hypoallergenic milk formula.
    •    Response to hypoallergenic diet:
              o     Refer for specialist advice.
              o     Continue until weaned on to solids.
    •    No response to hypoallergenic diet:
              o     Consider possibility of rare conditions.
              o     Refer if concerned.
    •    Simeticone (activated dimeticone) could be considered for a trial. Take personal
         preferences into account when deciding whether to try simeticone before or after trials
         of dietary modification.

Practical prescribing points
For further information please see the Medicines Compendium (www.medicines.org.uk) or the
British National Formulary (www.bnf.org).

Should I refer or investigate?
Refer?
    •    Refer to the health visitor if the parents/carers are struggling to cope on their own.
    •    Refer to dietician if cows' milk allergy is strongly suspected.
    •    Refer to paediatrician or paediatric gastroenterologist as appropriate if a serious
         medical condition is suspected in the baby.
    •    Refer as appropriate if a serious psychosocial disorder is suspected in parents.

Follow-up advice
Prescriptions
Advice note
Advice only: symptom management
    •    Age under 6 months
    •    Advice: Colic is common. The cause is not known. In most babies it has gone by 3-4
         months. There is little evidence that the available medicines are effective but they may
         be worth a try. Try not to over handle the baby or become anxious - colic does not
         harm the baby. If possible have 'time out', for example by arranging a 'rota' of colic
         times with other family members. Stopping cows' milk from the diet may help in some

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Clinical Knowledge Summaries: Previous version – Colic - infantile



          babies. It may be worth a try for a week if colic is severe. For breastfed babies, this
          means the mother stops eating all dairy produce. For bottle fed babies it means
          switching to a special type of baby feed. Let your health visitor know if things become
          difficult to cope with.

1-week trial of eliminating lactose
Breastfed or bottle-fed infants: lactase drops
Age under 6 months
     •    Tilactase 50,000units/g oral drops. Add to the prepared feed (or expressed breast milk)
          as directed in the instructions to patient. Supply 7 ml.
     •    NHS Cost £7.00
     •    OTC Cost £9.00
     •    Licensed use: no

Bottle-fed infants: SMA LF low-lactose infant milk formula
Age under 6 months
     •    SMA LF powder. Use as baby milk. Follow directions on the side of the container.
          Supply 430 grams.
     •    NHS Cost £3.99
     •    OTC Cost £4.99
     •    Licensed use: no

Bottle-fed infants: Enfamil Lactofree infant milk formula
Age under 6 months
     •    Enfamil Lactofree powder. Use as baby milk. Follow directions on the side of the
          container. Supply 400 grams.
     •    NHS Cost £3.51
     •    OTC Cost £4.50
     •    Licensed use: no

1-week trial of eliminating cows milk protein
Breast-fed infants: advice note
     •    Age under 6 months
     •    Advice: Some babies cry less if cows milk is stopped, but this does not occur in most
          babies. However, if colic is severe, it may be worth Mum trying without cows milk for
          one week. This means not having any dairy products as part of the cows milk can get
          into breast milk. If there is an improvement, continue without cows milk until the baby
          is three months old. Colic is not a 'true' allergy though, and after the colic has settled
          the baby will be able to take cows milk again. If there is no improvement after one
          week, there is no point in continuing without cows milk, and you should resume normal
          feeds.

Bottle-fed infants: Nutramigen 1 milk formula (casein-based)
Age under 6 months
     •    Nutramigen 1 powder. Use as baby milk. Follow directions on the side of the container.
          Supply 425 grams.
     •    NHS Cost £7.81
     •    OTC Cost £11.51
     •    Licensed use: no

Bottle-fed infants: Pregestimil milk formula (casein-based)
Age under 6 months
     •    Pregestimil powder. Use as baby milk. Follow directions on the side of the container.
          Supply 400 grams.
     •    NHS Cost £8.91
     •    OTC Cost £13.00
     •    Licensed use: no

Bottle-fed infants: Pepti-Junior milk formula (whey-based)
Age under 6 months
     •    Pepti-Junior powder. Use as baby milk. Follow directions on the side of the container.
          Supply 450 grams.

