Parents frequently present to their family doctor with concerns related to infant feeding. Common issues that cause worry include whether breastfeeding is successful, whether weight gain is adequate, is crying or vomiting normal, how to manage constipation and how to ensure a balanced diet in their strong-willed toddler. 

There are several common functional GI disorders in infants ie. when symptoms occur within the expected range rather than have an identifiable structural or biochemical cause. These can all be identified and dealt within the consultation with a dual approach of addressing both symptoms and parental concerns. 

A recent study suggested that these conditions can sometimes be neglected and more research is needed, as quality of life is reduced.¹ An Irish study also recommended that these conditions deserve greater recognition more generally.²

Healthy eating for infants and toddlers means consuming a combination of age-appropriate foods that provide sufficient energy and nutrients to allow for growth and development and which also help to optimise health and reduce the risk of disease. 

Exclusive breastfeeding for six months is the feeding option of choice for early infancy as it ensures protection against bacterial and viral infection in addition to its nutritional superiority. Sadly, many studies have shown that fewer than 50% of Irish mothers initiate breastfeeding and a much smaller number continue exclusive breastfeeding for six months.

Prior to discharge home, mothers should be advised to feed their babies frequently, to keep their infant on the first breast until a feed is completed, not to time feeds and to avoid the use of dummies and supplemental formula feeds. No specific intervention is required for bilateral inverted or retractile nipples. They should be advised to seek help if their infant is producing scant urine, is lethargic or extremely fretful, if no swallowing is felt or heard or if there is extreme nipple soreness or breast engorgement that persists after the first week. 

Where there is more than the usual weight loss (ie. over 8% of birth weight), the infant should be carefully evaluated and may require review by a paediatrician. One may supplement with expressed breast milk or formula milk (rarely). 

Assessment of urea and electrolytes is essential as the most serious consequence of inadequate intake is hypernatraemic dehydration which although rare, is potentially life-threatening. Significantly, the infant may not appear dehydrated as normal skin turgor is maintained.

Enthusiastic support and monitoring of breastfeeding mothers is essential to promote continuation of breast-feeding following discharge from hospital.

Infant formulae are based on modified cow’s milk. Breast milk or infant-based formula should be the main milk drink for the first year of life and unmodified cow’s milk should not be used as the main milk drink before the age of one year. All specialised formula should be used under medical supervision. 

Infant formula is either whey dominant or casein dominant. Whey dominant formula is designed to reflect the composition of breast milk and casein-dominant formula is similar to cow’s milk. Weaning the infant onto solids is seldom necessary before six months.

Gastro-oesophageal reflux

Gastro-oesophageal reflux (GOR) occurs in up to 50% of normal healthy infants and involves the passage of gastric contents into the oesophagus with or without regurgitation and vomiting. It is a normal physiological process that occurs several times a day.

Most reflux episodes last less than three minutes and occur in the period following feeds. GOR affects breast-fed and formula-fed infants equally. Very few require treatment with H2 antagonists or omeprazole.

Colic affects up to 15% of young infants and is not related to ‘silent reflux’ but, if severe, can be related to cow’s milk protein intolerance. Bowel habit is highly variable in early infancy and one should not overreact to minor changes in stool frequency. 

Lactose intolerance is very rare, causes watery acidic stools and an associated nappy rash. Food allergies affect over 5% of infants, with both milk and egg being the most common food allergens  

GOR gradually decreases with age so that by 12-15 months of age, only 5% of infants regurgitate. A small number of infants will have gastro-oesophageal reflux disease (GORD) with significant oesophagitis and symptoms of forceful vomits, poor weight gain, inconsolable crying, back arching and feed refusal after starting  

Simple advice to manage GOR is to:

• Keep the baby upright for at least 30 minutes after a feed
• Raise head of the cot to a 30-degree angle
• Avoid use of car seats immediately after feeding
• Avoid clothing or nappies that are tight around the abdomen
• Check volume of feeds and avoid over-feeding
• Feed thickening with carob bean gum and maltodextrin (Carobel) – one scoop per 150ml and allow to stand for three to four minutes after adding. Pre-thickened feeds thicken on contact with stomach acid. Prepare using previously boiled water that has been chilled and vigorously roll bottle between hands
• Antacids such as sodium and magnesium alginate (Gaviscon) form a surface gel over the milk. Gaviscon shouldn’t be used with feed thickeners or pre-thickened formulae. A trial of Gaviscon is best reserved for breast-fed infants
• Use ranitidine or omeprazole only if the infant is unresponsive to simple measures as above
• Barium swallow is not recommended for GOR.

