Colic in the Breastfed BabyJack Newman, M.D., FRCPC
Colic is one of the mysteries of nature. Nobody knows what it really is, but everyone has an opinion. In the typical situation, the baby starts to have crying periods about two to three weeks after birth. These occur mainly in the evening, and finally stop when the baby is about 3 months of age (occasionally older ). When the baby cries, he is often inconsolable, though if he is walked, rocked or taken for a drive, he may settle temporarily. For a baby to be called colicky, it is necessary that he be gaining weight well and be otherwise healthy.
The notion of colic has been extended to include almost any fussiness or crying in the baby, and this may be valid, since we do not really know what colic is. There is no treatment for colic, though many medications and behavior strategies have been tried, without any proved benefit. It is admitted that everyone knows someone whose baby was cured of colic by a particular treatment. It is also admitted that almost every treatment seems to work—for a short time, anyhow.
The Breastfeeding Baby with Colic
Aside from the colic that any baby may have, there are three known situations in the breastfed baby which may result in fussiness or colic. Once again, it is assumed that the baby is gaining adequately and that the baby is healthy. Feeding Both Breasts at Each Feeding
Human milk changes during a feeding. One of the ways in which it changes is that the amount of fat increases as the baby nurses longer at the breast. If the mother automatically switches the baby from one breast to the other during the feed, before the baby has "finished" the first side, the baby may get a relatively low amount of fat during the feeding. This may result in the baby getting fewer calories, and thus feeding more frequently. If the baby takes in a lot of milk (to make up for the reduced concentration of calories), he may spit up. Because of the relatively low fat content of the milk, the stomach empties quickly, and a large load of milk sugar (lactose) arrives in the intestine all at once. The protein which digests the sugar (lactase) may not be able to handle so much milk sugar at one time and the baby will have the symptoms of lactose intolerance--crying, gas, and explosive, watery, greenish bowel movements. This may occur even during the feeding. These babies are not lactose intolerant. They have problems with lactose because of the sort of information women get about breastfeeding. This is not a reason to switch to lactose free formula.Do not time feedings. Mothers all over the world have breastfed babies successfully without being able to tell time. Breastfeeding problems are greatest in societies where everyone has a watch and least where no one has a watch. The mother should feed the baby on one breast, as long as the baby breastfeeds, until the baby comes off himself, or is asleep at the breast. If the baby feeds for only a short time only, the mother can compress the breast (handout #15 Breast Compression) to keep the baby nursing. Please note that a baby may be on the breast for two hours, but may actually feed for only a few minutes. In that case the milk taken by the baby may still be relatively low in fat. This is the rationale for compressing the breast. If, after "finishing" on the first side, the baby still wants to feed, offer the other side. The next feeding, the mother should start the baby on the other breast in the same way. The mother's body will adjust quickly to the new method, and she will not become engorged or lop sided. Just as there should be no "rule" for feeding both breasts at each feeding, there should be no rule for one breast per feeding. Let the baby finish on one breast (compress milk into his mouth if necessary to keep him swallowing longer) but if he wants more, then offer the other side. In some cases, it may be helpful to feed the baby two or more feedings on one side before switching over to the other side for two or more feedings. This problem is made worse if the baby is not well latched on to the breast. A proper latch is the key to easy breastfeeding. Overactive Letdown Reflex
A baby who gets too much milk too quickly, may become very fussy, very irritable at the breast and may be considered "colicky". Typically, the baby is gaining very well. Typically, also, the baby starts nursing, and after a few seconds or minutes, starts to cough, choke or struggle at the breast. He may come off, and often, the mother's milk will spray. After this, the baby frequently returns to the breast, but may be fussy and repeat the performance. He may be unhappy with the rapid flow, and impatient when the flow slows. This can be a very trying time for everyone. On rare occasions, a baby may even start refusing to take the breast after several weeks, typically around three months of age.
