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Comparison between chiropractic and lactobacillus in the reduction of crying time for infants with colic: Should chiropractic treatment be included in the treatment protocol of infant colic?

A SYSTEMATIC REVIEW OF SYSTEMATIC REVIEWS

ABSTRACT: Colic in infants causes one in six families (17%) with children to consult a health professional. The author is unaware of any study comparing the effects of chiropractic treatment and probiotics (lactobacillus) for the treatment of infant colic.

OBJECTIVE: This study compared chiropractic treatment and lactobacillus in reducing crying time in babies with infantile colic.

METHODS: A search of literature reviews for the treatment of infant colic using chiropractic and lactobacillus was made using the Cochrane collaboration software program, review manager (RevMan) (RevMan 2008). A search of literature reviews, systematic reviews and meta-analysis using the pubmed and google scholar database was also performed. Chiropractic treatment and lactobacillus were compared in the mean difference of the reduction of crying time for babies with infantile colic after 21 days of probiotic treatment. Literature or systematic reviews and meta-analysis were found by a search of the pubmed and google scholar electronic database. An inclusion and exclusion criteria was performed. Only chiropractic data with low risk of selection bias (random sequence generation and allocation concealment), low risk of performance blinding (parental blinding) and low risk of attrition bias (selective reporting) were included.

RESULTS: Chiropractic was more effective than lactobacillus at reducing crying time when considering only studies with low risk of selection bias (random sequence generation and allocation concealment) (1.24 and 1.20/56.03) and low risk of attrition bias (selective reporting) (1.95/56.03). Chiropractic was similar to lactobacillus at reducing crying time when considering only studies with low risk of performance bias (participant/parental blinding) (0.58 56.03).

CONCLUSION: The inclusion of spinal manipulative therapy as part of the protocol for the treatment of infantile colic is promising. Based on the lack of efficacy and safety of certain drugs and the lack of evidence for overall treatment options, physicians may want to consider chiropractic treatment as part of the management of infantile colic. A possible treatment protocol could be the combination of chiropractic and probiotics (L. reuteri ATCC 55730 and L. reuteri DSM 17938) which were both shown to reduce crying time in this study. Further studies confirming these findings are warranted.

INTRODUCTION

Colic is often defined by the "rule of three": crying for more than three hours per day, for more than three days per week, and for longer than three weeks in an infant who is well-fed and otherwise healthy. Medications available in the United States have not been proved effective in the treatment of colic, and most behavior interventions have not been proved to be more effective than placebo. (1)

Infantile colic causes one in six families with children to consult a health professional. (2) The complexity of the treatment for infant colic relies on the unknown etiology of the condition. In 2004, Shenassa, et al, conducted a review of six studies and concluded that new epidemiologic evidence suggests that exposure to cigarette smoke and its metabolites may be linked to infantile colic. (3) In 2015, Gelfand, et al, conducted a systematic review and metaanalysis and concluded that infant colic was associated with increased odds of migraine. (4)

The condition of infantile colic was selected because of the evidence of efficacy for both chiropractic and probiotics in reducing crying time. In 1999, Wiberg, et al, conducted a randomized controlled trial comparing chiropractic to dimethicone and found that by trial days 4 to 7, hours of crying were reduced by 1 hour in the dimethicone group compared with 2.4 hours in the manipulation group. On days 8 through 11, crying was reduced by 1 hour for the dimethicone group, whereas crying in the manipulation group was reduced by 2.7 hours. From trial day 5 onward the manipulation group did significantly better that the dimethicone group. (5) In 2011, Alcantara, et al, conducted a systematic review of 26 articles and concluded that chiropractic care is an alternative approach to the care of the child with colic. (6) In 2012, Miller, et al, conducted a randomized controlled trial of 104 patients and found that in chiropractic manual therapy improved crying behavior in infants with colic. The findings showed that knowledge of treatment by the parent did not appear to contribute to the observed treatment effects in this study. Thus, it is unlikely that observed treatment effect is due to bias on the part of the reporting parent. (7)