Referral for specialist opinion if:

• Not thriving
• Blood-stained vomitus
• Bilious vomiting
• Consistent forceful vomiting
• Severe distress during or shortly after feeds
• Recurrent apnoea.

Growth in infancy is rapid and typically infants gain 6-7kg during their first year. Thereafter the growth slows down and toddlers take on a leaner physique as they become more active. Children aged one to five years typically gain 1-3kg per year. When weight gain is below that expected, the term ‘failure to thrive’ or ‘faltering growth’ is used. 

A toddler’s growth may falter after an illness or if the child is a fussy or restrictive eater. Failure to thrive can also be caused by an illness or medical condition, so referral is necessary if weight gain is very poor or if the child has lost weight. Indicators that an infant or child may not be thriving include:

• Documented sustained weight loss
• Downward crossing of more than two major centile lines on standard centile charts 
• Weight below 0.2 centile.

Colic

“Colic is not serious unless you happen to be the infant’s parents!”

Healthy babies signal their need for a response from their caregiver (usually their mother) along a gradient of progressively intense cues beginning with changed breathing patterns to increasing movements and vocalisations, and finally to a full-blown cry. 

The excess crying typically begins at about two weeks of age, reaches a peak sometime in the second month and then declines to baseline levels at about four months of age. Crying tends to cluster during the late afternoon and evening. It occurs in prolonged bouts and these bouts are resistant to all kinds of soothing attempts, including feeding.  

During such bouts, infants may clench their fists, flex their legs, arch their backs and grimace giving the impression that they are in pain. The crying bout may include regurgitation and the passage of gas per rectum. Although most infants who cry excessively in the first three months have no long-term adverse effects, excessive crying is not a trivial issue as it places families under measurable strain. 

While it is often difficult to determine when an infant should be considered to have colic, the most widely used definition is that proposed by Wessel and colleagues and is known as the ‘rule of threes’.³ An infant should be considered to have colic if he/she cries for more than three hours per day for more than three days per week for three weeks. 

However, this definition has its limitations in that the actual duration of crying may be difficult to quantify and very few parents are prepared to wait three weeks until an official announcement proclaiming that their infant has colic is made! It is important to note that most cases of colic cannot be accounted for by pre-existing maternal personality characteristics, postnatal depression or non-optimal caregiving. 

Due to inexperience, first-time mothers may bring their crying infants to medical attention more often but there is no difference in the amount of crying in first-born and later-born infants. Thus most cases of colic are unlikely to be due to problems in either the mother or infant, Differences in caregiving (such as the amount of contact, the frequency and type of feeding) may modify both the duration and pattern of crying.

Conditions that may underlie excessive crying

Infection

Always enquire about a history of recent fever as the presence of fever in an under-three-month-old may indicate the possibility of a serious bacterial infection (urinary tract infection, septicaemia or meningitis). 

Feeding issues 

There is an important link between feeding problems and excessive crying. Refusal to feed and excessive crying are not related to silent gastro-oesophageal reflux (GOR). Difficulties with breastfeeding (such as problems of attachment or positioning) may put susceptible infants at risk of increased crying and aversive feeding behaviours. 

Functional lactose overload occurs when the breastfeeds do not contain enough fat, resulting in rapid milk transit through the intestine. Undigested lactose ferments in the colon with resulting explosive or frothy stools, excessive crying and a desire to feed very often.  

Cow’s milk protein (CMP) allergy

There are many symptoms of this common condition including gastrointestinal, dermatological and respiratory. Signs of this as a cause of excessive crying include infants with ‘high-pitched’ crying, infants who regularly arch their backs during crying bouts, and cases where the crying pattern does not fit a pattern of evening clustering. 

A late onset of increased crying in the third month of life or following a switch from breast to formula milk may implicate CMP allergy. The management approach is to take the problem seriously and to ensure that feeding is adequate for the infant. A switch to an alternative suitable infant formula may be appropriate. A detailed examination of the infant is important and this can include family history. In cases of very severe symptoms, referral may be warranted.

