About the Author
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As one of the few pediatric troenterologists
serving Houston’s referral area of nearly eight million, Dr.
Bryan Vartabedian has diagnosed and treated more than 5,000
children with reflux disease. He is an assistant professor
of pediatrics at Baylor College of Medicine in Houston and serves
as an attending physician at Texas Children’s Hospital, America’s
largest children’s hospital. The issue of reflux disease is of
personal interest to Dr. Vartabedian because his daughter
suffered during her early months with severe reflux esophagitis.
He lives with his family in The Woodlands, Texas.
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1
THE TRUTH ABOUT crying BABIES
If your baby screams, she’s not alone. It’s estimated that about
1 of 5 babies have unexplained irritability. It’s been 50 years
since the initial pigeonholing of irritable babies with a
condition that we’ve affectionately come to call colic. At the
time that colic was first described, doctors had few means of
knowing what was going on inside a baby. And in the absence of
any better explanation, the idea of a five-letter word to sum it
all up was warmly received. And despite what we have come to
know, colic as a wastebasket diagnosis remains alive and well, a
vestige of history and a comfortable place to put the babies we
have such a hard time with. But your baby is screaming for a
reason. It’s a cry for help.
THE CASE OF BABY HANNAH
Hannah was 2 months old when she first visited me in my Houston
office. Her pediatrician had referred her because he had
exhausted all of his resources as a busy primary care
pediatrician. Hannah wouldn’t stop crying, and he didn’t know
why. The best explanation this seasoned and reputable
pediatrician had was that Hannah had colic.
Her problems began at around 2 weeks of age when she began crying
after her feeding. Her crying progressed to throughout the day
and started to affect her feeding. The pediatrician advised that
her mother discontinue feeding her because he feared that
milk was the problem. Formula feeds began strong, but
after a half ounce became difficult, with Hannah arching, pulling
from the nipple, and in apparent pain, all while still being
hungry and wanting more. The frustration of Hannah’s hour-long
feeding episodes were matched only by her , which was
regularly interrupted with piercing screams and painful .
Her waking hours were marked by nearly constant hiccups and the
need to be held and moved. Hannah’s parents were told that she
had colic, yet colic medication never seemed to make much of a
difference. Formula changes became nearly as frequent as diaper
changes, but nothing seemed to make a difference.
The baby’s incessant irritability, impossible feeding, and
unpredictable ing patterns soon began to take its toll on
her parents. When her mother returned to work when Hannah was 3
months old, understanding day care was hard to come by. At the
end of their rope with a marriage at its limits, Hannah’s parents
came to see me.
WELCOME TO MY WORLD
Whether it’s a pleasure or not, I have the rtunity to work
with babies like Hannah every day. Thousands of screaming,
miserable, less, and impossible-to-feed babies have found
their way to my office over the past several years, some er
than others, but all delivered by desperate parents looking for
answers and looking for help. This book is about what I’ve
learned and what I know.
I’ve always said that it was far easier being a pediatrician
before I ever had children of my own. Calls in the middle of the
night from the less parents of screaming babies were handled
as a matter of course early on in my career. But despite my
comforting words, my attitude beneath was “Deal with it.” I had
bought into the idea that all babies scream and that some babies
scream because of the stress and pressure that young parents
convey to their babies. While I have always done my best to
evaluate and treat every baby thoroughly, I was very much inside
the system at first . . . a paternalistic, board- certified
know-it-all with 6 years of residency and fellowship training at
America’s largest children’s hospital. But I had never lived with
a baby. More important, I had never lived with a baby with
reflux.
The birth of my daughter, Laura, represented a turning point for
me as a pediatrician. Laura was a lot like Hannah, with the
exception that her her was a pediatric troenterologist. And
with that came expectations from my wife to make things better.
Laura was treated for reflux and morphed from a bundle of
misery to something far more tolerable. I was vindicated as both
a her and a physician, and my view of the screaming baby has
never been the same.
I should note that my son, Nicholas, happily spit everywhere and
all the time until nearly a year of age. But for us this was
nothing more than an inconvenience. In nearly all of his baby
pictures, he is wearing a crusty burp bib intended to protect the
expensive outfits we bought him as the firstborn. So you could
say that I’ve had it both ways: a bundle of misery and a happy
spitter, two patterns that you’ll read about in Chapter 3, “Seven
Signs of Reflux in Your Baby.”
