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Bryan Vartabedian, M.D., author of Colic Solved, demystifies colic, discusses revolutionary diagnostic and treatment options, and explains why colic is an "urban legend."
Also: Get advice from real moms who experienced colic.
Wondertime: The title of your book is Colic Solved. Those are pretty strong words. When you say you "solve" colic, what do you mean?
Initially, I started out to write a book that tells parents about gastroesophageal reflux and milk protein allergies. But it became evident that parents of kids who have GERD or milk protein allergy are very often perceived as having colic.
The "solved" part of it discusses the changes that have occurred over the past 50 years since colic was first described. What was once a mysterious condition can, in many cases, be explained.
Wondertime: I'm not sure how much you see this in your practice, but in my experience a lot of people still see colic as this mysterious condition. Is your impression that the word is getting out that colic can be explained?
I think the word is getting out that colic is a wastebasket term that's used when we can't explain what's going on inside a baby. I think pediatricians are zeroing in more and more on the fact that these babies do have treatable conditions.
Now, I think it's important to understand that not every baby who screams or fusses suffers with reflux or milk protein allergies, or a problem with elimination. There are babies who have temperament issues.
In the book, I discuss the "blob theory": the idea that parents tend to view their babies as little peaceful cherubs who should do nothing more than eat, sleep, poop, then be quiet.
The reality is that there are variations among temperament and personality among babies. Some are finicky and frisky. Others are irritable. Some don't like light or sound. Some get upset easily.
Wondertime: So when people use the word "colic," that's kind of a catchall.
Yes. In the vernacular, the word is a catchall term to describe any baby who's not at ease. From the technical, academic perspective, colic does have some very loose criteria. You know, The Rule of Three: crying for more than three hours a day, for three days, for more than three weeks.
This was what the original criteria were in 1954. But if you look at that, it's difficult — if your baby cries only two hours and 59 minutes, then technically he doesn't have colic. So you can see how the criteria, from a scientific or academic perspective, are very, very difficult to define.
Wondertime: The Rule of Three has been around for so long. Is there anything to it?
I have absolutely no idea why three hours was the number as opposed to four hours, or why three days was the number as opposed to two days or four days. Irritable is irritable.
Wondertime: Do you find that the Rule of Three is something that pediatricians still cite?
Not so much. But there are people who still refer to those original criteria. Academics do. In fact, there are still research papers published today that use the original criteria for defining a baby as having or not having colic. Which is inconceivable to me.
But in general, pediatricians don't apply those criteria. They use the term very, very loosely in any number of circumstances where babies have inexplicable fussiness.
In fact, many pediatricians use it as a crutch. To a certain extent, the term absolves them from any real responsibility for going further.
Wondertime: You used the phrase "urban legend" in your book to describe colic.
Yes, colic has evolved into a bit of an urban legend and the criteria are loose too. I have one pediatrician friend who describes a baby as having colic only if she can't be put down. There are others who say it's colic if the baby quiets with white noise like a hair dryer or a washing machine.
The reality is that any baby who is suffering with any kind of pain or discomfort — be it from an ear infection, a sore throat, or pain in the intestinal tract — is going to be happier when he is surrounded by that humming white noise.
So that by itself doesn't define a baby as having colic. That's more related to a baby's central nervous system and what he likes.
Wondertime: According to your book, there's a pretty high percentage of these so-called colicky babies who have acid reflux disease. How many kids, roughly?
Well, in my practice, between acid reflux disease and milk protein allergy, probably 60 percent of the kids I evaluate for inexplicable irritability are ultimately found to have one of those two problems.
Wondertime: Let's talk about acid reflux disease for a bit. It used to be thought that just grownups had it. When did the field start to recognize that babies and children had reflux too?
Well, I think it's been known for a long time that babies spit up and regurgitate, and that this represents acid reflux. Now, this is a very important point: There's a difference between acid reflux and acid reflux disease. As it turns out, all babies have acid reflux, and that's kind of a shocker to a lot of parents.
