Dietary modification is a treatment option for the management of some patients with infantile colic (25
). Bovine milk proteins can elicit symptoms of infantile colic in certain infants (2
). Studies have shown that removal of cow’s milk from the infant’s diet may result in a significant reduction of the symptoms of colic in a certain percentage of infants (evidence level A) (2
). It is probable, though not proven, that atopic infants with severe colic would benefit most from the elimination of cow’s milk (evidence level C) (5
). It has been suggested that mothers who breastfeed their infants should, with appropriate nutritional support, consider eliminating cow’s milk from the diet and avoid potentially allergenic substances such as caffeine, chocolate, eggs and nuts (4
). If breastfeeding is not possible, the use of a hypoallergenic formula should be considered (2
). The use of soy formulas in the treatment of infantile colic should be avoided because soy protein is an important allergen in infancy (1
). There is no evidence that low lactose milk formulas and fibre-enriched milk formulas are effective cow’s milk formula substitutes.
The literature on colic is very susceptible to observer bias. We are dealing with a condition that universally improves over time. There is a huge placebo effect and a ‘tincture of time’ effect resulting from any intervention. Therefore, it is very risky to draw conclusions unless studies are rigorously controlled and outcomes are determined by blinded observers. There is also a decided ‘publication bias’ for studies that show an effect of intervention and discount the many studies that show ‘no effect’. Studies rarely stratify populations into children prone or not prone to atopy and often reflect the referral bias of the particular institution or country. Moreover, there can be nutritional, monetary and attitudinal consequences derived from the recommendation of maternal exclusion diets or the use of ‘hypoallergenic’ formulas in a large percentage of the population.
Most of the studies have, so far, involved a small sample size, and some of the studies have methodological flaws. It is hoped that future well-designed, large-scale, randomized, double-blind, placebo-controlled studies will provide more information in this area. A well-designed study should include the use of a common case definition, objective outcome measures, appropriate washout times in crossover trials, adequate blinding and repeated blind challenges of the proposed intervention to account for spontaneous resolution with increasing age (12
). Until results from such trials are available, no unequivocal recommendation can be made. In the meantime, temporary dietary modification should be considered for infants with severe colic, especially for those with atopic features or a strong family history of atopy (25
). Periodic challenges at monthly intervals are used to ensure that the improvement is related to dietary modification and not a result of natural resolution.