Probiotics, in particular strains of lactobacillus have been shown to reduce crying time in babies with infant colic. In 2007, Savino, et al, conducted a prospective randomized study and found that Lactobacillus reuteri improved colicky symptoms in breastfed infants within 1 week of treatment, compared with simethicone. (8) In 2012, Bruyas, et al, conducted a systematic review and concluded that pharmaceuticals have not proven effective (simethicone, lactase) and some (dicyclomine) can cause potentially serious adverse reactions. Furthermore, the study concluded that the most validated treatment for infantile colic is the substitution of a hydrolysed cow's milk formula, the use of Lactobacillus reuteri, and of fennel extracts. (9) While the aforementioned studies compared both chiropractic and Lactobacillus to simethicone, they fail to compare chiropractic to lactobacillus in reducing crying time.

The purpose of this study is to compare chiropractic to lactobacillus (after 21 days of treatment) using only data with low risk of selection bias (random sequence generation and allocation concealment), low risk of performance blinding (parental blinding) and low risk of attrition bias (selective reporting).

METHODS

Chiropractic treatment and lactobacillus were compared in mean difference of the reduction in crying time for babies with infantile colic after 21 days of probiotic treatment. A search of literature reviews for the treatment of infantile colic using chiropractic and lactobacillus was made using the Cochrane collaboration software program, Review Manager (RevMan) (RevMan 2008). Literature or systematic reviews and meta-analysis were found by a search of the pubmed and google scholar electronic database.

An inclusion and exclusion criteria was performed. Only data with low risk of selection bias (Random sequence generation and allocation concealment), low risk of performance blinding (parental blinding) and low risk of attrition bias (selective reporting) was included.

RESULTS

One review including 5 studies and 223 patients measuring the efficacy of chiropractic treatment in reducing crying time met the inclusion criteria. Also, one study including 3 studies and 209 patients measuring the efficacy of lactobacillus in reducing crying time was found.

Of the chiropractic studies, 4 were peer reviewed while all 3 studies for lactobacillus had a low risk of selection, attrition and performance bias except Savino, et al, 2007 rated with a high risk of performance bias. Savino, et al, 2010 was rated with an unclear risk of selection bias for allocation concealment. All the ratings were performed by their respective authors.

Chiropractic was more effective than lactobacillus at reducing crying time when considering only studies with low risk of selection bias (random sequence generation and allocation concealment) (1.24 and 1.20/56.03) and low risk of attrition bias (selective reporting) (1.95/56.03). Chiropractic was similar to lactobacillus at reducing crying time when considering only studies with low risk of performance bias (participant/parental blinding) (0.58/56.03).

DISCUSSION

The available literature providing support for the inclusion of chiropractic care in the treatment of infantile colic was reviewed in the introduction. Another study supporting the treatment of infant colic with chiropractic has to do with the long term effects of chiropractic treatment in babies with infantile colic. In 2009, Miller, et al, conducted a survey of parents of 117 post-colic toddlers in a treatment group and 111 toddlers in the non-treatment group and found that toddlers who were treated with chiropractic care for colic were twice as likely to not experience long-term symptoms of infant colic, such as temper tantrums and frequent nocturnal awakening than those who were not treated with chiropractic care as colicky infants. The study concluded that untreated post-colicky infants demonstrated negative behavioral patterns at 2 to 3 years of age. In this study, parents of infants treated with chiropractic care for excessive crying did not report as many difficult behavioral and sleep patterns in their toddlers. (10)

Other treatment modalities not explored or reviewed include treatment with pharmaceuticals. Studies indicate that some drugs either lack efficacy or safety in the treatment of infantile colic. In 1994, Metcalf, et al, conducted a randomized placebo controlled study involving eighty-three infants between 2 and 8 weeks of age with infant colic and found that simethicone is no more effective than placebo in the treatment of infantile colic. (11) In 1998, Lucassen, et al, conducted a systematic review and concluded that Dicyclomine was effective, but serious side effects had been reported like breathing difficulties, seizures, syncope, asphyxia, muscular hypotonia, and coma. No benefit was shown for simethicone. (12) In 2012, Hall, et al, conducted a systematic review of 19 studies and found that there is little scientific evidence to support the use of Simethicone, Dicyclomine hydrochloride and cimetropium bromide. (13)

Hall, et al, also concluded that there is some scientific evidence to support the use of a casein hydrolysate formula in formula-fed infants.