What can be done? If you have not already done so, try feeding the baby one breast/feed. In some situations, feeding even two or three feedings on one breast before changing to the other breast may be helpful. If you experience engorgement on the unused breast, express just enough to feel comfortable. Feed the baby before he is ravenous. Do not hold off the feeding by giving water (a breastfeeding baby does not need water even in very hot weather) or a pacifier. A ravenous baby will "attack" the breast and cause a very active letdown reflex. Feed the baby as soon as he shows any sign of hunger. If he is still half asleep, all the better. Feed the baby in a calm, relaxed atmosphere, if possible. Loud music, bright lights and lots of action are not conducive to a successful feeding. Lying down to nurse sometimes works very well. If lying sideways to feed does not help, try lying flat on your back with the baby lying on top of you to nurse. Gravity helps decrease the flow rate. If you have time, express some milk (an ounce or so) before you feed the baby. The baby may dislike the rapid flow, but also become fussy when the flow slows too much. If you think the baby is fussy because the flow is too slow, it will help to compress the breast to keep up the flow (handout #15 Breast Compression). This problem is made worse if the baby is not well latched on to the breast. A good latch is the key to easy breastfeeding. On occasion giving the baby commercial lactase (the enzyme that metabolizes lactose), 2-4 drops before each feeding, relieves the symptoms. It is available without prescription, but fairly expensive, and works only occasionally. A nipple shield may help, but use this only if nothing else has helped and only if you have gotten good help without any relief. As a last resort, rather than switching to formula, give the baby your expressed milk by bottle. Foreign Proteins in the mother's milk
It has been shown that some proteins present in the mother's diet may be excreted into her milk and may affect the baby. It would seem that the most common of these is cow's milk protein. Other proteins have also been shown to be excreted into some mothers' milk. The fact that these proteins and other substances appear in the mother's milk is not necessarily a bad thing. Indeed, it should be considered a good thing. Ask about this if you have any questions.
Thus, in the treatment of the colicky breastfed baby, one step would be for the mother to stop taking dairy products. These includes milk, cheese, yogurt, ice cream and anything else which may contain milk. When the milk protein has been changed (denatured), as in cooking for example, there should be no problem. Ask if you have any questions.
Please note: Intolerance to milk protein has nothing to do with lactose intolerance. A mother who is herself lactose intolerant should also still breastfeed her baby.
Suggested Method: The mother should eliminate all milk products for 7-10 days. If there has been no change, the mother can reintroduce milk products. If there has been a change for the better, the mother should then slowly reintroduce milk products into her diet, if these are normally part of her diet. (There is no need to drink milk in order to make milk). Some babies tolerate absolutely no milk products in the mother's diet. Most tolerate some. The mother will learn what amount of dairy products she can take without the baby reacting. If there is concern about your calcium intake, calcium can be had without taking dairy products. Ask if you have any questions. One week off milk products will not cause any problems. Actually, evidence suggests that breastfeeding may protect the woman against the development of osteoporosis even if she does not take extra calcium. And the baby will get all he needs. The mother should be careful about eliminating too many things from her diet. Everyone will know someone whose baby got better when the mother stopped broccoli, beef, bananas, bread etc. The mother may find that she is eating white rice only. Our diets are too complex to be sure exactly what, if anything, is affecting the baby.
Be patient, the problem usually gets better no matter what. Formula is not the answer, though, because of the more regular flow, some babies do improve on it. But formula is not breastmilk. In fact, the baby would also improve on breastmilk from the bottle because of the regularity of the flow. Even if nothing works, time usually helps. The days and nights may seem eternal, but the weeks will fly by.JACK NEWMAN, MD, FRCPC, is a Toronto pediatrician who has practiced medicine since 1970. He is a graduate of the University of Toronto medical school. In 1984 he established the first hospital-based breastfeeding clinic in Canada at Toronto's Hospital for Sick Children. He has practiced as a physician in Canada, New Zealand, and South Africa. He now holds breastfeeding clinics in several hospitals in the Toronto area. He is a consultant with UNICEF's Baby Friendly Hospital Initiative and is a popular speaker at breastfeeding conferences across North America and beyond. He is the father of three children, all breastfed.
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