In fact, all people have reflux continuously throughout the day. Material passes from the stomach up into the esophagus on and off throughout the day, but our bodies have a way of handling that. The bicarbonate in our saliva helps clear it, our esophagus squeezes and helps push it back down to the stomach. Typically it's not a problem.
There are some people, though, for whom those natural protective mechanisms don't work very well. And that acid that comes up hangs out a little bit longer and doesn't get flushed away the way that it should. And it can create problems.
Now what defines gastroesophageal reflux disease in babies? We put the D on it. We go from GER (gastroesophageal reflux) to GERD (gastroesophageal reflux disease). GERD is when babies have an inability to feed or marked difficulty with feeding, failure to thrive or poor growth, chronic lung disease, wheezing and coughing, that sort of thing. Or in very young babies, apnea, where they stop breathing. When we look at those problems, those are the babies we consider to have acid reflux disease.
The past 20 or 30 years have allowed for the development of new technologies for actually examining the lining of a swallowing tube and examining the reflux activity with pH probes, and that's allowed us to define GERD.
Some babies are actually very sick with acid reflux — kids who, 30 or 40 years ago, we never knew existed. I think that back then, reflux disease as a serious problem was probably vastly underestimated.
Wondertime: Let's talk a little bit about the influence of pediatric gastroenterology. You belong to the North American Society of Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN). This group got together in 2001 to create a consensus for how to manage acid reflux disease in kids. So is that consensus the gold standard now?
The NASPGHAN position paper is as close to a gold standard as we can come. Let's put it this way: I see Colic Solved as kind of an extension of the NASPGHAN position paper. I've tried as much as I can to embody the standards that are printed in the NASPGHAN position paper. But some parts of the book represent my own opinions about things, my own point of view based on my extensive experience with babies with reflux.
I think some of my colleagues, as I've said, probably think I overstate the role of reflux in irritable babies. And perhaps I do. We're sort of still in the infancy stages of understanding babies with reflux, babies with milk protein allergy. So we do have more to learn.
There was a study, interestingly, just published in January in Pediatrics in which they gave babies what's called "probiotics." They're the live bacteria found in yeast and other active cultures that have beneficial effects on the health of an individual when given in appropriate quantities. These researchers gave probiotics to 83 babies. Half got simethicone, which are the standard infant drops. The other half received a probiotic by the name of Lactobacillus reuteri.
The babies who received Lactobacillus reuteri showed a significant decrease in their crying scale, in their screaming, compared to the simethicone babies. This is kind of interesting because it raises the questions: What were these probiotics doing and what role do colon bacteria have in the irritable baby?
For sure, we know that probiotics are effective in treating inflammation. Perhaps it's possible that a chunk of these babies who got better had milk protein allergy and had relief because of the effect of the probiotic on the inflammation. So the study raises as many questions as it answers.
Wondertime: It sounds like this is, to say the least, an interesting time in the history of medicine to treat sick infants.
It is! There's still a lot that isn't known, though. We look at irritable babies a lot differently than we did 30 years ago.
Wondertime: How?
Because 30 or 40 years ago, we really didn't have super-hypoallergenic formulas to treat these babies. Because we didn't have appropriate medication for treating acid-related disease. And because we didn't even know a lot of these [conditions] existed in these irritable babies.
Because of that, back then, pediatricians had no other options than to tell a family that "this is the way it is, and we need to cope with it." While coping strategies are good, it's much nicer to have something to wrap our hands around.
Wondertime: Well, along those lines, let me ask you about the beginning of your field, pediatric gastroenterology. I think that it was 1988 that it was officially recognized?
That's the year the American Board of Medical Specialties developed a board for that. Pediatric gastroenterology extends beyond that; it didn't necessarily start then. There've been people well before then who devoted their time and attention to the digestive health of babies.
Wondertime: But it's interesting to me that it became official, so to speak. Is that because we were learning that circumstances warranted it being a new specialty? Did the field start and then the studies were done, or were studies starting to be done and they realized a specialty needed to be set up?