This PRODIGY guidance topic is obsolete and has been replaced by a CKS Topic Review.
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Clinical Knowledge Summaries: Previous version – Colic - infantile



    •    NHS Cost £8.80
    •    OTC Cost £13.00
    •    Licensed use: no

1-week trial of simeticone drops
Simeticone (activated dimeticone) drops
Age under 6 months
    •    Simeticone 40mg/ml oral suspension sugar free. Give one dropperful (0.5ml) before
         each feed. Increase to two dropperfuls (1ml ) if required. Supply 50 ml.
    •    NHS Cost £1.97
    •    OTC Cost £3.29
    •    Licensed use: yes

Drug rationale
Drugs not included
    •    Antimuscarinic drugs are not recommended. There is limited evidence that
         dicycloverine (dicyclomine) reduces crying compared with placebo. However, serious
         adverse effects can occur, including breathing difficulties, seizures, syncope, asphyxia,
         apnoea, muscular hypotonia, and coma [Kilgour and Wade, 2003]. Dicycloverine is
         contraindicated in infants under the age of 6 months. Antimuscarinic drugs are used for
         colic causing abdominal pain in adults and older children. However, they have no place
         in the treatment of infantile colic.
    •    Soya formula milk: the Chief Medical Officer has advised that soya-based infant
         formulas should not be used as first choice in the management of infants with proven
         cows' milk sensitivity, lactose intolerance, galactose deficiency or galactosaemia [CMO,
         2004]. This follows a report from the Committee on Toxicity advising that soya-based
         formulations have a high phytoestrogen content which could pose a risk to the long-
         term reproductive health of infants [Committee on Toxicity, 2003].

Drugs included
    •    Lactase added to usual milk for a minimum of 3 days. There is limited evidence
         that the symptoms of infantile colic can be relieved if parents use lactase to eliminate
         lactose from infant formula and expressed breast milk. Lactase 50,000 units/gram
         drops are available on NHS prescription when endorsed ACBS by the prescriber.
    •    Low-lactose formula milk. There is an absence of evidence for the efficacy of low-
         lactose infant milk formulas. However, if parents find benefit from using lactase to
         eliminate lactose from infant formula, it would seem reasonable to expect that similar
         success would be obtained if they used an infant milk formula with no lactose. Low-
         lactose infant milk formulas available on NHS prescription (when endorsed ACBS by the
         prescriber) are SMA LF® and Enfamil Lactofree®.
    •    Hypoallergenic milk formula. There is weak evidence of efficacy for hypoallergenic
         milk formula derived from either casein or whey hydrolysate. Hypoallergenic infant milk
         formulas available on NHS prescription (when endorsed ACBS by the prescriber) are:
              o     Casein hydrolysate milk formula: Nutramigen 1® and Pregestimil®
              o     Whey hydrolysate milk formula: Pepti-Junior®
    •    Simeticone (activated dimeticone). There is no convincing evidence of benefit but it
         is widely used, cheap and safe. A low-sodium, sugar-free formulation is included.

Shared decision making
    •    The cause of colic is not known. Colic has usually gone by 3–4 months of age.
    •    Tips which may help include:
              o   If possible, arrange to have 'time out'. For example, by having a 'rota' of colic
                  times with other family members.
              o   A trip out in a pram or car.
              o   'White noise' such as a washing machine or vacuum cleaner.
    •    Medicines do not usually help.
    •    Lactose intolerance may be a factor in some cases.
              o   Adding lactase to the usual milk (breast or formula) may help.
              o   An alternative is to use a low-lactose milk formula.
    •    Eliminating cows' milk may be worth a try.
              o   For breastfed babies, this means that the mother stops eating all dairy
                  produce for the trial period.


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Clinical Knowledge Summaries: Previous version – Colic - infantile



              o   For bottle-fed babies, it means switching to a special 'hypoallergenic' milk
                  formula for the trial period.
    •    Soya milk is usually not recommended.
    •    Let your health visitor know if things become difficult to cope with.

