Infants have a small stomach, a shorter bowel and reduced levels of digestive enzymes and bile compared to an adult¹. This has implications on the way an infant`s body functions including their ability to digest, absorb and utilise nutrients.

Approximately 20 percent of infants suffer symptoms associated with mild digestive problems, such as colic, regurgitation and constipation, amounting to approximately 150,000 young babies each year³. Such digestive problems can be upsetting for infants, distressing for parents and have an impact on costing for the NHS for the treatment.

Minor feeding problems that occur during infancy are more often related to bottle-feeding than breastfeeding^4,5,6. Symptoms such as colic, constipation and regurgitation are often reasons for consultations with paediatricians, Health Visitors and GPs. The symptoms can differ in epidemiology, clinical manifestations, pathophysiology and treatment⁷.

Colic
Colic is one of the most common gastrointestinal symptoms affecting about 20 percent of babies⁸. Infantile Colic is defined as when an infant is diagnosed with having had at least three episodes of unexplained full-forced crying lasting more than three hours a day on at least three days a week, according to Wessel criteria⁹. Crying episodes are considered significant when they endure for more than 40 minutes⁹.

Colic is usually temporary with no long term adverse consequences¹⁰ and it often appears within the first three weeks after birth and usually disappears by three to four months of age⁸. The most common symptoms that infants with colic suffer are difficulty sleeping, facial flushing, drawing up of knees to the chest and clenching of fists.

The specific causes of colic are often unknown. The early introduction of bottles may have an effect on suckling and may result in breast refusal which can pave the way from colic and crying¹¹. Research has shown that dietary factors play an important role in digestive problems and infantile colic ^11,12,13 and differences have also been shown in the gut microflora of colicky infants^14,15.

The dietary factors that are often linked with colic are an immature digestive system with reduced levels of beneficial bacteria in the gut, reduced ability to digest lactose, sensitivity to or a reduced ability to digest cows` milk protein, and trapped wind.

Cows` milk protein intolerance affects approximately 3% of infants under the age of 12 months and is often misdiagnosed as gastro-oesophageal reflux disease or colic, which can cause a dangerous exposure to antigens<sup>16</sup>. Some more severe cases of colic may be caused by cows` milk protein allergy. Cows` milk proteins are found in most infant formulas and can also be passed on in breastmilk where a mother has consumed dairy products, so dietary interventions may be required in these circumstances.

Constipation
Before the age of six months between 16-40% of infants suffer from constipation^17,18. The type of feeding has a significant bearing on the bowel patterns of infants in the first six months. As with other minor feeding problems, constipation is more common in formula-fed infants as they have a more prolonged gastrointestinal transit time and harder stools than breastfed infants¹⁹. The reason for this is that the stools of breastfed babies are richer in lactic acid than those of the formula fed baby. Lactic acid is more resistant to absorption by the digestive system than the other short chain fatty acids helping to retain more water, which could help to form softer stools.

The fat blend is also important as it can affect the formation of insoluble soaps with calcium, which can lead to harder stools. Research shows that feeding a formula containing a fat blend closer in structure to breastmilk promotes softer stools, helping to prevent constipation⁷. The long chain polyunsaturated fatty acids (LCPs) found in breastmilk and recently added to some formula also appear to have a significant effect on stool hardness.

Protein has also been shown to have an impact on constipation in formula fed infants. The reason for this is that there is a difference between bovine and human milk in terms of the protein quality and quantity and the structure and composition of the lipids⁷. Some infants who have a cows` milk protein allergy can suffer from infantile colic, gastrointestinal reflux and regurgitation and also constipation, however these symptoms tend to be unusual<sup>20</sup>. For those infants who are being breastfed one third of the symptoms disappear when the mother has a cows` milk free diet²¹.

Regurgitation
Regurgitation is deemed as the effortless return of the gastric contents to the mouth²². It affects a half of all babies at the age of 2 months²³ and up to 67% at four months²⁴. There is a peak of incidence at three months²⁵ and there tends to be a resolution from the problem by 6-12 months²⁴.