Well, I don't have the answer to that, except that I would probably think that the research was evolving. Our understanding of the infant or the childhood digestive tract had evolved to the point where we recognized that babies and children are different from adults.
Back in the old days, there were adult gastroenterologists who were oftentimes forced to treat children because there were no pediatric specialists in many parts of the country. So as the field evolved and as treatments evolved and as diagnostic procedures evolved, it became evident that there needed to be a body to certify specialists in pediatric care and pediatric gastroenterological care, and I think that's how it came together.
Wondertime: I'm going to switch gears here and ask you to tell us a bit about how reflux affected you and your family.
Nicholas, my firstborn, was a good baby. No problems with him, except he spit continuously throughout the day. Just a fountain! And everywhere we went, we had him in bibs. And we would exchange these crusty bibs — one for another — and in many of our pictures with him he's shown with a crusty bib. Right before his baptism picture, you know, we pulled the bib away so we wouldn't have it. So beyond that he was a happy kid who had just this innocent spitting up, which was not an issue for us.
Wondertime: And then your daughter came along a few years later.
She was a different story! Laura spit up some, but she was miserable beginning late in the first month of her life and had symptoms that are really pretty typical of reflux disease: difficulty feeding, arching back, pulling from the nipple.
My wife was breast-feeding at the time, and it was very difficult. It was difficult on Deidre, my wife, but also on Nicholas and the rest of the family. I think when you have a remarkably difficult baby living in the house, it impacts everyone, not just the baby.
Wondertime: How did this impact you as a father and as a doctor?
Well, I think it gave me a newfound respect for what parents go through when they live with one of these babies day in and day out.
Prior to that experience, when I was speaking with a family late at night who had a bundle of misery or markedly irritable baby, it was very easy to distance myself. Very easy to make judgments about their coping abilities. And that changed when I had Laura, because I recognized that it's very difficult for anyone to cope with a remarkably irritable baby.
Honestly, in many respects, it's made my job a whole lot more difficult.
Wondertime: How so?
Because, in a way, I empathize a little bit too much. As physicians, we try to keep a certain distance from sick patients because when you get too involved it's emotionally exhausting.
I think it's the perfect physician and the perfect pediatrician who knows how far to get involved with a family but also when to pull back. Because when you get in too close with people, it just, it just can be exhausting, and you burn out a lot quicker.
Wondertime: Does that mean you flash back to your experience with Laura more often than you might otherwise? Because you see babies like her over and over?
Yeah, I can flash back and recognize what these people are going through. And it's particularly difficult when we're treating a baby and none of the therapies we're trying seem to be doing the trick.
At that point, I feel really obligated to be helping the family to make things better. When, in fact, there are some children with reflux disease who don't respond. Even though we know they have bad reflux disease, they don't respond optimally to medicine. We can get them 50 percent better or whatever.
As I said, not every baby has reflux or milk protein allergy for sure, and helping parents adjust to a difficult baby can be really trying. But things do improve with time.
Wondertime: Why do things improve with time? What is changing anatomically so that babies grow out of their misery?
The word on the street is that colic disappears at three months of age. If we put that aside for just a moment and look at babies with reflux or babies with milk protein allergies, both of those problems are typically self-limiting problems.
Take acid reflux. The theory is that babies have acid reflux so much because:
- They're on an all-liquid diet.
- They tend to spend most of the time in the horizontal position.
- Their tummies don't empty very well. In other words, their motility or squeezing of their intestinal tract is uncoordinated, just like their arms and legs are uncoordinated.
- The valve at the top of the stomach likes to open and close in babies in order to let out air that they swallow. This valve is called the lower esophageal sphincter, LES for short.
When we're swallowing, it opens just at the right time when food is coming down the esophagus and allows the food to enter. So it acts as a valve that keeps things in the stomach, essentially. The integrity of that valve is one of the key elements in preventing acid reflux or acid reflux disease.
Babies have transient relaxations of the LES that serve to help get rid of air that babies naturally swallow. So that's a natural pop-off mechanism that babies have for air. But when that happens it allows milk to come up, and that's why babies spit up more frequently than, say, adults do.