Detailed knowledge about this topic
Goals and outcome measures
Goals
    •    To reduce parental anxiety and stress
    •    To relieve the baby's symptoms

Outcome measures
    •    Parents' and carers' ability to cope
    •    Frequency and duration of crying

Background information
What is it?
    •    Infantile colic causes repeated episodes of excessive and inconsolable crying in an
         infant that otherwise appears to be healthy and thriving.
    •    For research purposes infantile colic is defined as crying for at least 3 hours a
         day, at least 3 days a week, and for at least 3 weeks' duration [Garrison and
         Christakis, 2000].
    •    The underlying cause of infantile colic is unknown and may be due to multiple
         factors. Theories include transient intolerance to lactose and/or cows' milk protein, and
         psychosocial factors (e.g. emotional and behavioural problems in the mother) [Gupta,
         2002].

How common is it?
    •    Estimates of prevalence range from 5–20% of infants [Lucassen et al, 2001].
    •    Maternal smoking may be associated with infantile colic [Reijneveld et al, 2000].
    •    A large community survey found that colic was more likely to be reported with
         breastfeeding [Crowcroft and Strachan, 1997]. However, this result may be biased by
         methodological problems in the study [Lucassen et al, 2001].

How do I know my patient has it?
    •    Colic starts in the first weeks of life and usually resolves by the age of 3–4 months.
    •    Crying typically occurs in the late afternoon or evening.
    •    Frequently noted features are high-pitched, inconsolable crying, flushing of the
         face, drawing up of the legs, passing of wind, and difficulty in passing stools. However,
         these are not specific to infantile colic [Lucassen et al, 1998; Reust and Blake, 2000].
    •    History and examination reveal no abnormality other than inconsolable crying.

What else might it be?
    •    Discomfort e.g. poor feeding technique, hunger, pain, cold, heat, or itch.
    •    Parental psychosocial problems e.g. excessive concern, inability to interact
         normally with the baby.
    •    Gastrointestinal conditions:
             o    Gastro-oesophageal reflux disease (GORD) can present with excessive
                  crying. But this is less intense than in infantile colic and is usually
                  accompanied by visible regurgitation and sometimes by respiratory
                  symptoms due to aspiration. These babies may have difficulty feeding and
                  sucking, and discomfort associated with feeding [Miller-Loncar et al, 2004].
             o    Acute intestinal conditions such as intussusception, volvulus, and
                  strangulated hernia may need to be excluded if symptoms started suddenly
                  and recently.
    •    Metabolic conditions e.g. lactose intolerance, cows' milk intolerance.
    •    Cognitive deficit
             o    A prospective cohort study found that, at the age of five years, children who
                  had had prolonged crying (defined as symptoms of infantile colic reported at
                  the ages of 6 weeks and 13 weeks) had an adjusted mean IQ 9 points lower
                  than children who had not had colic [Rao et al, 2004].


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Referral for specialist advice may be required if, on follow-up, the history and examination cannot
confirm that the parents are coping and that the child is otherwise well and thriving.
[Gupta, 2002]

Complications and prognosis
     •    Babies usually 'grow out' of infantile colic by 3–4 months of age.
     •    The child suffers no harm in the short term, although some doubts have been raised
          about long-term outcomes:
                o    Some studies have suggested an association with later psychosocial problems
                     in the child and family [Gupta, 2002].
                o    There is conflicting evidence for an association with the later development of
                     allergies [Gupta, 2002].
     •    A prospective cohort study found that, at the age of five years, children who had had
          infantile colic that had resolved by the age of 13 weeks had no detectable cognitive
          deficit [Rao et al, 2004].
     •    Infantile colic causes significant suffering:
                o    Parents are distressed and sleep deprived.
                o    Stress on the parents may affect their relationships with the child.
                o    Breastfeeding might be stopped earlier and weaning on to solid foods begun
                     sooner than otherwise would have happened.

