GNS Vietnam 2025: Managing Infant Colic and Constipation

Suporn Treepongkaruna, MD

Narrator

Introducing professor Suporn Treepongkaruna, Professor of Pediatrics at the Faculty of Medicine, the Ramathibodi Hospital, Mahidol University in Bangkok, Thailand. Doctor Treepongkaruna is a leading expert in pediatric gastroenterology and hepatology. Her research spans functional gastrointestinal disorders, inflammatory bowel disease, and liver transplantation with over 90 peer-reviewed publications. She has held key leadership roles, including Chair of Pediatric Gastroenterology, Head of the Liver Transplant Program, and Director of the Ramathibodi Excellence Center in Organ Transplantation. Doctor Treepongkaruna has served as President of the Thai Society of Pediatric Gastroenterology and Hepatology, Asian Pan Pacific Society for Pediatric Gastroenterology, Hepatology and Nutrition. She currently leads the Federation of International Societies of Pediatric Gastroenterology, Hepatology and Nutrition as President, championing global collaboration and pediatric gastrointestinal care. Please welcome professor Suporn Treepongkaruna.

Professor Suporn Treepongkaruna

Hello. Good morning everybody. I'm very pleased to be here and I would like to thank Mead Johnson for the kind invitation and, I’m really excited to, be in this, excellent, scientific program and to also visit the nice city of Da Nang. This is my first time.

So, I'm going I'm going to talk about managing infant colic and constipation. Here are my disclosures.

We are going to talk about the infant colic, focusing on the diagnosis and management, and also functional constipation in infants and young children. Why do we need to talk about these two topics? Because, they are really common and, they also have a lot of impact. So if you look at the slide here, the top three functional GI disorders are shown in the blue bar:  infant regurgitation, functional constipation and infant colic. In children aged to 4 years, the most common functional GI disorders is functional constipation. And the systematic review shows that the prevalence of infant colic is about 5%. And, functional constipation affects 7% of infants and, 22% of the toddler and preschool children.

The other systematic review also supports that functional constipation is very common in children across all age groups, including the worldwide report and regional reports from European countries and Asian countries. And, you can see that, not only in infant and the young children, but in older children and adolescents, functional constipation is also very common. And if you look at the Asian data, the prevalence of the Asian students also had a high prevalence of functional constipation, comparable to the western population.

The impact / consequences of the infant colic - even though it is the benign and a self-limiting condition, it causes a lot of parental stress and anxiety associated with maternal depression, and also the cost of early cessation of breastfeeding and repeated medical consultation.

The long-term study also suggests that there is association with the, developing of the later functional GI disorders and the migraine headache. Also, the behavioral and psychological problems.

The functional constipation, on the other hand, is usually chronic and reduces the health-related quality of life of affected children, their family, and also affects their family function.

So now we look, in detail, at infant colic. Before we start, I would like to have a quiz. Which of the following statements about infant colic is correct. A) for clinical practice, it is defined as persistent crying for more than three hours for day, more than 3 days per week and, for longer than three weeks, B) It requires routine investigations before diagnosis, and C) colic symptoms reach their peak around six weeks of age and gradually resolved by five months. And D) Always due to cow’s milk protein allergy, so elimination diet is a first line treatment. So now, please vote!

Most of you, show us the answer A, so let's look at the answer in my presentation.

OK so, look at the pattern of crying. Typical, colic has a peak at the six weeks of age. And, the duration of the crying is, nearly, three hours per day, and, then this declines gradually, until the result by the five months of age. And so, what is the pathophysiology of infant colic? Actually, it remains unclear and, maybe, likely to be multifactorial, involving neurodevelopmental, psychological and biological factors. Gastro factors are a contributor; could be cow’s milk protein allergy, lactose intolerance and also gas production and abnormal motility of GI tract. Recently the concept of dysbiosis has come to interest. As Doctor Marion said dysbiosis may contribute to the pathophysiology of infant colic, and Doctor Marion also showed that dysbiosis is also common in the infants with colic, such as an increase in the proteobacteria, a decrease in the Lactobacilli and Bifidobacteria, and these babies have gut inflammation caused by the dysbiosis, and this may contribute to the colic development. However, we need more studies to confirm this hypothesis.

