EDUCATION - Colic, Constipation, Bottle/Breast Feeding

COLIC

Colic is more of a developmental "shtick" than a definable medical entity. Normal full term infants cry mostly during the evening hours and their crying behavior peaks in the second month of life, gradually decreasing thereafter. Classically, babies may become "colicky" at 3-5 weeks of age and the extended crying jags usually resolve by 3-4 months of age. Parents commonly describe an infant with prolonged crying periods and perceived "gassiness" with pulling up of the legs. The irritability often seems worst in the evenings or the middle of the night (of course!). Taking this into account, one clinician describes colic as "paroxysms of irritability, fussing, or crying lasting for a total of more than three hours a day and occurring on more than three days in any one week, for at least three weeks." However, other clinicians have documented that this probably falls into the normal spectrum of infant crying behavior.

Colic is a diagnosis of exclusion. A gassy, squirmy, cranky baby in the first two weeks of life may have other issues worth evaluating. Even in the classic age group, constipation, gastrointestinal reflux, formula sensitvities, and other medical problems must be considered. These treatable conditions may, occasionally, be mistaken for or aggravate colic. Scientific research has not identified any specific medical dysfunction with "colicky" babies, not even excess gas. Crying babies swallow a lot of air as they yell and scream; "gassiness" is probably more a byproduct of crying than the cause of colic (although there is probably something of a "vicious cycle" effect going on - crying leads to gas which leads to more crying). Although playing "formula change monopoly" is common, it often works only temporarily or not at all. Simethicon drops (a mild antigas medication), alcohol-free gripe water (dill) or camomille tea are sometimes helpful but most doctors will avoid the use of potent antispasmodic/sedative drugs. Many parents find that motion (carrying in snuglis or slings, swings, crib rockers, car rides) helps soothe the raging munchkin. Classical or New Age music, white noise tapes, or recorded "womb ultrasounds" may also be helpful.

Ultimately, time is the savior. The infants crying behavior will eventually subside - usually gradually. If a baby is feeding well, gaining weight well, and is developmentally normal, parents can usually relax with the thought that their "colicky" baby is a healthy baby.

CONSTIPATION

Constipation is a frequent and frustrating problem for many children. Even defining constipation may be difficult. Is it 3 days without a bowel movement, or is it hard, straining bowel movements, or is it simply a change from one’s usual regularity? Constipation is often defined as any or all of the above.

Although constipation can be annoying and even painful, serious medical causes in children are few and usually evidenced by failure to thrive, vomiting and abdominal distension. Nursing infants, particularly in the first 2 weeks of life, are less likely to be constipated. A pokey nursing connection may be the cause.

In dealing with constipation, prune juice is a simple, safe and cheap way to go, even for infants as young as 2-3 weeks. Many parents start with 1 ounce mixed in with the first formula feed of the day and then titrate up or down depending on results. If 2-3 ounces of prune juice per day doesn’t help or is irritating to the baby, malt supex may be helpful. This is simply a barley extract in liquid or powder form, available without prescription for a whopping $40+ for a large bottle. Titrate up or down from 1 tsp in 1-2 bottles per day. Karo syrup is much cheaper but somewhat controversial and often more irritating. If a constipated infant or young child is in pain, parents may administer a pediatric glycerin suppository or use Baby-Lax for immediate but temporary relief. In older children, a pediatric fleet enema may be used.

More potent laxatives such as senna products (Senokot, Ex-Lax), mineral oil or lactulose should be used with medical advice. These are commonly used for constipation in the 2 ½ – 5 year old who may be stool withholding as an ambivalent response to toilet training. In older kids and adolescents, psyllium products (Metamucil) may be helpful. Of course, a balanced, fiber-rich diet and good liquid intake is necessary for healthy regularity. Easier said than done.

BREAST FEEDING

Breast milk is the optimal food for infants in the first year of life. Breast milk provides high-quality proteins, suitable calories and the proper mineral content for infant growth. Breast milk also contains antibodies and macrophages from the mother’s immune system that help protect the infant from illness. Infants who breastfeed are less likely to have ear infections, respiratory infections, allergies, and gastrointestinal disease. Some mothers who breastfeed report a special bonding experience when they nurse their infant.

However, even though there are many advantages to breastfeeding, breastfeeding is a feeding system that requires practice and a lot of patience. Reading and/or watching videotapes prior to delivery help provide some basic information. Grandmothers, friends, nurses and lactation consultants are excellent resources in the first weeks to help with technique and answering specific questions.

