Basics
Description
Crying is considered a normal part of human behavior and is a baby's most effective form of communication. However, when crying is perceived to be in excess than what is expected, it can cause a family a great deal of distress. Colic is a syndrome of excessive crying for which no organic cause can be identified. It is described as unexplained end of the day crying that begins at age 2-3 weeks, peaks at 8 weeks, and tapers at 12 weeks.
No standard definition of colic exists. The most widely used definition is from 1954 (Wessel) and referred to as the rule of 3's. He defined colic by the amount of crying: >3 hours a day, >3 days a week, and lasting at least 3 weeks. Colic episodes usually begin suddenly, with no clear reason, and at the end of the day or evening. The crying is intense and high pitched. Infants may have a flushed face, furrowed brow, and postural changes such as bending or drawing up of the knees, clenched fists, and tensed abdominal muscles. Episodes may end with a bowel movement or passing of gas.
Epidemiology
- Crying is one of the most common reasons families present to a health care professional during the 1st months of life.
- 1 in 6 families who have children with colic seek care from a health care professional.
- Estimates are difficult to make due to lack of standard definition; literature suggests a prevalence of 3-40%.
- Incidence is similar in male and females and in breast- and bottle-fed infants.
Risk Factors
Possible risk factors include maternal smoking, increased maternal age, and being the firstborn child. In addition, colic has been associated with higher levels of maternal stress, anxiety, and depression.
General Prevention
Although no study has shown any certain way to prevent colic, educating parents about infant crying can be helpful. Remind parents that crying is an infant's way to communicate, inform them of the expected average hours a day and infant may cry, and teach them soothing techniques.
Etiology
- The term colic is now considered a misnomer because it derives from the Greek word for colon. Studies in the early 1900s suggested colic was a result of gastrointestinal (GI) dysfunction, whereas today, there are many theories.
- Typically, colic is considered to result from an interaction between infant factors and the environment at a unique time of biologic vulnerability. No single cause has been identified. Several hypotheses for the etiology exist.
- GI disturbances are often implicated in colic. Abnormal motility has been hypothesized and is somewhat supported by the fact that anticholinergics may improve symptoms. Other studies have shown infants with colic have decreased amounts of lactobacilli and increased amounts of coliform bacteria. Although another theory is that increased gas production can cause colic, this theory is not supported based on radiographs taken during crying spells. Recent studies have suggested an association with Helicobacter pylori and infantile colic. Others theorize that colic is a form of milk protein allergy. However, these studies are limited and no causality has been established.
- Psychosocial issues have been implicated including family tension, parental anxiety, or inadequate parent-infant interactions. However, in studies where infants are cared for by trained occupational therapists, symptoms did not improve.
- A neurodevelopmental etiology is supported by the fact that infants with colic have similar patterns of crying to infants without colic and that colic is outgrown. Excessive crying has also been considered a manifestation of normal emotional development where colic is on the end of a spectrum of crying.
Diagnosis
History
- Obtain details about the infant's behavior around the start of a crying episode and the intensity, time of day, and duration of crying. Documenting this can help both the caregivers and health care providers.
- Prenatal history and history of fever in the infant is important to assess infant's risk of infection.
- History about stooling and vomiting should be elicited to eliminate organic etiologies of crying such as gastroesophageal reflux, malabsorption, or pyloric stenosis.
- History of color changes, apnea, or respiratory distress should help assess for a cardiac or respiratory etiology for crying.
Physical Exam
- For the diagnoses of colic, vital signs, growth, and physical exam should be normal.
- Look for signs of trauma or evidence of nonaccidental injuries. Look for bruises and palpate bones to look for fractures. A thorough GI and neurologic exam should also be performed.
Diagnostic Tests & Interpretation
No tests are indicated if there are no concerning signs on history or physical.