Infants who have uncomplicated regurgitation, i.e. those who do not have complications of gastroesophageal reflux disease such as nutritional deficits or blood loss, are frequently perceived by their parents as having a problem. The parents will seek medical attention for these infants and this will lead to the infants undergoing lots of awkward tests which will be uncomfortable for the already distressed infant. Research by Vandenplas shows that a nutritional therapy may be the best and most cost effective treatment, leading to an improvement of the both the problem for the infant and also the reduction of parental stress²⁴.

The European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) published regurgitation management guidelines in 1996, including both dietary and non-dietary recommendations. They state that milk thickeners are an adequate therapeutic tool for regurgitation but not in the case of reflux disease. They do question the efficacy of antacids, even though they are used to a wide degree in some countries²⁶.

Research
The findings of the latest research suggest that the modulation of gut microflora can help the prevention of common gastrointestinal symptoms such as constipation and prolonged colicky crying, particularly in formula-fed infants¹¹. There are several components in breastmilk and in certain specialised infant formulas that can help reduce the symptoms of minor feeding problems.

Partially hydrolysed whey protein
Breastmilk is comprised of 60% whey to 40% casein protein compared to cows` milk which is a casein dominant milk (80% casein and 20% whey), and it is this difference that has a role in causing minor feeding problems in those infants who are not breastfed. The whey protein, which is dominant in breastmilk, forms a custard/single cream like consistency in the stomach and is more easily digested than casein. Casein forms a thicker consistency in the stomach, more like cottage cheese and as such has a slower gastric emptying, helping to satisfy those hungrier infants who are struggling to settle.

There is research that shows that when the protein is broken down it is more easily digested. Partially hydrolysed protein is where the whole protein has been broken down into shorter peptides. When the protein has been broken down into short peptides and amino acids then it has been extensively hydrolysed. Partially and extensively hydrolysed formulas have been shown to be effective in the treatment of infantile colic^5,12,13. Hydrolysed protein formulas have also been shown to lead to softer stools than standard cows` milk infant formulas<sup>27</sup> intact cows` milk protein can contribute to constipation.

Carbohydrate blend of reduced lactose and starch
Due to the immaturity of the infants` digestive system, there may be insufficient levels of lactase. If the lactose is undigested it is fermented by colonic microflora and can lead to flatulence, intestinal discomfort (i.e. bloating) and diarrhoea. Therefore a reduced lactose level can be beneficial to the immature digestive system.

Research has shown that when the carbohydrate content is changed in an infant`s feed then behavioural changes are unlikely to occur in normal infants. However formula changes involving protein and carbohydrate can reduce the colonic gas production, leading to crying in the infant. Such effects may be implicated when feeding changes occur in normal infants, but their potential role in treatment of crying problems such as colic has yet to be demonstrated²⁸.

Prebiotics oligosaccharides
There have been multiple reports in literature that have shown that prebiotic oligosaccharide supplementation in infant formulas may promote gastrointestinal health^27,29,30. Collins & Gibson have postulated that in the infant gut an elevated bifidobacterial count may be associated with health advantages that breastfed infants may have over formula-fed infants. Cow & Gate Comfort milk contains a patented mix of prebiotic oligosaccharides which are non digestible food ingredients that occur naturally in breastmilk and some fruits, grains and vegetables and unique to Nutricia.

Through clinical trials this prebiotic oligosaccharide mix (fructo- and galacto-oligosaccharides) has demonstrated a bifidogenic effect in infants^29,32,33; increasing the growth of friendly bacteria in the gut such as bifidobacteria and lactobacacilli and decreasing the presence of pathogens in the gut flora^29,32,33 improving stool viscosity, transit time and characteristics^29,32,34 which may help with enteral feeding tolerance and advancement^32,35.

Helping to reduce symptoms of minor feeding problems
It is well known that the incidence of constipation and other minor feeding problems are lower in breastfed infants³⁸ and therefore breastfeeding should be encouraged where possible. However for those infants who cannot breastfeed, there are ways of altering an infant formula to help reduce the symptoms associated with minor feeding problems.