Lactose intolerance

The main symptoms of carbohydrate or lactose intolerance are watery loose stools, abdominal distension and poor weight gain. The skin around the bottom becomes excoriated and red due to the acid character of the stools. Transient lactose intolerance may follow gastroenteritis (one in 10 cases) and should be suspected if loose stools recur within three days of the re-introduction of a lactose-containing milk.

The diagnosis of lactose intolerance can be made by testing the watery portion of the stool (bowel motion) with Clinitest tablets while the child is on a lactose-containing feed and finding 0.5% or more (1% or more in newborns) of reducing substances.

Therefore the diagnosis of lactose intolerance rests upon the demonstration of abnormal carbohydrate in the stools and the response to the exclusion of lactose from the diet.

Guidance for parents of a crying infant

Most breast-fed infants in the first few weeks to months of life need 8-12 feeds a day with at least one feed between midnight and 6am. Babies may seek cluster feeds whereby they take to the breast every 30-60 minutes for a period, most commonly in the evening. 

It is advisable for mothers of crying infants to respond in a relaxed manner to pre-cry cues with an offer of a breastfeed before the baby becomes even more distressed and difficult to soothe. This can be an exhausting schedule for even the most committed mother. 

Cue-based care from birth, combined with an average of 10 hours of physical contact (whether awake, feeding or sleeping) in a 24-hour period is associated with 50% less crying in early infancy 

It is helpful to spend time reassuring and explaining the problem to parents and do not be afraid to advise admission to hospital if necessary to alleviate a very stressful situation at home.

There is a group of infants with colic that are classified as ‘Wessel’s plus’. They fulfill Wessel’s criteria for colic but in addition have other cues that cause concern and these  infants tend to display clenched fists, flexed legs, back arching, distended abdomens, regurgitation with crying and a pained face when crying. In this ‘Wessel’s plus’ group (especially if there is associated diarrhoea and/or vomiting), a trial of elimination of cow’s milk protein (either from the mother’s diet if breastfeeding or from the infant’s diet by changing to a CMP-free formula) may be indicated.

Crying and fussing usually reduce significantly after three months of age. This relates to the maturing central nervous system of the infant and coincides with a changing role for the cry signal – from expressive crying to communicative crying. Therefore, the most important aspect of the management of colic is to reduce psychological pressure on the caregivers, especially the mother. This is best achieved by using the following principles:

• Acknowledge the reality of the parents’ concern, regardless of the amount of crying 
• Take a thorough history (including perinatal and feeding history) and perform a thorough physical examination of the infant
• Encourage parents to experiment with relaxed cue-based care, sleeping in the same room as the infant, with increased physical contact (including skin-to-skin contact)
• Dietary management. Ensure correct breastfeeding technique (if breast-fed), implement a trial of probiotics (Lactobacillus reuteri) for 10 days and then a trial of maternal dairy-free diet for two weeks. If formula-fed, ensure correct feeding technique and winding and, if parents are at their wits’ end, implement a trial of extensively hydrolysed formula for two weeks.  

It is helpful to assess the supports for the mother and encourage that these support persons (eg. grandparents) are also educated regarding the best approach to crying. It is useful to ask the mother to keep a diary of crying. Request that the practice nurse or public health nurse supports the family and regularly weighs the infant. Suggest regular ‘respite’ periods for the mother, if possible. Safe swaddling and infant massage may be helpful.

In severe cases, especially if the increased crying is occurring in the context of a fragile or otherwise challenged family, refer for a paediatric opinion and perhaps consider admission to alleviate the situation.

Several studies point to excessive crying as a condition of the first three months in normal infants. All young infants display crying, which peaks at four to six weeks of age. As doctors, we shouldn’t ignore or downplay parental concern regarding colic and the infant with excessive crying should be regularly monitored. Medical therapy is ineffective and dietary changes are rarely indicated.

Referral for specialist opinion is appropriate if the parents are unable to cope and are at breaking point or there are organic causes suggested by history or examination including weight loss, blood in vomitus, watery diarrhoea, severe perianal burning or blood in the stools. 