Ideally, the infant should be placed on the breast shortly after birth. Initially the mother will produce colostrum- a thick yellow-white substance that provides a concentrated food source. Over the next few days, with the stimulation of the baby’s suck, the breast milk will be released and "let down" will occur spontaneously at the start of each feed. Initially, while the milk supply is trying to be established, mothers should try to nurse at least every one and a half to two hours during the day and at least every three to four hours at night. Infants may switch to a "on-demand" schedule within the first one to two weeks as long as the infant has regained his or her birth weight. We do not recommend allowing your baby to go more than four hours without breast feeding for the first couple of weeks.

Mothers are often worried that their baby is not getting enough to eat, especially in the first few days of life. Remember- no one's breast milk comes in before 3-5 days after birth. Babies are designed not to need tremendous amounts of milk before that time and do just fine with only their mother's colostrum. Most infants are tired initially after birth. It takes them some time to acclimate to their new environment that has new sights, sounds and food which is why all babies lose up to ten percent of their birth weight in the first few days after birth. It is important to remember that when you are breastfeeding you can not be exactly sure of the infant's intake, but you can follow the output. Your infant should have at least 6 to 7 wet and/or soiled diapers per day. Occasionally, if you use the super-absorbent diapers, it may be difficult to tell how many times your baby urinates during the day. If there is any question, you can always switch to old-fashioned cloth diapers for a few days. When cloth diapers get wet they stay wet and this may give you a more accurate feeling for how many times your baby is wetting. While the stool output can be variable, the urine output should always be present. If you are concerned that your infant is not urinating sufficiently, please contact the nurse and/or physician.

Mothers who are nursing should continue to take their prenatal vitamins and drink adequate fluid to keep up with their milk supply. Lanolin or other over-the-counter products may be applied to the mother's nipples regularly to help prevent dry and cracking nipples. It is also a good idea to leave the nipples open to air as much as possible. Breast feeding more frequently, for shorter time periods, may also help prevent sore nipples. Mothers need to be aware that most medications (prescription and over-the-counter) as well as alcohol, tobacco and caffeine are passed into the breast milk in small quantities. Mothers should review the medications that they take with their physicians.

Breastfeeding is not an all or none phenomenon. Some families choose to breastfeed and bottle-feed. Once breast feeding is well established, usually by about two weeks, many infants are able to accept a night time or occasional bottle. Bottle-feeding may be either pumped breast milk or formula. For some families this combination provides both the advantages of breast-feeding as well as a chance for the father to feed and the mother to rest.

Breast milk can be stored in the refrigerator for 48 hours, in the compartment freezer for 3-4 months, and in the deep freezer for 6 months. Previously frozen breast milk should be used within 24 hours and never refrozen. Frozen breast milk is best thawed under warm water. Microwave ovens may heat the milk unevenly, occasionally causing burns.

Infant feeding should be a nurturing and loving experience. Mothers need to choose for themselves which type of feeding is right for them. Infants can grow and thrive on breast milk, formula or some combination.

Bottle Feeding

Infant formula provides an excellent source of nutrition. There are many different formulas on the market today. Your physician will provide you with some guidance as to which formula is best for you and your infant. It is important to remember that all babies, both breast-fed and bottle-fed, will have periods of fussiness, gassiness, constipation and spitting up. These symptoms alone are not indications to change formulas. If you are concerned about your infant, please consult your physician prior to changing formulas.

Formula may be purchased as powder, concentrate or ready-to-feed. All three types contain the same nutritional components; however, there are slight differences secondary to their preparation. The powder is prepared by mixing a ratio of one scoop of formula (that is provided within the can of formula) with two ounces of water. The powder has the advantages of lower cost, ease in carrying large quantities, and ease in removing stains from clothing. The concentrate is made in a 1:1 ratio of concentrate to water. The ready to feed has the highest cost and is difficult to remove from clothing.

The water used for formula preparation can be the same water that is used by the rest of the household, whether it is tap or bottled. No boiling is needed. It is important to know whether your water supply has fluoride added. Contact the water bottling company or your local water supplier for more information. Infants who do not receive fluoride in the water should receive supplementation.

There are numerous bottles and nipples to choose from. The "best bottle" is the one that works the best for you and your infant. The bottles and nipples do not need to be sterilized or sanitized. Simple soap and water by hand or through the dishwasher will suffice.

The amount of formula you feed your infant is individual. Most newborns will feed 1 ½ - 2 ½ ounces every 3-4 hours but large babies may take more formula during each feed. As they grow infants will gradually take more and more formula. Infants have a natural instinct to suck. They will not necessarily pace themselves while they are feeding. By allowing times to pause and burp, the infant will release air that they have swallowed without spitting up too much. Sometimes infants will eat faster than their stomach can empty. In these circumstances, the infant may spit up or vomit a portion of their feed. Most importantly, the type and amount of formula should provide good steady growth as documented at each well child visit.