Журнал «Здоровье ребенка» (62) 2015. Тематический выпуск "Детская гастроэнтерология"
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Discussion questions about etiopathogenesis of the infantile colicphenomenon
Авторы: Rakovska L.O. — V. N. KarazinKharkiv National University, Kharkiv, Ukraine
Рубрики: Педиатрия/Неонатология
Разделы: Клинические исследования
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INTRODUCTION. Infantile colic is a common problem for the first 3-4 months of life; it is one of the most common causes of seeking medical care,and can cause considerable distress for parents and caretakers. Often, babieswith infantile colic are exposed to unreasonable, sometimes costly investigations and excessive treatment.Despite more than 50 years of research, its etiology and pathogenesis are incompletely understood.
METHODS. An analysis of available publications about the causal factors and pathophysiological mechanisms of infantile colicorigin and development.
RESULTS. Universally accepted definition of infantile colic does not exist because of the absence of a common view on the causes and mechanisms of this phenomenon. Currently, infantile colic is defined as a sudden unexplained attack of crying and restlessness of a child of first few months of life.
For diagnosingcolicthe “rule of three” is usuallyused: crying for more than 3 hours per day, more than 3 days per week, and longer than 3 weeks.The infant is otherwise healthy, active and well fed, with no other features suggestive of underlying disorders. This distinctive pattern was first described in 1954 by the famous pediatrician M.Wessel and it still remains the main diagnostic criteria, whichwas established by Room III consensus in 2006 yr. [1-6].
Data on the prevalence of infantile colic are very different. Some authors indicate ranges 5-19% of children of the first months of life [2, 4, 8, 9], others - 10-20% [5, 10, 11, 12].Recent studies demonstrate numbers up 30% [3,4], although there are the publications which suggested, that up to 70-80% [13, 14, 15], and even 90% of children in the first months of life [16]may have such a condition. Such significant differences in epidemiological data are likely due to the lack of common approaches and criteria for evaluation of this phenomenon.All researchers reported no difference in the rate of infantile colic among all socio-economic groups, races, and between boys and girls [5, 10, 12].
Currently, according to the Rome III criteria [6],colic is discussed in the section of functional gastrointestinal disorders and has a code G4, corresponding to the code ICD - K59.0 [17].It is noteworthy that colic is covered in the section of the behavioral disorders in English languagecourse books[9].
Infantile colic typically begins approximately at the age of 2-3 weeks, reaching a peak at 6 weeks, and then after 8 weeks their intensity and frequency are gradually reduced and eventually it disappears after 12-16 weeks [2, 5]and it is also known as "three months" colic [3, 7, 12].
Most healthy infants usually cry two or three hours a day in regular intervals during the day. A typical feature of the infantile colic phenomenon is the occurrence of the paroxysmal crying attacks in the evening and night hours, usually at the same time; due to the circadian rhythm it is sometimes called "evening colic" [4].
Although the condition is well recognized, its exact etiology is not defined. Various hypotheses of the causes of colichave been suggested,but none of them is not complete, comprehensive and acceptable to all researchers. Some of the theories are controversial, others are complementary.
The main theories of infantile colic:
1. The theory of gastrointestinal disorders
Studying the causes of infantile colic, many scientists proceed from the position that the above-mentioned bouts of crying are associated with the presence of abdominal pain (the term "colic" is derived from the Greek «kolikos», which means "pain in the colon") [1, 2].Because the symptoms observed during the attacks of infantile colic are similar to the symptoms of organic abdominal pain, the term "intestinal colic"is often used [1, 2, 13, 14, 16-18].
Many studies have provide evidence of differences in physiological processes in the gastrointestinal tract in a baby with and without colic. These violations include increasing secretion ofgastrointestinal hormones,such asmotilin and serotonin, which stimulate the peristalsis and provoke spasm; deficit cholecystokinin regulating the perception of pain, impaired function of the gall bladder, increasing hydrogen production, excessive gas, due to incomplete breakdown of fats and carbohydrates due to the immaturity of the enzyme systemand intestinal disbiosis and others [2, 4, 15, 19, 20].
In a brief study of Egyptian scientists a possible link with infection with H. Pylori is detected [25]. However, these findings need to be further confirmed.
The results of studies ofinfantile colic andnutrition connection are ambiguous. Some authors suggest a higher incidence of colic in breastfeeding infants [26], the majority do not find any differences with the babies who are bottle-fed [5, 10, 12, 27]. Havingcertain foodby a nursing mother may increase the frequency and intensity of colic. However, it has not been proved that the change of maternal nutrition can prevent from future attacks of infantile colic [5].
The role of hypersensitivity to food and food allergies, especially to cow's milk protein, as a significant factor in the cause and colic is actively discussed [4, 8, 10, 19].
2. Neurodevelopmental hypothesis
Advocates of this theory consider the colic as a special behavior of an infant or a developmentalstep, a kind of physiological transient state. They believe that colic notis generally associated with a pain - abdominal one or any other.Infantile colic probably representsthe upper end of the normal “crying curve” of healthyinfants. Colic “is something infants do, rather than a conditionthey have”[6, 12, 28].
3. The theory of psychosocial disorders
This theory is based on the assumption that the colic ismost likely a psychological problem, thana somatic one.It may be a response of the infant- environment interaction and violation of the parents-infant interaction [4, 12]. There is the evidence of infantile colic and stress during pregnancy connection [29]. It is shown that infantile colic is correlated with maternal depression [30], however, there is no proof that the maternal (or paternal) personality or anxiety can cause colic. It is more likely that a severely colicky infantincreases the risk factor for maternal depression, but inexperienced and anxious parents create a situation for more intensive colic.However, colic is not limited only by the first-born and even when infants with colic are taken care by experienced specialists, they cry twice more than those without colic [28]. It has cast doubt on the theory of an inexperienced caretaker as an etiological factor [12].
4. Infantile colic - an early form of migraine
First results of sensational research on the possible link of infantile colic and migraine were published in 2012 [31]. A recent meta-analysis, combining the results of three studies clearly indicates that colic is an early form of migraine rather than a gastrointestinal problem, as previously assumed. This finding requires confirmation in further studies and the important implications may cause the revision of approaches to colic treatment.
CONCLUSION:
Thus, among a variety of different hypothesis that attempt to analyze the causes of colic, none can unify all the known facts and explain all the cases of infantile colic, as there is no single pathophysiological model, so this topic continues to be a subject of much debate and researches.Probably only ongoing large-scale multicenter studies will be able to definitively clarify the nature of this amazing phenomenon and help to find effective and safe methods of its correction.