Management issues
How do I manage infantile colic?
     •    Exclude common causes of excessive crying such as hunger and discomfort from
          pain, cold, heat, and itch.
     •    Reassure the parents. This alone may suffice. Reassure them that:
               o    Although most babies do not respond to treatment, no physical harm is done
                    by colic.
               o    Most infants are free of symptoms by the age of 3–4 months.
               o    Parents are in no way at fault.
     •    Advise the parents:
               o    They may need to 'take time out', and they should share caring for the baby.
               o    Interventions such as increased carrying, early/delayed response to crying,
                    soothing motion, or 'white noise' (e.g. from a vacuum cleaner) have not been
                    shown to be effective, but they may be worth trying as they are safe,
                    inexpensive, and involve the parents.
               o    Some herbal products (e.g. star anise) have poisoned babies, and these are
                    not recommended.
               o    Many alternative therapies are promoted, but none have been shown to be
                    effective, and they may be expensive.
     •    Consider therapeutic intervention after weighing up the following factors:
               o    The level of distress of the parents.
               o    The ability of the parents to cope — on follow-up assess the level of
                    confidence that reassurance and explanation have given them.
               o    The evidence to support therapeutic interventions — the evidence is limited
                    and the interventions may be costly for prolonged treatment.
     •    Consider sequential trials of eliminating lactose then cows' milk protein, or a trial of
          simeticone (activated dimeticone).

Sequential trials of eliminating lactose then cows' milk protein, or a trial of simeticone
     •    Begin a trial of lactase added to the usual milk or, alternatively, a trial of low-
          lactose milk formula, and reassess in about a week.
               o   Breastfed infants:
                        ▪     Lactase is advised to avoid having to change to an infant milk
                              formula
               o   Formula-fed infants:
                        ▪     Some mothers might prefer lactase to avoid having to change
                              infant milk formulas if the infant is fussy about their milk.
                        ▪     Other mothers might find a low-lactose infant milk formula more
                              convenient than lactase.
     •    Sustained response to lactose elimination:
               o   Continue lactose elimination until about 12 weeks of age.

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               o     Then, over about 1 week, wean to usual milk. Suddenly changing to the usual
                     milk is not recommended because it is theoretically possible that temporary
                     lactose intolerance might have been induced by the extended period over
                     which the gut has lacked the stimulation by lactose to produce lactase.
     •    No sustained response to lactose elimination:
               o     Consider a trial eliminating cows' milk allergens for several days.
                          ▪     Breastfed infants: mother eliminates all dairy products from her
                                diet.
                          ▪     Formula-fed infants: give a hypoallergenic milk formula.
     •    Sustained response to elimination of cows' milk antigens:
               o     Refer for specialist advice.
               o     Continue elimination diet until weaned on to solids.
     •    No sustained response to elimination of cows' milk antigens:
               o     Consider the possibility of rare but serious conditions that would usually
                     present with features such as failure to thrive.
               o     Refer if concerned:
                          ▪     Health visitors can support parents.
                          ▪     Specialists can help with the diagnosis and management of rare
                                conditions.
     •    Simeticone (activated dimeticone) could be considered for a trial. As supporting
          evidence of efficacy is limited, the decision to try simeticone before or after trying
          dietary alterations depends largely on personal preferences and cost.

Supporting evidence
There is limited evidence to support the above protocol, but the underlying theory is plausible, no
better treatments are available, it is safe and relatively inexpensive, and a similar approach is
advocated by the 'Expert Working Group' [Marks et al, 2003].

Using lactase to reduce the levels of lactose in milk formula or breast milk
     •    Lactase added to milk formula or, for breastfed babies, the expressed foremilk, has
          been studied in four small randomized controlled trials. Methodological weaknesses in
          the trials make it difficult to place much weight on the claims of benefit [Kilgour and
          Wade, 2003].

Using low-lactose infant milk formulas to reduce the levels of lactose in the diet
     •    Low-lactose formula milks containing cows' milk proteins have not been studied as a
          treatment for infantile colic [Kilgour and Wade, 2003].