For better or worse, I can now empathize with the families I
see—for better because I can understand their situation and react
to it more sensitively; for worse because I can understand their
situation and relive the misery that they feel whenever I’m
called to evaluate a screamer.
COLIC—THE DIAGNOSIS FOR ALL OCCASIONS
Unfortunately, not everyone has a pediatric troenterologist as
a her. In many cases, babies are left alone to cry, either by
parents who don’t know how to advocate for them or by doctors who
don’t know where to turn. In fact, in Hannah’s case the diagnosis
was colic because there was nothing else to explain her problem
and the symptoms loosely fit with something that her pediatrician
had been taught many years ago.
So What Is Colic?
The quest for the cause of colic or even an agreed-on definition
of it over the last half century has aed to something of an
optical illusion. Like one of those abstract images that you must
stare at for minutes on end before actually identifying the
picture, colic has been something of an elusive diagnosis among
pediatricians. And the many who never quite see it ultimately
agree that they see it just so they won’t have to continue
squinting.
I’ll have to admit that from early on in my career I was never
able to see the pretty picture when it came to the illusion of
colic. While I’ve evaluated and treated thousands of irritable
babies, the problem is that I’ve never seen colic and can’t get
straight answers about what it is or what it looks like from
those who cl to have seen it. Like the UFOs that seem to land
everywhere but at Harvard and MIT, colic has evolved into one of
our culture’s greatest urban legends—a mythical explanation meant
to explain the seemingly unexplainable.
A Baby Cannot “Have” Colic
The problem comes with the fact that colic is a description and
not a disease. This descriptive term has, in turn, been morphed
into a real and recognizable condition that served an important
role for parents and pediatricians in our not-so-distant past.
Much as fables and myths help provide order and explanation for
different cultures, colic was once a comfortable resting place
for weary pediatricians dealing with weary parents. And when
medical science failed to offer any better explanation, it served
to conveniently absolve the pediatrician from any further
responsibility to parent or child.
Because colic represents a pattern of behavior and not a disease,
a baby cannot “have” colic or have it “diagnosed.” Much like
fever or that typically represent signs of some other
problem in a child, colic doesn’t stand on its own as a
diagnosis. To use the words diagnosis and colic together suggests
that intelligent, established criteria, backed up by clinical
research, were used to come to that conclusion. But
unfortunately, such criteria or compelling clinical studies don’t
exist. In the words of a distinguished researcher on the topic of
infant irritability recently quoted in the Journal of Pediatric
troenterology and tion, “The term colic implies a
mechanism responsible for the distress displayed by these
infants. Such a mechanism has never been demonstrated.”
Colic—Whatever You Want It to Be
But colic advocates and researchers who have built their careers
on the urban legend that is colic will beg to differ. The
criterion they use, as determined in 1954, suggests that the
diagnosis should be considered in babies who experience
inconsolable screaming for 3 days a week, for 3 hours a day, for
at least 3 weeks a month. Unfortunately, if your baby screams for
only 2 hours and 45 minutes for only 20 days straight, you’re a
day early and a dollar short. Had I created criteria for colic, I
would have suggested adding the fact that you haven’t had sex
with your spouse in 3 months, you’re up 3 hours each night, and
you’re 3 weeks away from losing your job unless you get some
. But I wasn’t practicing in the 1950s, and things were
different then.
If we give our 1950s’ researchers the benefit of the doubt and
accept the out-of-thin-air rule of threes, as it is called, not
everyone sticks to it. In fact, when it comes to the diagnosis of
colic, everyone seems to have his or her own rules. A colleague
whom I work closely with will diagnose colic only if the baby
cannot be put down. Another employs a white-noise rule—the
diagnosis is confirmed if the baby settles with the sound of a
vacuum cleaner, hair dryer, or other loud neutralizing sound. It
seems that the number of random, self- imposed criteria for
diagnosis are limited only by the imagination.
So despite the complete absence of a consensus of what
constitutes colic, it remains nonetheless a convenient
wastebasket diagnosis that can be retrofitted to suit the need of
the individual making the diagnosis. If you haven’t caught on,
colic would appear to be a well- orchestrated five-letter defense
mechanism for doctors who are either outdated, outwitted, or just
plain out of ideas.
THE COLIC REVOLUTION—SCREAMING INTO
THE TWENTY-FIRST CENTURY
Our experience and medical research tell us that babies scream
for a reason. While Colic Solved doesn’t intend to suggest that
there aren’t high-need babies or those with sensitive developing
nervous systems, it is here to introduce the idea that something
physical may in fact be wrong.