Differential Diagnosis
- Normal crying
- As studied by Brazelton in 1962, at 2 weeks, normal infants cried for a median of 1 ž hour a day, just under 3 hours at 6 weeks, and ~1 hour by 12 weeks. Normal crying, like colic, tends to occur predominantly in the evening and can vary from day to day.
- Organic causes of excessive crying:
- Cardiac: congenital heart disease, supraventricular tachycardia
- Respiratory: upper respiratory infection, pneumonia, foreign body aspiration, pneumothorax
- GI: constipation, cow's milk protein intolerance, gastroesophageal reflux, lactose intolerance, intussusception, rectal fissures, and strangulated inguinal hernias
- Neurologic: hydrocephalus, subdural hematoma, infantile migraine, neonatal drug withdrawal
- Metabolic: hypoglycemia, electrolyte abnormalities, ingestions, inborn errors of metabolism
- Infectious: meningitis, otitis media, urinary tract infections, and viral illnesses
- Trauma: child abuse, corneal abrasions, foreign bodies in the eye, fractures, and hair tourniquets
Alert
Although organic causes are found in less than 5% of infants who present with crying, it is important to look for red flags in the history and physical such as the following:
- Symptoms elicited in history:
- Vomiting that is frequent, large quantity (>1 oz), bilious, or projectile
- Bloody stools
- Poor weight gain
- Respiratory difficulties including apneic or cyanotic episodes
- Fever, lethargy, poor feeding
- Signs observed on physical exam:
- Irritability, tachycardia, pallor, mottling, poor perfusion
- Abnormal neurologic findings including hypotonia, a full fontanelle, or a head circumference >95%
- Petechiae, bruising, tachypnea, cyanosis, nasal flaring
- Weight decreasing
Treatment
Medication
The literature does not support the use of pharmacologic interventions in colic. Although some studies have shown certain pharmacologic agents to be effective, these studies lack methodologic rigor or involve medications with serious adverse effects.
- Anticholinergic medications such as dicyclomine hydrochloride and cimetropium have been proven to be effective. However, these medications are contraindicated in infants younger than 6 months in the United States due to side effects such as apnea and drowsiness.
- Simethicone is an over-the-counter drug that decreases intraluminal gas. Studies of its efficacy have been mixed and any reduction of symptoms has been attributed to a placebo effect.
- Probiotics may play a role in reducing symptoms. Studies comparing Lactobacillus reuteri DSM 17938 to placebo in breastfed infants have shown a reduction of symptoms. These studies are promising; however, further studies confirming these results are needed.
Additional Treatment
General Measures
The most important and effective treatment is for health care providers to acknowledge the difficulty of the situation and to provide reassurance. Parents of a colicky infant often feel tired and inadequate and need their concerns to be substantiated by a provider who acknowledges how difficult of a time this must be. Main points to reassure and guide parents include the following:
- The crying of colic can be persistent, but there is no evidence of a physical problem or proof that the infant is in pain. Periods of wellness each day followed by periods of crying is reassuring.
- Colic is benign and self-limited; the majority of infants improve by age 3-4 months.
- During crying spells, the infant is probably overaroused and tired.
- On average, a healthy infant will cry 2-3 hours per day.
- Strategies for soothing their infant such as swaddling, making "Shh" sounds, swinging the baby (no more than 1 inch back and forth), pacifier use, repetitive sounds, and decreasing environmental stimulation
- Anticipatory guidance on child abuse prevention (e.g., encouraging parents to take a break when their infant's crying is causing them excessive distress or to turn to each other or others for support)
Diet Modification
- Breastfeeding mothers are encouraged to continue to breastfeed. There is conflicting evidence about whether mothers should eliminate allergenic foods from their diet.
- Although hydrolyzed formulas have been shown to reduce symptoms of colic, most of these studies lack methodologic rigor. In addition, if symptoms do improve, milk protein allergy must be considered.
- Although soy milk formula has been shown to reduce crying, it is not recommended in the treatment of colic due to the prevalence of allergy to soy.