Using hypoallergenic infant milk formulas to eliminate cows' milk proteins from the baby's
diet
     •    Whey hydrolysate formula milk, in one study of 43 infants, reduced crying by 63
          minutes a day, but the 95% confidence interval was very wide (from 1 to 127 minutes
          crying/day) and the blinding may have been unmasked [Lucassen et al, 2000; Kilgour
          and Wade, 2003].
     •    Casein hydrolysate formula milk has limited evidence of benefit: there have been two
          small randomized controlled trials and both have methodological weaknesses [Forsyth,
          1989; Hill et al, 1995; Kilgour and Wade, 2003].
     •    Soya-based infant feeds were found to reduce the duration of crying compared with
          standard cows' milk formula in one randomized controlled trial of 19 infants [Campbell,
          1989; Kilgour and Wade, 2003]. The Chief Medical Officer recommends that soya infant
          milk formulas should not be the first choice of treatment for cows' milk sensitivity or
          lactose intolerance [CMO, 2004]. This is because they have a high phytoestrogen
          content, and this may pose a risk to future fertility and sexual development
          [Committee on Toxicity, 2003].

Excluding dairy products from the diet of breastfeeding mothers
     •    For breastfed infants intolerant of cows' milk protein, a trial of continuing breastfeeding
          while excluding dairy products from the mother's diet might be effective, because
          breast milk contains intact cows' milk proteins. But, there are no randomized controlled
          trials to test this hypothesis [DTB, 1992; Lucassen et al, 1998].

Drug treatments
     •    Dicycloverine (dicyclomine), an antimuscarinic antispasmodic, is effective, and
          historically has been widely used. However, dicycloverine is not safe: serious adverse
          effects include breathing difficulties, seizures, syncope, asphyxia, apnoea, muscular
          hypotonia, and coma [Kilgour and Wade, 2003].

This PRODIGY guidance topic is obsolete and has been replaced by a CKS Topic Review.
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Clinical Knowledge Summaries: Previous version – Colic - infantile



              o    Antimuscarinics are used for colic and abdominal pain in adults and older
                   children. However, they have no place in the treatment of infantile colic.
    •    Simeticone (activated dimeticone) has been commonly used to treat infantile colic.
         Two trials in a total of 110 babies showed no significant difference, while a third trial in
         26 babies had methodological limitations and found a small improvement in the
         number of crying attacks on days 4–7 of treatment [Lucassen et al, 1998; Garrison and
         Christakis, 2000; Kilgour and Wade, 2003].

Behavioural interventions
    •    Evidence for the efficacy of behavioural interventions comes from studies with
         methodological weaknesses [Garrison and Christakis, 2000].
    •    Other strategies, such as increased carrying, early response to crying, soothing motion,
         car-ride simulators, white noise and so on, have not been shown to be of benefit
         [Garrison and Christakis, 2000].

Miscellaneous treatments
    •    Herbal teas and infusions:
               o     Japanese star anise is neurotoxic and has been reported to have poisoned
                     babies, possibly by contaminating Chinese star anise, which has been
                     advertised as a remedy for infant colic [Minodier et al, 2003].
               o     One trial of an infusion with five different herbs showed a marked decrease in
                     crying, but there were methodological problems with the study, and the
                     safety of the infusion has not been established [Garrison and Christakis,
                     2000].
               o     Fennel seed oil emulsion, in a randomized placebo-controlled trial of 125
                     infants with colic, eliminated symptoms in 65% of the treatment group and
                     24% of the placebo group, p <0.01, but its safety has not been established
                     [Alexandrovich et al, 2003].
    •    Sucrose: sucrose seems to have a pacifying effect, but the benefit is so short-lived
         that it is not a practical treatment [Garrison and Christakis, 2000].
    •    Chiropractic spinal manipulation: one randomized, blinded trial showed no
         difference from placebo [Olafsdottir et al, 2001]. An earlier trial of spinal manipulation
         reported improvement with respect to simeticone (activated dimeticone) [Wiberg et al,
         1999], but interpretation of the results is marred by methodological weaknesses.
    •    Cranial osteopathy: no randomized controlled trials were found [Kilgour and Wade,
         2003]. One randomized controlled trial of 25 infants with colic compared treatment
         with infant massage with treatment with a crib vibrator and found no statistically
         significant difference [Kilgour and Wade, 2003].