Now, the diagnosis of the infant colic, can be diagnosed in infants under five months of age who have recurrent and long periods of crying, fussing, irritable. That's without any obvious cause. And it cannot be prevented or resolved by caregiver, and importantly, with no failure to thrive or any disease. And the rule of the three hours per day is a used for the research purpose.  Now, how to approach this infant. Careful history and physical examination are really important. And we need to, look at the red flags, if the baby have red flags, like, extreme high pitch cry, or lack of diurnal rhythm, it means that the baby cries throughout the day.

And so, associate these symptoms, symptoms suggestive of the allergy. So, if there is not any red flags, we can diagnose, infant colic. But, if there are some red flags, investigations are, indicated. And, if the result, is normal, so we still can diagnose the infant as well.

I would like to mention that only 5% of babies who have colic symptom have organic disease. So, most of them have no disease. And the most common, the organic disease, that far in these babies, is due to an infection. So if you are not sure, you can do the urinalysis or urine culture. But, if the baby looks well, we don't need to do any investigation.

So now, how about the management? So the goal of the treatment is not to kill the colic, but, to help the caregiver to cope with this temporary period and, the cornerstone of treatment is reassurance and, parental support and, we just emphasize that this is a benign and, self-limiting condition and try to encourage the coping method, like a soothing technique, calm environment and avoidance of overstimulation. And, importantly, never shake the baby.

And if parents feel that they are exhausted, they should have a break, maybe come to Danang to have a rest!

Breastfeeding should be continued. It is very important. And, no any other formula is superior to breast milk in infancy with colic. Many other treatment options include dietary intervention, probiotics, medications, and complementary therapies. However, there are no proven benefits of medication and complementary, or alternative therapies. So, they can have side effects.

About the dietary intervention - one option is partially hydrolyed, low-lactose formula. And this randomized control trial compared this formula with soy. And the results showed that more formula can improve the colic symptoms rapidly and persist over the study period of the 28 days, and, but there is still soft, stool found only in the partial hydrolysed formula. It's seen that there is some evidence for the benefit of this formula. However, according to the ESPGHAN, there is insufficient evidence to recommend to use low lactose and partially hydrolysed, formula in the routine practice. So it is not used as a routine. But, in clinical practice, you may consider, to use, in selected cases and this may benefit, some babies.  And, also there is no recommendation for use of the the other anti-colic formula, because there is no evidence of soy for pre and probiotics and for the beta-palmitate formula.

What about cow’s milk protein allergy? There is insufficient data to support that infant colic occurs due to cow’s milk protein allergy. So, the cow’s milk elimination diet is not recommended. However, if these colic babies have other symptoms suspected of cow’s milk protein allergy; in that case, we can use the time-limited elimination diet for 2 to 4 weeks, followed by the oral food challenge to confirm the diagnosis.

And what about probiotics? So, probiotics in this recent meta analysis show the efficacy of the probiotics. Probiotics can reduce colic, by crying by 51 minutes per day. So, this is quite a lot and a strong effect is observed in the group of the Lactobacillus reuteri with a reduction of 64 minutes per day, especially in the breastfed, exclusively breastfed infants. In this group, the crying time reduced by 70 minutes per day.

And, so ESPGHAN recommends two strains of probiotic; Lactobacillus reuteri and Bifidobacterium lactis. And, it should be used for the 3 to 4 weeks, but, there is no evidence to support the use in the formula-fed babies and it is not common to use for prevention of infant colic.

So the quiz, the answer is number C, it is used only for the research purpose.

Okay. So, this is my summary. You must provide parental reassurance for every cases and this is a mainstay of treatment, including parental support. And, consider Lactobacillus reuteri in the breastfed baby. And, for the formula-fed baby, consider a trial of the low-lactose, partially hydrolysed formula.

Now, let's move on to functional constipation.

So, we start with the quiz again. Who do you think has constipation? Number A) 4-week-old infant who strains and cries for ten minutes before passing soft stool, B) the six-week old, exclusively breastfed infant, who passes soft stool once a week, nut otherwise normal. C) A one-year-old boy who has bowel moment every other day, with a large stool and painful defecation. D) A four-year-old boy previously toilet trained who passes stool twice weekly with frequent faecal soiling.

So, most of us selects C and D, so let's see the answer the later on.