Whey hydrolysate formula has shown efficacy in the treatment of infantile colic. In the year 2000, Lucassen, et al, conducted a double blind placebo controlled randomized trial that showed a difference in the decrease of crying duration of 63 minutes per day. (13) This reduction in crying time is similar to both chiropractic treatment and lactobacillus discussed in this study.

Another topic that wasn't mentioned in this study was the role of diet in the treatment of infantile colic. In the year 2000, Garrison, et al, conducted a systematic review and suggested there was evidence of efficacy of hypoallergenic diet for the breastfeeding mother to reduce the incidence of infantile colic. In breastfeeding pairs (67%), the hypoallergenic diet was a maternal diet free of milk, egg, wheat, and nut products; the control diet was a maternal diet that included all of these products. In bottle-feeding pairs (33%), the hypoallergenic diet was a hypoallergenic infant formula; the control diet was a cow milk-containing infant formula. (14)

In 2012, Lacovou, et al, conducted a systematic review and concluded that in formula-fed infants, colic may improve after changing from a standard cow's milk formula to either a hydrolysed protein formula or a soy-based formula. (15) Also in 2012, Hall, et al, found that there is some scientific evidence to support the use of a casein hydrolysate formula in formula-fed infants or a low-allergen maternal diet in breastfed infants with infantile colic but that further research of good methodological quality on low-allergenic formulas and maternal diets is indicated. Based on the previously mentioned studies it is important to explore the knowledge and practice patterns of digestive conditions have been surveyed. In 2012, Martinez, et al, conducted a survey questionnaire completed by 43 fellowship training directors of 62 active programs affiliated to the North American Society of Pediatric Gastroenterology, Hepatology and Nutrition including sites in the United States, Canada and Mexico. The study concluded that program directors cited a lack of faculty interested in nutrition and a high workload as common obstacles for teaching.

Furthermore, the methodology of nutrition education during gastroenterology fellowship training is for the most part, unstructured and inconsistent among the different programs. The minimum Level 1 requirements are not consistently covered. (16) In 2013, Lin, et al, also conducted a survey to 272 members of the North American Society of Pediatric Gastroenterology, Hepatology and Nutrition and found that pediatric gastroenterologists identified gaps in their nutrition knowledge base that may be attributed to the present nutrition education training during fellowship. (17)

The practice patterns for chiropractors regarding digestive conditions has been surveyed. In 2009, a multidisciplinary panel of 37 was made up primarily of doctors of chiropractic with a mean of 18 years in practice, many with post-graduate training in pediatrics. The panel represented 5 countries and 17 states; there were members of the American Chiropractic Association, the International Chiropractors Association, and the International Chiropractic Pediatric Association. A broad-based panel of experienced chiropractors was able to reach a high level (80%) of consensus regarding specific aspects of the chiropractic approach to clinical evaluation, management, and manual treatment for pediatric patients, based on both scientific evidence and clinical experience. (18)

In 2010, Alcantara, et al, conducted a survey of 548 chiropractors, the majority of whom are practicing in the United States, Canada, and Europe. This survey found that digestive conditions were the third most common treated condition by the Chiropractors participating in the survey. (19)

The safety of chiropractic treatment in the pediatric population has been evaluated. In 2009, Alcantara, et al, conducted a survey of chiropractors and parents in a practice-based research network and found that Chiropractor responders indicated three adverse events per 5,438 office visits from the treatment of 577 children. The parent responders indicated two adverse events from 1,735 office visits involving the care of 239 children. Both sets of responders indicated a high rate of improvement with respect to the children's presenting complaints, in addition to salutary effects unrelated to the children's initial clinical presentations. (20)