In a sense, this book is the result of a revolution in pediatric
medicine—a culmination of technology and in. Advances in
endoscopy (viewing the inside of body organs or cavities with a
device that uses flexible fiber optics), cology, and
tion have allowed us to rethink why babies cry. In the
twentieth century, we called it colic only because no one knew
any better. And while developments in conquering diseases such as
polio and smallpox obviously take center stage, other seemingly
less impressive advances are important minor characters. Our
understanding of the irritable baby is one of them.
Technology Has Changed Our Babies for the Better
So what are the changes in pediatric care that have
created a better understanding of why babies do what they do?
•The creation of pediatric troenterology as a specialty. While
there have been pediatricians dedicated to the understanding of
pediatric digestive since the early 1900s, it was the
formal organization of the field of pediatric troenterology
that has created an atmosphere of
organized discussion and research. The subspecialty of pediatric
troenterology was recognized by the American Board of Medical
Specialties in 1988, and since then the number of trained
trointestinal (GI) spets conducting research and setting
the standards of care has continued to grow. Alongside the
expansion of troenterology as a pediatric subspecialty has
been the development of smaller endos (flexible-tube optical
instruments that use fiber optics to illuminate the inside of the
intestinal tract) for understanding what happens in a baby’s
digestive system. pH probes came into popular use by pediatric
troenterologists in the 1980s, allowing doctors to begin to
associate patterns of reflux with patterns of irritability. (pH
is a measure of or alkalinity of a substance.)
•Identification of reflux as a key contributor to a number of
common conditions. Beyond simply understanding reflux (the
backflow of stomach into the esophagus, the muscular tube
that carries food and drink to the stomach) in babies, this
evolution of technology involving fiber-optic endos and pH
probes has allowed the correlation of reflux with other problems
such as asthma, sinus conditions, and feeding disorders.
•The advancement of infant tion. Understanding of the
growing immune system has led to the development of
hypoenic formulas, specifically superhypoenic
formula, which became available for common use in the early
1990s. This has revolutionized the care and feeding of the infant
with severe ic disease. Our ability to understand the
reactions of the intestinal immune system has been furthered by
our ability to “see” intestinal y with endoscopic
technology. And while we continue to learn more and more about
the incredible benefits of feeding, formula manufacturers
are learning from it to benefit babies who can’t feed.
Formulas, which were once nothing more than a vehicle for
protein, , and carbohydrate, now sometimes contain long-chain
ty s that have been shown to improve visual and cognitive
function in infancy and beyond.
•The evolution of pediatric drug development. The development and
improvement of safe, effective ants for use in children have
revolutionized the way we see and care for the screaming baby.
The technology of drug delivery has provided pediatricians with
more options for facing the challenge of administering medicine
to infants and children. And recent changes in federal law now
mandate clinical trials (research studies) in children for many
of the new drugs being released for adults.
•The popularization of the Internet. While many doctors consider
it a curse, the Internet has empowered parents to network and ask
questions about their baby’s misery. Parents whose babies have
been dealt the once dead-end diagnosis of colic now are learning
in chat rooms and on Web sites that there may be identifiable and
treatable problems at work. While the Web has the downside of
sometimes offering too much information, its ability to raise
questions is unparalleled.
So as we enter the twenty-first century, it sure seems like a
great time to be a baby, particularly one who screams. All of
these developments have made it easier to help the fussy baby.
Why Hannah Is Screaming
We now know that children with the type of irritability described
as colic often suffer with either reflux or milk protein y.
A major study reported in 2004 by one of the world’s most
respected reflux researchers created quite a stir in the medical
community. Clinical researchers treated a group of irritable
babies with hypoenic formula. The babies whose symptoms
didn’t lessen when they were given hypoenic formula were
then evaluated for the presence of troesophageal reflux using
endoscopy and a pH probe (you’ll learn more about these in
Chapter 8, “A Parent’s Guide to Tests and Studies,” but for now
understand that this is how reflux is formally assessed). Of 60
markedly irritable infants between the ages of 1 and 6 months,
66% had pH probe results consistent with abnormal reflux and 43%
had evidence of reflux injury shown by biopsy of the
esophagus. While the report’s authors make it clear that proving
an absolute cause-and-effect relationship between crying and
obvious reflux can be difficult, the results are
thought-provoking.
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