For those infants who are not being breastfed, Cow & Gate Comfort has been shown to help comfortable digestion in infants with minor feeding problems^7,39 as it contain 100% partially digested whey proteins, a reduced lactose level, a special blend of vegetable oils, and is thicker than a standard formula. We will discuss this in more detail below.



Research carried out by Savino et al.³⁹ published in the European Journal of Clinical Nutrition (2006) showed that formula-fed infants diagnosed with infantile colic who were treated with a formula (Cow & Gate Comfort) supplemented with prebiotics; fructo- and galacto-oligosaccarides (FOS/GOS), experienced a significant decrease in crying episodes after just seven days, and a greater reduction in crying episodes after 14 days, compared to a control group¹¹. The results confirm earlier findings by Savino et al. (2003)⁷ which also showed a reduction in regurgitation and constipation among infants treated with the same prebiotic mix^10. Cow & Gate Comfort also contains structured vegetable oils, which helps to make the fat content and profile within the milk closer to human milk as it contains 41% of all of the palmitic acid in the β-palmitate position. The structured vegetable oil in Cow & Gate Comfort helps to increases absorption of palmitic acid and other saturated fatty acids, i.e. stearic acid. It also increases the absorption of total fat and reduces the excretion of calcium fatty stools, which in turn promotes a better use of the energy from fat⁴⁰ with less stress on the digestive system.

Certain formulas like Cow & Gate Comfort provide a carbohydrate blend of lactose, glucose syrup and starch. This has a reduced lactose level compared to standard infant milks which helps to aid comfortable digestion. These products also contains potato starch, which helps to increase the viscosity of the feed helping to provide a controlled and regular milk intake with less air swallowing, thereby aiding comfortable digestion and thus helping to reducing the risk of an infant getting trapped wind.

Cow & Gate Comfort also contains a hydrolysed protein and the prebiotic mixture which have been shown to have a beneficial effect on the stools of infants. Therefore, Cow & Gate Comfort contains 100% partially hydrolysed whey to aid comfortable digestion, helping to reduce episodes of crying associated with colic³⁹ and making the stools softer^29,32,34.

Research has also shown that the removal of cows`-milk protein from the maternal diet eliminates colic in about 30 percent of infants⁴¹ and thus can be used as a method of treatment for infants where the mother is breastfeeding and symptoms are not settling. Other methods of treatment that are employed in the management of minor feeding problems are by using simeticone which helps to reduce bloating, discomfort and pain in the stomach and intestinal tract and is an antispasmodic agent are sometimes helpful^41.

Myths associated with minor feeding problems
As with any medical conditions there are several myths behind them. Here are just a few of them:

Colic isn`t temporary; This is not the case. Colic usually disappears by six months of age with no lasting effect on the infant.

An infant is in a lot of pain when they have colic; Studies have shown that colicky babies when they are crying, experience no greater increase in the indicators of pain (the stress hormone cortisol) than those infants who do not have colic⁴².

A dietary change won`t help colic; A study carried out in 2004 by Miller-Loncar et al. showed that a small percentage of infants who had severe colic improved rapidly when their breastfeeding mothers stopped consuming dairy products<sup>43</sup>. The reasoning behind this is that some infants have an intolerance to cows` milk and this can cause minor feeding problems like colic. Colic can also be due to a cows` milk protein sensitivity which can be managed by switching to a hydrolysed formula⁴⁴. Other strategies that are used within the NHS are to eliminate caffeine intake in breastfeeding mothers, which can help to reduce colic. Caffeine and some painkillers such as Solphadeine, have been shown to be a contributor of reflux and fussiness in infants (patient.co.uk, 2007).

Iron in infant formulas cause constipation; There is a common belief that iron-fortified formulas can make infants suffer from constipation, however research has shown that this is not the case, and there was no difference in the type of stools, number of days without stools and stools per day⁴⁵. However, on occasion, iron-fortified formulas have been associated with changes in stool flora⁴⁶ colour, or consistency⁴⁷ in younger infants.

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