That valve is important in preventing reflux, and in babies it's relaxing a little bit anyway, so that's why babies have reflux.
In you and I or in normal adults, the LES serves the role of opening up when food comes down the pipe and hopefully staying closed as much as possible to keep food in the stomach when we're exercising and doing other things.
Early on in life that valve likes to undergo frequent relaxations. These are called "transient relaxations" of the LES. And it's kind of interesting because these transient relaxations probably serve the role of allowing babies to decompress their stomach from the air that naturally comes in.
Wondertime: And the air comes in because they haven't quite figured out the sucking and so they're swallowing a lot of air?
Right. When a baby sucks and swallows, they're going to take in a certain amount of air through their uncoordination. When a baby breaks the seal from the nipple, they're going to make a smacking noise and they're going to swallow air. When babies cry they swallow air.
So, compared to you and me, they're more set up for swallowing air. And so I think these relaxations are probably nature's way of helping a baby decompress when they've got that air.
Wondertime: Okay, you were saying in your practice that about 60 percent of screaming babies coming in have acid reflux disease or milk protein allergies. Let me break that down. What's the rough percentage of who has GERD and who has milk protein allergy?
Probably half and half, but I can't give you firm numbers on the breakdown there.
Wondertime: Okay. I want to go back to what you were saying about how having Laura come into you life changed the way you thought of parents of colicky babies. Does it seem there's a "blame the victim" culture out there? That if parents just knew how to hold the baby, calm the baby, they'd solve the problem. What do you think of that kind of thinking?
Well, certainly, in the irritable baby genre of books you have Secrets of the Baby Whisperer or The Happiest Baby on the Block. And all these books advocate techniques for settling babies. Now, Harvey Karp's four techniques of making shushing noises do work for babies who are stirred up or who are fussy.
The babies I see typically are profoundly irritable babies. Babies that are sick. Babies who are really having a hard time feeding and are profoundly miserable more than three hours a day.
What happens is we sometimes lump the baby with the fidgets with these babies who are profoundly irritable. There's no hard line between what makes a baby fidgety and what makes a baby remarkably irritable. But pediatricians, the media, and others will oftentimes say this is something that the parents need to deal with. They need to swaddle the right way. They need to make the right noises.
And parents can feel like their baby's pain is a consequence of their own inadequacy as a young parent. That's always heartbreaking to me when I see and hear that.
But, truth be told, I do see parents who have a much harder time coping than other parents do. And it's absolutely remarkable when I'm in a room with a baby who I can barely be in the room with because they're screaming so loud, but yet the mother's not having that hard a time. She's got a real high threshold. She's got good support.
I'll go in the next room, and there's a baby who appears to be happy all the time, or appears to be happy in the exam room. There's a mother-in-law standing there saying that he's not that irritable — but yet the mom seems to be falling apart.
So it's clear there are differences between the way mothers handle the stress of any kind of irritability, and that's often a variable that we overlook. That not all parents are alike.
Wondertime: So there is a percentage of screaming babies where it's not a medical problem?
Oh, absolutely. As I've said: temperament. There are babies with personalities that are hard to deal with, babies that are more sensitive to touch and sound and light. And these are babies who don't have acid reflux disease, who don't have evidence of milk protein allergy when we look for blood in the stool, or look inside the intestinal tract.
So I do think it's important to suggest that there are some babies who just are difficult like this. However, I don't think we should characterize this as disease, or a diagnosable condition. I know adults who are like this!
There are adults who are cranky at the end of the day, or are bothered by lights and sounds. But we don't give babies the same latitude. We expect them all to be, you know, placid, cherubic little creatures what just do exactly what we want them to do. Expectations are very important in this regard.
Wondertime: What do you mean about expectations?
I think a lot of parents expect their baby to look like the baby on the front cover of Parenting or Wondertime. During the nine months of their pregnancy, they envision, as I said, the idea of this little cherub who's going to bring peace and joy to their lives. And when it doesn't exactly fit their expectations of what a baby should be, they cry foul, and look for a diagnosis or disease or condition where one might not exist.