CONCLUSION

The inclusion of spinal manipulative therapy as part of the protocol for the treatment of infantile colic is promising. Based on the lack of efficacy and safety of certain drugs and the lack of evidence for overall treatment options, physicians may want to consider chiropractic treatment as part of the management of infantile colic. A possible treatment protocol could be the combination of chiropractic and probiotics (L. reuteri ATCC 55730 and L. reuteri DSM 17938) which were both shown to reduce crying time in this study. Further studies confirming these findings are warranted.

[FIGURE 1 OMITTED]

References

(1.) Roberts DM, Ostapchuk M, O'Brien JG. Infantile colic. Am Fam Physician. 2004;70(4):735-40.

(2.) Lucassen P. Colic in infants. Clin Evid (Online). 2010;2010

(3.) Shenassa ED, Brown MJ. Maternal smoking and infantile gastrointestinal dysregulation: the case of colic. Pediatrics. 2004;114(4):e497-505.

(4.) Gelfand AA, Goadsby PJ, Allen IE. The relationship between migraine and infant colic: a systematic review and meta-analysis. Cephalalgia. 2015;35(1):63-72.

(5.) Wiberg JM, Nordsteen J, Nilsson N. The short-term effect of spinal manipulation in the treatment of infantile colic: a randomized controlled clinical trial with a blinded observer. J Manipulative Physiol Ther. 1999;22(8):517-22.

(6.) Alcantara J, Alcantara JD, Alcantara J. The chiropractic care of infants with colic: a systematic review of the literature. Explore (NY). 2011;7(3):168-74

(7.) Miller JE, Newell D, Bolton JE. Efficacy of chiropractic manual therapy on infant colic: a pragmatic single-blind, randomized controlled trial. J Manipulative Physiol Ther. 2012;35(8):600-7.

(8.) Savino F, Pelle E, Palumeri E, Oggero R, Miniero R. Lactobacillus reuteri (American Type Culture Collection Strain 55730) versus simethicone in the treatment of infantile colic: a prospective randomized study. Pediatrics. 2007;119(1):e124-30.

(9.) Bruyas-bertholon V, Lachaux A, Dubois JP, Fourneret P, Letrilliart L. [Which treatments for infantile colics?]. Presse Med. 2012;41(7-8):e404-10.

(10.) Miller JE, Phillips HL. Long-term effects of infant colic: a survey comparison of chiropractic treatment and nontreatment groups. J Manipulative Physiol Ther. 2009;32(8):635-8.

(11.) Metcalf TJ, Irons TG, Sher LD, Young PC. Simethicone in the treatment of infant colic: a randomized, placebo-controlled, multicenter trial. Pediatrics. 1994;94(1):29-34.

(12.) Lucassen PL, Assendelft WJ, Gubbels JW, Van eijk JT, Van geldrop WJ, Neven AK. Effectiveness of treatments for infantile colic: systematic review. BMJ. 1998:316(7144):1563-9.

(13.) Lucassen PL, Assendelft WJ, Gubbels JW, Van eijk JT, Douwes AC. Infantile colic: crying time reduction with a whey hydrolysate: A double-blind, randomized, placebo-controlled trial. Pediatrics. 2000;106(6):1349-54.

(14.) Garrison MM, Christakis DA. A systematic review of treatments for infant colic. Pediatrics. 2000;106(1 Pt 2):184-90.

(15.) Iacovou M, Ralston RA, Muir J, Walker KZ, Truby H. Dietary management of infantile colic: a systematic review. Matern Child Health J. 2012;16(6):1319-31.

(16.) Martinez JA, Koyama T, Acra S, Mascarenhas MR, Shulman RJ. Nutrition education for pediatric gastroenterology, hepatology, and nutrition fellows: survey of NASPGHAN fellowship training programs. J Pediatr Gastroenterol Nutr. 2012;55(2):131-5.