- High-fiber formulas and lactase drops have not been shown to be effective.
Behavioral Modifications
- Car-ride simulators, crib vibrators, and increased carrying have not been shown to be effective.
- Other interventions such as modified parent and infant interactions involving decreased stimulation, "contingent music," and assisting parents in acquiring effective coping and consoling methods have shown some benefit. However, none of these studies involve randomization and blinding, and most are of small sample size.
Complementary & Alternative Therapies
- Although teas containing chamomile, vervain, licorice, fennel, and lemon balm have been shown to be effective if used 3 times a day with 150 mL per dose, they are not recommended. Adverse events have been reported. The dose is a large volume. In addition, there is no standard dosing or formulations of these products.
- Sucrose solutions have been found to improve symptoms compared to placebo, yet evidence is limited and there are concerns about nutritional effects and lack of standardization for formulation of preparations.
- Chiropractic care, infant massage, and acupuncture have also been studied, but due to mixed results and lack of methodologic rigor, they are not recommended in treating colic.
Ongoing Care
Follow-up Recommendations
Patient Monitoring
- It is important to keep in close touch with parents of an excessively fussy baby. Telephone contact every 2-3 days is essential until improvement.
- Although reexamination may not be needed, consistent follow-up from a supportive physician may help reassure parents.
Diet
Breast milk and formula changes are not recommended unless milk protein allergy is suspected.
Patient Education
Educate parents regarding the average number of hours an infant is expected to cry and provide soothing techniques. Reassure that colic is benign and self-limited.
Prognosis
- Without intervention, this prolonged crying usually diminishes around 3-4 months of age.
- Some studies suggest infants with colic can have difficulties later in life in family communication, dissatisfaction, and sleeping, psychological, or GI disorders; however, other research has shown no long-term consequences.
- There is no association between colic and later diagnosed asthma or allergic disease.
Complications
Most complications are related to the fatigue, anxiety, and distress that colic can cause in families. The most serious outcome is if parental exasperation leads to the physical abuse of the infant.
Additional Reading
- Brazelton TB. Crying in infancy. Pediatrics. 1962;29:579-588. [View Abstract]
- Drugs and Therapeutics Bulletin. Management of infantile colic. BMJ. 2013;347:f4102. [View Abstract]
- Radesky JS, Zuckerman B, Silverstein M, et al. Inconsolable infant crying and maternal postpartum depressive symptoms. Pediatrics. 2013;131(6):e1857-e1864. [View Abstract]
- Szajewska H, Gryczuk E, Horvath A. Lactobacillus reuteri DSM 17938 for the management of infantile colic in breastfed infants: a randomized, double-blind, placebo-controlled trial. J Pediatr. 2013;162(2):257-262. [View Abstract]
- Wessel MA, Cobb JC, Jackson EB, et al. Paroxysmal fussing in infants, sometimes called "colic." Pediatrics. 1954;14(5):421-434. [View Abstract]
Codes
ICD09
- 789.7 Colic
- 780.92 Excessive crying of infant (baby)
ICD10
- R10.83 Colic
- R68.11 Excessive crying of infant (baby)
SNOMED
- 35363006 Infantile colic (finding)
- 95629002 Excessive crying of newborn (finding)
FAQ
- Q: What is colic?
- A: Excessive crying in an infant for which no organic etiology is identified. Crying usually is for at least 3 hours a day, for 3 days a week, for a minimum of 3 weeks.
- Q: Why do certain infants get colic?
- A: The etiology of colic is poorly understood. Although there is evidence that GI dysfunction can cause colic, most believe colic is a neurodevelopmental syndrome.
- Q: How is colic treated?
- A: Pharmacologic, nutritional, and behavioral interventions are not recommended. The most important treatment a health care provider can provide is to substantiate a parent's concern, provide reassurance, educate, and provide anticipatory guidance about colic.