So, I would like to show you that the breastfed infant has more frequent stool per day, in comparison with the formula-fed infant. The breast-fed infant is shown by the green color and formula-fed is shown by the red color. But, at four months of age, both groups have a similar bowel movement, about two times per day. And interestingly, breastfed infants can have quite a variation of bowel movements. It can vary from up to ten per day, or as little as once in the week, or once in two weeks. So, this variation is still normal as long as the stool is soft and the baby is thriving. So, this is not constipation. So, please do not treat constipation.

And, for the diagnosis, using Rome IV criteria, the symptoms must last at least one month and have two, symptoms or more than this: Two or fewer defecation per a week, painful defecation, or hard stool. Large diameter stool, history of excessive stool retention, and large faecal mass in rectum, and faecal soiling in toilet training.

And, so, actually, more than 90% of the childhood constipation is functional. However, we still have to look for red flags for organic causes, and if there are some organic causes, then we need to investigate to exclude the organic disease.

This is another functional GI disorder. The baby cries and strains for at least ten minutes, but the stool is soft so this is not constipation so we do not need any intervention, and it will resolve by itself.

So now you can know that the answer is number C and number D.

Many factors contribute to constipation. But one of the most common causes in toddlers and the young children is the pain-withholding-pain cycle, because the child has the withholding behavior and this behavior leads to pain and more withholding and more pain. So, this is a cycle. So, when we treat constipation in toddlers and young children, we have to break this cycle. And so the treatment must include all modalities; reassurance, dietary intervention, laxatives, and behavioral modification, particularly in toddlers and young children. Positive reinforcement and also toilet training.

So, I'd like to share with you the case of an eight-month-old female infant. She has had constipation since six months of age. When the solid food is started and switching from breast milk to formula. But, before this, before six months, her bowel movement was fine and the physical examination is unremarkable, except for the anal fissure. So, this is a typical case of functional constipation in the infant. And, this has occurred during the transition of the diet and the transition of switching from breast milk to formula.

And, the question then; which formula can help, this, baby? High beta-palmitate formula? High magnesium formula? Or partially hydrolysed formula? Or prebiotics? Or soy? Or extensively hydrolysed formula?

So, the answer from ESPHAGAN? ESPHAGAN suggests that, in formula-fed infants, consider formula with high beta-palmitate and high levels of magnesium to soften stool consistency. However, they do not recommend for routine use in infants with constipation because there is insufficient evidence.

And what about cow’s milk protein allergy? Because cow’s milk protein allergy is in fact not a common cause of constipation. So, we should not consider cow’s milk protein allergy and, do not use the treatment as the first line. We consider cow’s milk protein allergy only when the children do not respond to conventional treatment for constipation.

So, in older children, we have to encourage adequate fiber and adequate fluid intake, but remember that dietary intervention alone is not enough for treatment of functional constipation. And most of the time, children need laxatives and we should not delay treatment because delay of treatment affects the outcome and prognosis.

So, the laxative treatment is involved in the three phases; disimpaction, either the high dose oral laxative or the rectal enema, but, actually high dose, oral laxative is a first choice, because it causes less discomfort. And, for the infant, we should not use the rectal enema, so we use the glycerin suppository instead. The next phase is maintenance laxitive. This is very important that that we need the adequate dose, adequate duration, and, usually, in young children, laxatives are usually required for a long period of time, until there are no symptoms and until the regular bowel habit is established and until toilet training is achieved. And then we gradually reduce the dosage until discontinuation of the laxative.

Osmotic laxative is the first line treatment in children because this medication is fully absorbed and so they are quite safe, even with use over a long period of time with very rare side effect.

Many guidelines suggest we use polyethylene glycol as a first line treatment. But lactulose can be used if polyethylene glycol is not available. However, in infants, particularly in infants below six months of age, lactulose is preferred because there is limited data for polyethylene glycol in young children. For the laxative treatment, this is really important to have the treatment adherence and engagement from family members.

So, this is my take home message. I think I show you that infant colic and functional constipation are really common. And diagnosis does not need investigation, we can use Rome IV criteria. And the cornerstone of treatment of infant colic is reassurance and parental support. For functional constipation, laxatives are usually required for one part of the treatment and, importantly, adequate laxative therapy, and treatment adherence is very important for good outcomes and for prevention of recurrence.

Thank you very much for your attention.