Wondertime: Let's say you've got acid reflux disease. Does that also mean you have disorganized feeding and sleep problems and so on? Is there a whole sort of boatload of symptoms that go together?
With respect to reflux, yes, there is a whole boatload of symptoms and not all babies exhibit all of them. You know, issues surrounding feeding are one of the big issues. Dysfunctional feeding. The indecisive feeder who is on and off the breast; they're off because of the pain, and they're back on because they're hungry. That's quite typical.
Wondertime: When you say "they're off because of the pain," what does that mean?
When a baby (or any person for that matter) has reflux esophagitis, it's very painful to swallow quickly. It's much like when you have a rip-roaring strep throat, and you want to drink your orange juice and you know you need to get it down, but you just wince when you start to swallow it. Babies want to feed, but it's painful for them to feed.
Wondertime: I'm just going to quote you from the book: "It's an exciting time to have a baby who screams and spits up everywhere — you're in the midst of a revolution!" When you say "in the midst of a revolution," what is the revolution in treatment?
Well, I think we're at a point where pediatricians are beginning to recognize, as I've said, babies who come in screaming don't just fit into one little diagnostic box. Pediatricians are beginning to recognize many of these babies have treatable conditions. We have pharmaceutical companies who are pursuing therapies, safety studies, in infants and young children.
A lot is evolving and a lot is changing. And a lot of these babies who were once written off now have treatable options. Neocate, which is one of our new super-formulas, has really revolutionized some of our most difficult milk protein allergy babies.
So I guess maybe "revolution" is a little dramatic. But things have changed. And parents today are in a little better position than their parents were.
Wondertime: How significant are the advances in using scopes and pH probes?
Fiber optic technology has evolved over the past generation to the point where we now have scopes that are small enough to go into the intestinal tract of babies and young children. That was unheard of a generation ago. And that's allowed us to correlate some of the signs and symptoms that we see in babies and young children along with actual findings in pathology.
We're just really beginning to learn about acid reflux disease in toddlerhood and how that evolved. As I've said, there was some time ago that we believed that acid reflux disease wasn't really even a problem in children. But it's evolved to the point where we give it more credibility because of what we've seen endoscopically.
Wondertime: How do pH probes work?
A pH probe is a little pH-sensitive detector that goes on a little wire that goes down through a child's nose and sits in the middle of the esophagus. It allows us to quantitate what's coming and going in the esophagus.
Wondertime: By measuring the amount of acid, you mean?
By measuring the amount of acid that's coming up and hitting the esophagus. In older children, we actually have a new probe that we can clip on the lining of the esophagus so the child doesn't have anything through their nose. And it sends a radio frequency signal through a little recording device and it allows us to record acid reflux activity in the esophagus.
Wondertime: About that probe in the nose, do parents ask you how you're going to make that stick? Wouldn't a baby yank it out?
If the tube is taped properly, taped cleanly on the face, and it doesn't itch the child's face, kids do a pretty good job of leaving it alone. If we're unsure, we'll send the child home with an elbow brace to keep their arms straight. It seems kind of primitive, but it works.
Wondertime: So it sounds like when you were talking about the so-called revolution, it's a revolution in the tools of the trade, it's a revolution in pharmacology, and it's a revolution in formulas. Are those all the fronts?
Right. It's a revolution in diagnostics, in therapeutics, a revolution in personnel.
Wondertime: When you say "personnel," do you mean better training?
Yeah, most cities now have trained pediatric gastroenterologists to care for sick kids. Most pediatricians have pediatric gastroenterologists available to give opinions on their kids and to help train pediatricians. There is a shortage in pediatric gastros, but it's probably safe to say that in most cities most parents have access to such specialists.
Wondertime: Say I have a baby, and he is screaming and screaming and I take him into my pediatrician — not a specialist — how do I advocate for my baby? How can I find out if my pediatrician is up to speed on treatment?
