Infantile (Baby) Colic – Causes, Symptoms, Diagnosis, Treatment and Ongoing care

Basics

Description

  • Colic is defined as excessive crying in an otherwise healthy baby.
  • A commonly used criteria is the Wessel criteria, or the “rule of 3”: Crying lasts for >3 hours a day, >3 days a week, and persists >3 weeks.
  • Many clinicians no longer use the criterion of persistence for >3 weeks because few parents or clinicians will wait that long before evaluation or intervention.
  • Some clinicians feel that colic represents the extreme end of the spectrum of normal crying, whereas most feel that colic is a distinct clinical entity.

Epidemiology

Incidence

  • Predominant age: Between 2 weeks and 4 months of age
  • Predominant sex: Male = Female.

Prevalence

  • Probably between 10% and 25% of infants
  • Range is somewhere between 8% and 40% of infants

Pediatric Considerations

This is a problem during infancy.

Risk Factors

Physiologic predisposition in infant, but no definitive risk factors have been established.

General Prevention

Colic is generally not preventable.

Etiology

The cause is unknown. Factors that may play a role include

  • Infant gastroesophageal reflux disease
  • Allergy to cow’s milk, soy milk, or breast milk protein
  • Fruit juice intolerance
  • Swallowing air during the process of crying, feeding, or sucking
  • Overfeeding or feeding too quickly; underfeeding also has been proposed.
  • Inadequate burping after feeding
  • Family tension
  • Parental anxiety, depression, and/or fatigue
  • Parent-infant interaction mismatch
  • Baby’s inability to console itself when dealing with stimuli
  • Increased gut hormone motilin, causing hyperperistalsis
  • Tobacco smoke exposure
  • Disorder of impaired synchronization between infant arousal and environment (1)[C]

Baby colic, Infant, Fennel, Wessel, tobacco smoke exposure, gastroesophageal reflux disease, breast milk,

Diagnosis

History

  • Evaluation for Wessel criteria: Crying lasts for >3 hours per day, >3 days per week, and persists >3 weeks
  • The colicky episodes may have a clear beginning and end.
  • The crying is generally spontaneous, without preceding events triggering the episodes.
  • The crying is typically different from normal crying. Colicky crying may be louder, more turbulent, variable in pitch, and appear more like screaming.
  • The infant may be difficult to soothe or console regardless of how the parents try to help.
  • The infant acts normally when not colicky.
  • Assess the support system of caregivers and families, including coping skills.

Physical Exam

  • A comprehensive physical exam is normal.
  • Since excessive crying may be a risk factor for shaken baby syndrome or other forms of child abuse (2)[B], be sure to examine the child carefully for signs of shaken baby syndrome or other forms of child abuse.

Diagnostic Tests & Interpretation

Diagnostic Procedures/Surgery

A thorough history and physical examination should be performed to rule out other causes. Otherwise, no diagnostic procedures or surgery is indicated.

Differential Diagnosis

Any organic cause for excessive or qualitatively different crying in infants such as

  • Infections such as meningitis, sepsis, otitis media, or urinary tract infection
  • GI issues such as gastroesophageal reflux, intussusception, lactose intolerance, constipation, anal fissure, or strangulated hernia
  • Trauma such as foreign bodies, corneal abrasion, occult fracture, digit or penile hair tourniquet, or child abuse

Treatment

Medication

  • Dicyclomine (Bentyl) has been proven beneficial, but the potential serious adverse effects such as apnea, seizures, and syncope have precluded its use. Further, the manufacturer has made the medication contraindicated for infants <6 months of age (3,4)[B].
  • Simethicone has not been shown to be beneficial (3,4)[B].

Additional Treatment

General Measures

  • Soothe by holding and rocking the baby (3)[C].
  • Use pacifier (3)[C].
  • Use of gentle rhythmic motion (e.g., strollers, infant swings, car rides) (3)[C].
  • Place near “white noise” (e.g., vacuum cleaner, clothes dryer, white noise machine) (3)[C].
  • Crib vibrators or car-ride simulators have not proven to be helpful (3,5)[B].
  • Increased carrying or use of infant carrier did not improve colic (3,5)[B].
  • Employ the “5 S’s” (need to be done concurrently):
    • Swaddling: Tight wrapping with blanket; may be especially beneficial in infants <8 weeks of age (6)[B]
    • Side/stomach: Laying baby on side or stomach
    • Shushing: Loud white noise
    • Swinging: Rhythmic, jiggly motion
    • Sucking: Sucking on anything (e.g., nipple, finger, pacifier) (3)[C]

Issues for Referral

Excessive vomiting, poor weight gain, recurrent respiratory diseases, or bloody stools should prompt referral to a specialist.

Complementary and Alternative Medicine

  • Herbal teas and supplements may help but are not recommended because of limited, inconclusive evidence. For example,
    • One study concluded that herbal teas containing mixtures of chamomile, vervain, licorice, fennel, and balm-mint used up to t.i.d. may be beneficial (4)[B]. However, the study used dosages of up to 150 cc t.i.d., raising clinical concerns that this dosage may impair needed milk consumption in infants and may be impractical to administer. Additionally, preparations used in the study may not be commercially available in the US.
    • A second double-blind, randomized trial of 0.1% fennel seed oil emulsion versus placebo demonstrated a decrease in colic symptoms according to the Wessel criteria. However, this preparation of fennel seed oil is not commercially available in the US, and the long-term health effects are unknown (7).
  • A home-based intervention focusing on reducing infant stimulation and synchronizing infant sleep-wake cycles with the environment, as well as parental support, was effective (1)[B].
  • Use of music may help (8,9)[C].
  • Chiropractic treatment has shown no benefit over placebo (3)[C].
  • Infant massage has not been shown to be helpful (3)[B].