Constipation

In general terms, constipation is defined as the infrequent passage of hard stools causing distress to a child. Constipated stools are usually hard and may be bulky and thus difficult to pass. At school age, there are a higher number of boys with constipation (male:female ratio 3:1) whereas it is equal at the toddler age group. Up to 15% of all visits to a paediatric outpatients involve constipation as a principle complaint 

Early recognition of symptoms and treatment is required to establish normal bowel habits and prevent recurrence. Treatment of constipation involves a committed and positive approach. Using the regimen described further on, the majority can be managed in primary care by their family doctor. 

In the first few weeks of life, there may be four or more stools per day depending on whether the infant is  breast feeding or bottle feeding. This reduces to two stools per day by four months of age to one per day at four years, by which time children should be toilet trained. Most children are toilet trained by three years of age. The social and psychological interaction between the child and parent is a key factor in successful toilet training. 

Pathophysiology of constipation

The normal process of defaecation is complex. If stool passage is delayed by voluntary contraction of the levator ani and external anal sphincter muscles, the urge to defaecate may lessen. Water loss produces hardened stool that is more difficult to pass. The lower colon gradually distends with accumulated stool and the urge to defaecate becomes irregular due to a decrease in rectal sensation. 

When the rectum is sufficiently distended, softer stool leaks around the bulk of hard stool and the passage of soft stool is not sensed by the child until soiling has actually occurred. 

Although 90-95% of constipation is functional, it is important that a detailed history is taken when assessing for constipation. This ensures that a child’s general health can be ascertained along with any other warning signs that might suggest pathology.

A medial history will provide an overview of a child’s general health and should include a developmental history. The initial consultation with parent and child should be handled with great compassion and sensitivity, exonerating the child from blame. A careful history documenting the time of onset of constipation should be taken.

Physical examination includes general systemic review and palpation of the abdomen for faecal masses. Digital rectal examination is generally not recommended  In practice, inspection to check for anal tears is more commonly done. 

Plain film of the abdomen may show a rectal faecal mass but there is little correlation between the clinical picture and radiological diagnosis. Routine radiography is not recommended except if tracers are given a number of days prior to x-ray and their path through the bowel charted.

Rectal biopsy is rarely required unless there are symptoms of intractable constipation from birth with associated abdominal distension and a delayed passage of meconium. Rectal biopsy is done to exclude Hirschsprung’s disease (a rare condition occurring in one-in-7,000 births). Barium enema is not recommended

Treatment of constipation

The management of functional chronic constipation has three components. 

• Motivation and compliance with treatment can only be sustained by educating parents and the child involved.
• Disimpaction must be completed prior to starting maintenance therapy. This can be via the oral or rectal routes , the oral being the preferable one.
• Once disimpacted, maintenance therapy aims to allow the muscles and nerves of the lower bowel to recover by promoting regular toileting and preventing further impaction. 

Maintenance therapy includes high-fibre intake with regular meals . Six to eight cups of water-based fluid is also recommended daily.

Important steps in management include education of parent and child regarding cause and treatment, dietary advice, increase fluids, increase exercise, check toilet routine, try using ‘star ‘charts.

If there is no improvement, add stool softeners such as Lactulose which can be used from six weeks of age and can be mixed with water or juice, or macrogol PEG 3350 (Movicol Paediatric) acts as a single agent for both disimpaction and maintenance treatment of constipation.

Refer for specialist opinion if:

• Delayed passage of meconium over 24 hours
• Failure to thrive
• Indolent constipation from birth
• Severe abdominal distension
• Features suggestive of inflammatory bowel disease 
• Abnormal neurological examination
• Spinal abnormalities. 

Useful resources:

• www.livingwithreflux.org 
• www.purplecrying.info    
• www.zerothree.org 
• www.mothersmatter.co.nz

References

1. van Tilburg, MA et al. Prevalence of functional gastrointestinal disorder in infants and toddlers. J Pediar 2015 Mar;166(3):684-9. doi: 10.1016/j.jpeds.2014.11.039. Epub 2014 Dec 31
2. Ir J Med Sci. 2012 Mar;181(1):81-6. doi: 10.1007/s11845-011-0756-7. Epub 2011 Sep 24
3. Wessel MA et al. Paroxysmal fussing in infancy, sometimes called ‘colic’. Paediatrics 1954; 14:421-423