Well, knowing whether they're up to speed on treatment, specifically, may be very difficult for a parent to assess. I think some of the clues that a pediatrician is doing a good job is they need to be taking the time to conduct a thorough history of a baby's condition.
The length of time it takes them to find out how the baby is feeding, how much they're feeding, what's their total daily volume, what's their feeding behavior, how's the baby eliminating. Most parents will get a sense of whether the doctor is doing a thorough job. Very often, many doctors are in and out of the room very quickly and they don't want to take the time.
But with respect to irritable babies, the devil is in the details. And there's no way that a pediatrician is going to pick up what's happening with a baby without spending, at least on the initial visit, a significant amount of time.
Wondertime: What's a significant amount of time?
It may take up to 30 minutes as far as taking a history. So going through all these exhaustive questions with an irritable baby are critical to determining (a) whether he needs to do any diagnostic studies or (b) what therapeutic approach does the doctor want to try?
Wondertime: If you go on the Internet and search for colic cures, a million things seem to come up. Gripe water is one of them. Is this stuff just silly? Or is there anything to it?
Well, it depends what you're talking about. There are a variety of things out there. The ingredient in many of the colic drops, like in Mylicon, is simethicone, which is a compound that takes bubbles and breaks those bubbles into smaller bubbles. Now there is a small body of literature that's apparently shown some efficacy in treating fussiness with simethicone compared to controls.
My experience has been that it doesn't make too much of a difference. But I'm probably dealing with a little bit of a sicker population than the average bear. Most gas in my babies and most gas in many babies comes from chaotic disorganized feeding and excessive crying.
Wondertime: Because of the swallowing of the air, you mean?
Swallowing of the air, even just screaming from an ear infection is gonna cause excessive gas from air swallowing.
There's no way a couple of colic drops are going to take that massive quantity of air and make it disappear. That doesn't happen.
Wondertime: Here's one recipe for gripe water: "dill oil, sodium bicarbonate, and 3 percent to 5 percent alcohol." Is that something that helps? Or is just kind of a palliative?
Gripe water, I don't think, has a standardized formulation. Different companies and different people have adopted that name. I don't think it's a branded name. But the bicarbonate may have some role in treating reflux-related symptoms.
The other stuff I can't comment on. I'm open to alternative therapies for babies and children with conditions that can't be treated with traditional means.
With respect to supplements and those sorts of things, I would tell parents that as long as (1) they're safe and (2) the parents aren't getting taken advantage of, I'm certainly open to alternative therapies. And that includes gripe water, if parents want to try it.
Wondertime: Since we're talking about concoctions, what medicines do you give to a baby who has acid reflux disease?
The main treatment for babies with acid reflux is an acid suppressant. What a baby is treated with will depend on (1) who's treating them and (2) how sick the baby is. Many pediatricians will start out with a basic antacid such as Zantac, which does the trick in many babies.
The symptoms that a baby or a child experiences with acid reflux are a direct consequence of the acid that's coming from the stomach. So by targeting acid production, we're minimizing the acidity of the stomach, and therefore helping minimize the child's symptoms.
Wondertime: With adults Zantac feels like it works pretty quickly. Does it work quickly with babies?
While many babies, probably most babies, who suffer with painful reflux symptoms and painful reflux esophagitis don't have a lot of damage because they're too young, it may take several days for parents to see a significant improvement in the baby's behavior. It's not gonna happen overnight and that can be a stumbling block for parents, who naturally want an immediate fix.
We can't exactly do that. We need to allow a little bit of time for that esophagus to heal. We need to allow some time for that acid to decrease.
Wondertime: Okay, so you start with Zantac. And if that doesn't work, what happens next?
In sicker babies who have significant irritability, difficulty feeding, poor growth, or lung problems, we'll often consider a medication like Prevacid or Prilosec.
These are proton pump inhibitors, a different class of acid suppressant medications that work a little bit better. It's better — certainly in older children — at healing an esophagus than Zantac and other H2 receptor antagonists, such as Axid. These drugs decrease the production of stomach acid.