What resources can support parents of babies with infantile colic?
CRY-SIS is a support group for families with excessively crying, sleepless, and demanding
children. Their helpline is available every day from 9 am to 10 pm. Tel: 08451 228 669.
The CRY-SIS website is at: www.cry-sis.org.uk.

What infant milk formulas are available on NHS prescription? And, how do they
differ?
Low-lactose and lactose-free infant milk formulas
    •    Low-lactose infant formulas are prepared by removing almost all lactose from cows'
         milk, and the resultant product is 'clinically lactose free'. Completely lactose-free milks
         are prepared from non-milk sources of protein, fat, carbohydrate, and micro-nutrients.
    •    Available, clinically lactose-free infant milk formulas (with cows' milk protein) are:
              o    Enfamil Lactofree® and SMA LF®.

Hypoallergenic infant milk formulas
    •    Hypoallergenic infant milk formulas are made from hydrolyzed cows' milk protein
         (casein or whey) or other sources of protein such as soya.
    •    Hypoallergenic infant milk formulas are also low in, or free of, lactose.
    •    Available infant milk formulas are:
               o    Casein hydrolysate — Nutramigen 1® and Pregestimil®
               o    Whey hydrolysate — Pepti-Junior®
    •    The Chief Medical Officer recommends that soya infant milk formulas should not be the
         first choice of treatment for cows' milk sensitivity or lactose intolerance [CMO, 2004].
         This is because they have a high phytoestrogen content, and this may pose a risk to
         future fertility and sexual development [Committee on Toxicity, 2003].


This PRODIGY guidance topic is obsolete and has been replaced by a CKS Topic Review.
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Clinical Knowledge Summaries: Previous version – Colic - infantile



Managing treatments with lactase and infant milk formulas
Lactase
     •    Formula feeding: add two drops of lactase to the feed; shake gently; refrigerate for
          about 4 hours before warming and feeding.
     •    Breastfeeding: express the foremilk into a sterile container; add four drops of lactase;
          breastfeed as usual, and give foremilk with lactase at the end of the feed.
     •    Stopping treatment: stop treatment after about 1 week if there has been no
          response. If there has been a response, wean off the lactase over about 1 week after
          the age of 3 months.

Low-lactose, lactose-free, and hypoallergenic infant milk formulas
     •    Feeding is the same as with usual infant milk formulas. Preparation is similar; full
          instructions are with the packaging.
     •    Continue a trial of treatment until the product is finished, unless it is poorly tolerated.

References
NHS staff in England can link, free of charge, from references to the full text journal
articles by clicking on [NHS Athens Full-text]. You will need an NHS Athens password to
access these resources. Click here for Athens registration.
All references with links to [Free Full-text] are freely available online to users in
England and Wales. This includes the full text of Department of Health papers and Cochrane
Library reviews.
1    Alexandrovich, I., Rakovitskaya, O., Kolmo, E. et al. (2003) The effect of fennel (Foeniculum
     vulgare) seed oil emulsion in infantile colic: a randomized, placebo-controlled study.
     Alternative Therapies in Health and Medicine 9(4), 58-61. [NHS Athens Full-text]
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This PRODIGY guidance topic is obsolete and has been replaced by a CKS Topic Review.
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Clinical Knowledge Summaries: Previous version – Colic - infantile



18   Olafsdottir, E., Forshei, S., Fluge, G. and Markestad, T. (2001) Randomised controlled trial
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21   Reust, C.E. and Blake, R.L., Jr. (2000) Diagnostic workup before diagnosing colic. Archives
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22   Wiberg, J.M., Nordsteen, J. and Nilsson, N. (1999) The short-term effect of spinal
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