(17.) Lin HC, Kahana D, Vos MB, et al. Assessment of nutrition education among pediatric gastroenterologists: a survey of NASPGHAN members. J Pediatr Gastroenterol Nutr. 2013;56(2):137-44

(18.) Hawk C, Schneider M, Ferrance RJ, Hewitt E, Van loon M, Tanis L. Best practices recommendations for chiropractic care for infants, children, and adolescents: results of a consensus process. J Manipulative Physiol Ther. 2009;32(8):639-47

(19.) Alcantara J, Ohm J, Kunz D. The chiropractic care of children. J Altern Complement Med. 2010;16(6):621-6.

(20.) Alcantara J, Ohm J, Kunz D. The safety and effectiveness of pediatric chiropractic: a survey of chiropractors and parents in a practice-based research network. Explore (NY). 2009;5(5):290-5.

(21.) Dobson D, Lucassen PL, Miller JJ, Vlieger AM, Prescott P, Lewith G. Manipulative therapies for infantile colic. Cochrane Database Syst Rev. 2012;12:CD004796.

(22.) Anabrees J, Indrio F, Paes B, Alfaleh K. Probiotics for infantile colic: a systematic review. BMC Pediatr. 2013;13:186.

by: Adrian Isaza, DC, DACBN, CCAP
TABLE 1
REVIEWS FOR CHIROPRACTIC EFFICACY IN REDUCING
CRYING TIME IN BABIES WITH INFANTILE
COLIC CONSIDERING ONLY LOW RISK OF BIAS STUDIES

Year                                                 Inclusion


Dobson, et al, 2012 (20) Low risk of selection bias  Randomized
(Random sequence generation)                         controlled trials
Dobson, et al, 2012 (20) Low risk of selection bias  Randomized
(Allocation concealment)                             controlled trials
Dobson, et al, 2012 (20) Low risk of
performance bias                                     Randomized
(parental blinding)                                  controlled trials
Dobson, et al, 2012 (20) Low risk of attrition bias  Randomized
(selective reporting)                                controlled trials

Year                                                 Number of
                                                       Studies

Dobson, et al, 2012 (20) Low risk of selection bias          5
(Random sequence generation)
Dobson, et al, 2012 (20) Low risk of selection bias          4
(Allocation concealment)
Dobson, et al, 2012 (20) Low risk of
performance bias                                             2
(parental blinding)
Dobson, et al, 2012 (20) Low risk of attrition bias          1
(selective reporting)

Year                                                 Number of
                                                      Patients

Dobson, et al, 2012 (20) Low risk of selection bias         30
(Random sequence generation)
Dobson, et al, 2012 (20) Low risk of selection bias        205
(Allocation concealment)
Dobson, et al, 2012 (20) Low risk of
performance bias                                           124
(parental blinding)
Dobson, et al, 2012 (20) Low risk of attrition bias         40
(selective reporting)

Year                                                       Mean
                                                     Difference

Dobson, et al, 2012 (20) Low risk of selection bias         1.2
(Random sequence generation)
Dobson, et al, 2012 (20) Low risk of selection bias        1.24
(Allocation concealment)
Dobson, et al, 2012 (20) Low risk of
performance bias                                           0.57
(parental blinding)
Dobson, et al, 2012 (20) Low risk of attrition bias        1.95
(selective reporting)

TABLE 2
REVIEWS FOR LACTOBACILLUS REUTERI STRAIN 55730 and
DSM 17 938 EFFICACY IN REDUCING CRYING
TIME IN BABIES WITH INFANTILE COLIC

Year                        Inclusion          Number of Studies

Anabrees, et al, 2013 (22)  Randomized         3
                            Controlled Trials

Year                        Number of Patients  Mean Difference

Anabrees, et al, 2013 (22)  209                 56.03
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Author:Isaza, Adrian
Publication:Original Internist
Article Type:Report
Date:Jun 1, 2016
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