Wondertime: What are proton pump inhibitors?
Proton pump inhibitors are a class of medication that decrease the amount of acid that's produced by the stomach. Those brand names include Nexium, Prevacid, Prilosec, and Protonix. They're more potent at suppressing acid production and more effective at healing a damaged esophagus.
These proton pump inhibitors work in a special cell called the "parietal cell." It's the parietal cell in the stomach that makes acid. Pumps in the top of the cell pump out the acid. Medications such as Prevacid and Prilosec inhibit those pumps so that less acid is produced.
Then there are triggers at the bottom of the cell, which stimulate acid production. Axid and Zantac block one of the receptors for those triggers. So the proton pump inhibitors tend to be a more effective means of suppressing acid because they work directly at the pumps, as opposed to the switches.
Wondertime: It's like a little engine that you're tinkering with there.
Yeah, exactly. And there's one more thing: Those little pumps need to be moving and working in order for the inhibitors to work. That's why we like to see these medications given 20 minutes before eating, so that they're in the blood when the stomach gets stimulated.
Wondertime: Is there a genetic component in acid reflux disease?
There's clearly a familial link with acid reflux disease between parents and kids. The question is whether the typical baby who arches and screams and has classic symptoms of acid reflux is more commonly born to parents who have acid reflux. I don't think that's been worked out.
We have severe cases of acid reflux in children. And I see the kids who go on through infancy up to toddlerhood, who we examine with scopes, who have erosive damage in the esophagus, there is a higher incidence of severe reflux disease in their parents.
We know there's an association between hiatal hernias, which are little defects at the bottom of the esophagus, that predispose to reflux. We know that those are genetically connected. And so there is a precedent for suggesting that reflux has a genetic element to it. But for most of these babies who are just miserable, it's not related to what Mom and Dad have experienced.
Wondertime: Let's talk about timing and healing for a minute. Say a parent brings a baby in and you identify, after a series of tests, that the baby has a milk protein allergy or acid reflux disease. What then is the prognosis for how quickly the baby will feel better? Saying "cured" is probably too extreme.
Right. Well, of course, it depends on the case. But take the typical baby with milk protein hypersensitivity. The miserable screaming baby who comes in, who we find has mucus in the stools, maybe there's a streak of blood, which means a milk protein allergy. We will put those children on a casein hydrolysate formula like Nutramigen or Alimentum.
The standard of therapy for a baby in that situation would be to use one of those two formulas. Once that's initiated it may take up to two to three weeks for a baby to start to feel better. It may be quicker, but it's probably going to progressively happen over the course of a couple of weeks.
Wondertime: And is that just because it takes a while for the damage to heal?
Right. When we put a scope into these kids, we see tiny little ulcers throughout the colon. And those don't heal up in a day. It takes several days for those to heal up and for babies to feel better. So in the case of protein allergy, we're looking at probably a week to two before a child can start to see some relief.
I will say that I've had some parents report that the child definitely feels better within a few days of initiating these types of super-formulas. But I try not to create that expectation for parents. I try to be realistic.
Wondertime: What a lucky child and parents if that is the case! I'm sure the people who come see you are just so on their last legs.
Sometimes they are, oh yeah. When we use Prevacid it's a little bit more effective. When we start that, we oftentimes see results within five to seven days. Although we don't call it a failure for up to two weeks. So if I have a mom call me in a week and the child clearly has reflux esophagitis and isn't better, I'm gonna push the family out to a couple of weeks before I consider that a failure.
In most babies who have typical reflux esophagitis, most aren't going to fail. But some will fail. And I think it is an important point that every baby, even babies who we absolutely know are suffering with typical symptoms of acid reflux disease and we know don't have milk protein allergy, not all these kids are going to respond to medication. Most will, but not all.
And it's very difficult when they don't, because we get into a situation where we have to try alternate medications, because sometimes one acid suppressant will work better over another for a particular child. Sometimes we'll use things that will coat the lining of the esophagus, like Carafate or even Mylanta.
