During the 3rd FrieslandCampina Institute symposium on 14 July 2018 in Cebu (Philippines), Associate Professor Marion Aw discussed the various dietary interventions available to treat regurgitation, colic and functional constipation in infants.
Functional gastrointestinal (GI) disorders are disorders of GI function (e.g., GI motility) wherein the symptoms cannot be attributed to another medical condition after appropriate medical evaluation (1). Among infants, the most commonly encountered functional GI disorders are infant regurgitation, infant colic and constipation. The pathophysiology of these disorders is not fully clear but is likely to be multifactorial. Proposed mechanisms include GI immaturity, low grade inflammation, dysbiosis of the gut microbiota, intolerance to components in the infant’s diet and feeding technique related issues (2). The possible role that diet may play in functional GI disorders among infants provides opportunities for dietary interventions.
It is common for healthy infants to regurgitate. Infants aged between 1 week and 6 months may regurgitate as many as four times per day. However, symptoms that may indicate underlying organic disease include those suggestive of oesophagitis (e.g., upper GI bleeding or feeding difficulties or refusal), acute life-threatening events (e.g., respiratory complaints or apnoea), failure to thrive and bilious vomiting. (3)
In formula fed infants, studies have shown that the use of thickened or anti-reflux formula may reduce the number of regurgitation episodes. A prospective, double-blind, randomized trial (n=115) investigated the efficacy of two anti-reflux formula in the management of infant regurgitation (4). One formula (ARF1) contained locust bean gum and nonhydrolyzed protein, while the second formula (ARF2) contained locust bean gum and specific whey hydrolysate. The study showed that from a mean baseline of 8.25 episodes of regurgitation per day, the use of ARF1 reduced the number of daily episodes to 2.32 while ARF2 reduced regurgitation to 1.89 episodes per day (both statistically significant reductions compared to baseline). (4)
According to the Rome IV criteria, infant colic is diagnosed when an infant younger than 5 months has recurrent and prolonged periods of crying, fussing or irritability without an obvious cause; and this is in the absence of failure to thrive, fever or illness and cannot be prevented or resolved by caregivers (1).
While the aetiology of infant colic remains unclear, evidence indicates that dietary factors may play a role. In a prospective randomized controlled study, investigators evaluated the efficacy of an infant formula with partially hydrolysed whey proteins, prebiotic oligosaccharides and high β-palmitic acid content in treating infant colic (n=267). After 14 days, infants receiving the investigational formula had fewer colic episodes compared to those who received the control formula (standard formula with simethicone) (Figure). (5).
FIGURE Effect of hypoallergenic infant formula on infant colic episodes
Treatment=partially hydrolysed whey proteins, prebiotic oligosaccharides and high β-palmitic acid content infant formula.
Control=standard formula with simethicone.
[Y-axis label: Number of colic episodes per day]
[p values: baseline, p=0.29; Day 7; p<0.0001; Day 7; p<0.0001]
Source: Savino, 2006
The majority (~95%) of infants and young children with constipation are functional in nature. In infants and children up to 4 years of age, functional constipation is defined as 1 month of at least two of the following criteria (6):
- Two or fewer defecations per week
- History of excessive stool retention
- History of painful or hard bowel movements
- Presence of a large faecal mass in the rectum
- History of large-diameter stools
In toilet trained children, the following additional criteria may be used:
- At least 1 episode/ week of incontinence after the acquisition of toileting skills.
- History of large-diameter stools that may obstruct the toilet.
The management of functional constipation in infants include the following:
- Caregiver education and reassurance
- Increased fluid intake
- Increased intake of fruits and vegetables in the diet for infants on mixed-feeding
- Osmotic laxatives as required
- Switching to infant formula containing partially hydrolysed protein and added prebiotics or a palm olein-free formula
In general, breast fed infants are less likely to have constipation than formula fed infants. In formula fed infants a partially hydrolysed, palm-olein free, prebiotic containing formula may results in a slight increase in stool frequency; increase of 0.60 bowel movements (BM) after 7 days (p=0.004) and another 0.53 BMs between days 7 and 14 (p=0.015). (7)
Functional GI disorders (symptoms) are common in infancy. After careful evaluation for alarm signs and symptoms of organic disease, these infants may be managed through caregiver education and a multimodal approach including dietary interventions. Often investigations are not required. Where appropriate, infants with regurgitation, colic or constipation who are not being breast fed, a switch in the composition of the infant formula to address their specific symptoms may be considered.
A/Professor Marion Aw
Department of Paediatrics
Yong Loo Lin School of Medicine
National University of Singapore
- Benninga MA, et al. (2016). Childhood Functional Gastrointestinal Disorders: Neonate/Toddler.Gastroenterology 2016;150:1443–1455.
- Indrio F, et al. J Mat Fet Neon Med 2011;24:64-66.
- Vandenplas Y. (eds). Gastroesophageal Reflux in Children. Cham, Switzerland: Springer Nature; 2017.
- Vandenplas Y. J (2013). Double-blind comparative trial with 2 antiregurgitation formulae. Pediatr Gastroenterol Nutr 2013;57:389-393.
- Savino F. (2006). Reduction of crying episodes owing to infantile colic: A randomized controlled study on the efficacy of a new infant formula. Eur J Clin Nutr 2006;60:1304-10.
- Hyman PE, et al. Gastroenterol 2016;150:1456–1468.
- Savino F. Acta Paediatr Suppl 2005;94:120-124.
- Alarcon PA, et al. Nutrition 2002;18:484-1489.