Ongoing Care

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Follow-Up Recommendations

Frequent outpatient visits as needed for parental reassurance, education, and monitoring and to ensure the health of the infant and parents

Patient Monitoring

Follow for proper feeding, growth, and development.

Diet

  • If breast-feeding:
    • Continue breast-feeding. Switching to formula probably will not help (3)[C].
    • Possible therapeutic benefit from eliminating milk products, eggs, wheat, and nuts from the diet of breast-feeding mothers (3,5)[B].
    • Along with eliminating the preceding foods from the maternal diet, removing soy, nuts, and fish may be beneficial (10)[C].
    • Probiotics (Lactobacillus reuteri) have been shown to be beneficial in a small study of breast-fed infants (11).
  • If formula feeding:
    • Feeding the infant in a vertical position using a curved bottle or bottle with collapsible bag may help to reduce air swallowing.
    • Consider a 1-week trial of hypoallergenic formulas, such as whey hydrolysate (e.g., Good Start) or casein hydrolysate (e.g., Alimentum, Nutramigen, Pregestimil) (4,5)[B].
    • American Academy of Pediatrics concluded that there is no proven role for soy formula in the treatment of colic (12)[C].
    • Adding fiber to formula has not been shown to be helpful (5,8)[B].
  • Supplementing with sucrose solution may be helpful, but the effect may be short-lived (<1 h) (4,5)[B].
  • Use of lactase enzymes in formula or breast milk or given directly to the infant has no therapeutic benefit (5)[B].

Patient Education

  • Reassure parents that colic is not the result of bad parenting, and advise parents about having proper rest breaks, adequate sleep, and help in caring for the infant.
  • Explain spectrum of crying behavior.
  • Avoid overfeeding or underfeeding.
  • Instruct in better feeding techniques such as improved bottles (low air, curved) and sufficient burping after feeding.
  • Colic: What You Should Know at www.aafp.org/afp/2004/0815/p741.html

Prognosis

  • Usually subsides by 3–6 months of age
  • Despite apparent abdominal pain, colicky infants eat well and gain weight normally.
  • A handful of studies indicate that temper tantrums may be more common among formerly colicky infants, as studied in toddlers up to 4 years of age (13,14).
  • Colic has no bearing on the baby’s intelligence or future development.

Complications

Colic is self-limiting and does not result in lasting effects to infant or maternal mental health (15)[C].

References

1. Keefe MR, Lobo ML, Froese-Fretz A, et al. Effectiveness of an intervention for colic. Clin Pediatr (Phila). 2006;45:123–33.

2. Reijneveld SA, van der Wal MF, Brugman E, et al. Infant crying and abuse. Lancet. 2004;364:1340–2.

3. Roberts DM, Ostapchuk M, O’Brien JG. Infantile colic. Am Fam Physician. 2004;70:735–40.

4. Wade S, Kilgour T. Extracts from “clinical evidence”: Infantile colic. BMJ. 2001;323:437–40.

5. Garrison MM, Christakis DA. A systematic review of treatments for infant colic. Pediatrics. 2000;106:184–90.

6. van Sleuwen BE, L’hoir MP, Engelberts AC, et al. Comparison of behavior modification with and without swaddling as interventions for excessive crying. J Pediatr. 2006;149:512–7.

7. Alexandrovich I, Rakovitskaya O, Kolmo E, Sidorova T, Shushunov S et al. The effect of fennel (Foeniculum Vulgare) seed oil emulsion in infantile colic: a randomized, placebo-controlled study. Altern Ther Health Med. 58–61.

8. Clemons RM. Issues in newborn care. Prim Care. 2000;27:251–67.

9. McCollough M, Sharieff GQ. Common complaints in the first 30 days of life. Emerg Med Clin North Am. 2002;20:27–48, v.

10. Hill DJ, Roy N, Heine RG, et al. Effect of a low-allergen maternal diet on colic among breastfed infants: a randomized, controlled trial. Pediatrics. 2005;116:e709–15.

11. Savino F, Pelle E, Palumeri E, et al. Lactobacillus reuteri (American Type Culture Collection Strain 55730) versus simethicone in the treatment of infantile colic: a prospective randomized study.Pediatrics. 2007;119:e124–30.

12. O’Connor NR. Infant formula. Am Fam Physician. 2009;79:565–70.

13. Canivet C, Jakobsson I, Hagander B et al. Infantile colic. Follow-up at four years of age: still more “emotional”. Acta Paediatr.2000;89:13–7.

14. Rautava P, Lehtonen L, Helenius H, Sillanpää M et al. Infantile colic: child and family three years later. Pediatrics. 1995;96:43–7.

15. Clifford TJ, Campbell MK, Speechley KN, et al. Sequelae of infant colic: evidence of transient infant distress and absence of lasting effects on maternal mental health. Arch Pediatr Adolesc Med. 2002;156:1183–8.

Codes

ICD9

789.7 Colic

Snomed

35363006 Infantile colic (finding)

Clinical Pearls

  • Colic is defined as excessive crying in an otherwise healthy baby.
  • Excessive crying may be a risk factor for shaken baby syndrome or other forms of child abuse.
  • Provide advice, support, and reassurance to parents (3)[B].
  • Prevent caregiver burnout by advising parents to get proper rest breaks, sleep, and help in caring for the infant.

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