So, I think that point that not 100 percent of kids respond is an important one.
Wondertime: I don't want to be incendiary, but if you were to sort of take your best guess at the pediatric community as a whole, how much do you think the general community of pediatricians is on top of the fact that acid reflux is so prevalent, and milk protein allergies are becoming so important? Do you feel like that's kind of generally known, or not as much as it ought to be? What's your sense of that?
You're asking, like, "How ignorant is the medical community?"
Wondertime: I suppose that's what I'm asking.
I think it depends where you are. The cosmopolitan, larger cities have populations of pediatric subspecialists who are helping with the management of kids. The pediatricians in those large cities are more on top of the fact that these irritable babies may actually be suffering with something.
When you get out to rural places where the pediatricians and doctors don't have any contact with anyone else, like so many other things, they're practicing sometimes in a way that's 10 or 15 years behind the curve.
Another question, a separate question that you didn't ask is "Are there pediatricians who have heard that this is the case, but don't believe it?"
There are some of those. There are some still in the old colic camp who think a lot of these babies' conditions are overstated. Their parents are nervous and there's really nothing wrong. Those exist, but I think those are becoming fewer and farther between.
Wondertime: Is it more of a generational thing?
I think, yeah, it's more of a generational thing. I really think that 30 years ago when the doctor-patient relationship was more paternalistic, things were more doctor-centered. And it was easier to tell a parent that "this is the way it is" and leave it at that.
I think the doctors coming out of training over the past 5 to 10 years, I mean they've been trained that these are possibilities, so they're open to them. And I don't think they even consider necessarily that the parents are crazy or anything like that.
Granted, there are parents who are nervous and doting. But anyway, yeah, I think it may be a generational thing as well.
Wondertime: So given what you've just said, how does your book help educate people?
Well, you know, after I wrote the book I looked at it, and I said, I hope that pediatricians aren't too angry when they read this, because it really tries to empower parents to advocate for their kids when they have these signs and symptoms that are noted in the book.
And I know sometimes I'm a little angered when parents bring things in off the Internet or bring in books and point to things. I think I've been more open to it recently, but some pediatricians can get put off. So I guess my book really tries to push parents to advocate for their babies when they have these signs and symptoms.
Obviously, I fall into the category that most of these babies are treatable. Not all of them are. Some people have misquoted me by saying that all babies who are irritable have reflux. And that simply isn't the case.
Wondertime: Okay, do you think we should just throw out the word "colic" altogether?
"Colic" as a diagnosis should be thrown out, absolutely. Colic as a description of behavior is probably okay, if we're describing a baby as having colicky behavior, that's probably reasonable.
I never use the term at all in my practice. The term doesn't even cross my lips, really, at any point, unless I'm quoting someone else. The word "colic" shouldn't have much of a role in modern medical practice.
This is supported by other people as well. Like Dr. William Sears, who is a pediatrician author and many would consider the modern-day Dr. Spock. He doesn't use the word "colic." He describes babies in this situation as "hurting babies."
We both share the same view on colic. He's a little more forceful with it, though. He suggests the parents should camp out at their doctor's office, if they're given the word "colic," and demand an answer! He's a little more, believe it or not, passionate about it than I am. But with my book, I tried to strike a middle ground and be balanced, you know.
Wondertime: It's interesting, because the general population says "colic" all the time, as you know. In my small anecdotal experience, everybody's rather kind of shocked when you say, "There's no such thing as colic." It's just a description of symptoms. People really think colic is a tangible disease.
I think people get offended when you say, "There's no such thing as colic," because they think you're saying, "There's no such thing as miserable babies." And that's absolutely not true.
Wondertime: Where do you think you would be placed in the medical community? Are you radical? Are you conservative?
I don't know if I'd be called radical. I think that Colic Solved is a little bit edgy, just because of what I suggest. I wouldn't call it radical; it pushes the envelope a little bit. I hope it gets parents to think and doctors to think. If I can at least open up a dialogue, it will have been worth it.
