Continuing Education Activity
Infant colic is estimated to affect 20% of all infants. Despite its prevalence, a clear cause for infantile colic remains elusive. There have been many theories regarding the etiology, but a lack of uniformity in study definitions for colic has made it challenging to identify a common cause. Colic typically presents in the second or third week of life, peaks around 6 weeks, and usually resolves by the age of 12 weeks. This activity reviews the etiology, presentation, evaluation, and management of colic and reviews the role of the interprofessional team in evaluating, diagnosing, and managing the condition.
- Review the potential etiology of infantile colic.
- Describe the presentation of an infant with colic.
- Summarize the treatment and management of infantile colic, including parental counseling points.
- Outline interprofessional team strategies for improving care coordination and communication to improve outcomes in patients with colic.
Infant colic is challenging for new parents and is a reason for 10% to 20% of pediatrician visits during the early weeks of an infant's life. Colic is estimated at affecting 5% to 40% of infants worldwide. The condition typically presents in the second or third week of life, peaks around 6 weeks, and resolves by the age of 12 weeks in 60% of infants and by 16 weeks of age in 90%. Inconsolable crying, irritability, and screaming without an obvious cause characterize colic; during these episodes of fussiness, which occur more frequently in the evenings, the affected infant classically appears red-faced, draws up the legs and tenses up the abdomen. The traditional methods of soothing the infant often fail to relieve the infant's distress. First described in 1954, the original "Wessel's Rule of 3s" diagnostic criteria (symptoms lasting for 3 hours per day, 3 or more days per week, for 3 or more weeks, starting around 3 weeks of age), has undergone a transition in recent years. The Rome IV criteria describe colic in infants from birth to 5 months of age to make the definition of infantile colic more consistent for research purposes. The criteria are as follows:
- An infant who is <5 months of age when the symptoms start and stop
- Recurrent and prolonged periods of infant crying, fussing, or irritability reported by caregivers that occur without obvious cause and cannot be precented or resolved by caregivers
- No evidence of infant failure to thrive, fever, or illness
While benign and self-limiting, the condition is frustrating for parents and has been linked to maternal postpartum depression and shaken baby syndrome. Since treatments for colic are controversial and inconsistent, the role of the physician as a counselor and educator to parents is critical.
Despite its prevalence, a clear cause for infantile colic remains elusive. There have been many theories regarding the etiology, but a lack of uniformity in study definitions for colic have made it challenging to identify a common cause. It is likely that the etiology of the condition is multifactorial. Many of the theories regarding the cause focus on immaturity of the nervous system, sleeping disruption, hypersensivitiy to the environment, sensory overload, food allergy, reflux, and a lower diversity of the gut microbiota. In breastfeeding infants with colic, maternal diets containing cow's milk may contribute to infant distress. Others have suggested a link between colic and migraine physiology, as there are a growing number of studies showing an association between infantile colic and the later development of childhood migraines. Psychosocial issues have also been blamed, such as poor feeding techniques, maternal smoking, or nicotine replacement therapy, inadequate parental interaction, family tension, and parental anxiety. Unfortunately, this wide range of potential causes makes the treatment for colic challenging for both parents and physicians.
Colic affects around 20% of infants worldwide, although some studies suggest the prevalence may be significantly higher. A recent population-based survey in the United States suggested a prevalence rate of nearly 6%. These ranges in prevalence may reflect the previous lack of uniformity in defining colic. However, the recognition of colic also depends on the parental perception of crying intensity and duration. Parental wellbeing, as well as cultural differences in what is considered acceptable crying, may also affect these data. Regardless of the variability in prevalence, there is no association with gender, ethnicity, socioeconomic status, feeding preference or birth order.
Because a precise etiology for colic is unclear, the theories of pathophysiology are equally varied. An underlying organic disease is found in less than 5% of infants with inconsolable crying. Most pathways still focus on a GI process. The latest research has focused on the gut microbiota. Having a lower diversity in bacteria may be associated with a diagnosis of colic.
History and Physical
Although colic is a benign and self-limiting condition, a thorough history, physical examination, and reviewing growth charts are important to rule out more serious issues. After obtaining information regarding the pattern, frequency, circumstances, duration, and intensity of crying, the health care provider should take care to obtain information regarding fever, growth, feeding patterns, the presence of bilious emesis, constipation or diarrhea, bloody stools, lethargy, cough, wheezing, rash. The physical exam should then focus on identifying signs of failure to thrive or serious illness. Findings such as poor weight gain or growth, abdominal distension and tenderness, scrotal or inguinal swelling, suspicious bruises or burns, and signs of dehydration should prompt further evaluation. Findings such as a hair wrapped around a digit or penis should not be missed.
In the absence of significant physical findings and a history that is consistent with the Rome IV criteria or the "Rule of 3s" the diagnosis of colic can be made confidently, and further evaluation is unnecessary. However, the presence of fever may necessitate a workup for sepsis and involve blood and urine cultures, imaging and even lumbar puncture. Abdominal distension may suggest the need for abdominal radiography or ultrasonography, while positive fecal occult blood testing may support suspected cow's milk allergy. Increased lethargy should prompt consideration for a septic workup and computed tomography (CT) of the brain. Suspicion for traumatic injury should be evaluated by skeletal surveys and CT of the head. If the crying starts after the third month of life or persists beyond the fourth month of life then further work up is indicated.
Treatment / Management
The treatment of infantile colic is as varied (and often unproven) as the theoretical causes for colic. First-line treatment should be directed at the distressed parents, educating them about colic, and reassuring them that the condition is self-limiting and benign. Parents can be encouraged to develop coping responses when the child begins crying, minimizing the likelihood that they will become frustrated and injure the infant. In fact, parents who are frustrated by the infant's crying should place the infant safely in a crib and walk away briefly, to avoid shaking the infant and causing harm. Traditionally parents have resorted to methods such as white noise machines, swaddling, rocking, or driving the infant in a car to control the symptoms of colic. However, clear evidence for the effectiveness of these methods is lacking.
Studies examining the effectiveness of simethicone in treating colic have been inconsistent, but most demonstrate no effect. The anticholinergic dicyclomine has shown improvement in crying time, but its potential side effects of respiratory depression, apnea, seizures, pulse rate fluctuations, and muscular hypotonia make its use undesirable in young infants; dicyclomine is not approved for use in children under the age of 6 months. Proton pump inhibitors such as omeprazole are no better than placebo at reducing crying time in infants with colic. Thus, pharmacological approaches to the treatment of colic are not recommended.
Dietary modifications in the treatment of colic have been explored in some detail. Breastfed infants with colic have significant reductions in crying time if the mother is placed on a hypoallergenic diet, in which dairy foods, eggs, nuts, wheat, soy, and fish are eliminated from the mother's diet. Bottle-fed infants who are switched from traditional cow's milk formulas to soy-based formulas show no improvement in colic symptoms; at the same time, soy-based formulas are not recommended for infants less than 6 months of age due to the high concentrations of phytates, aluminum, and phytoestrogens in those formulas. The American Academy of Pediatrics discourages the use of soy-based formulas in the treatment of colic due to their lack of benefit. In contrast, a number of studies confirm the usefulness of hydrolyzed formulas in the reduction of crying times for infants with colic. Unfortunately, these formulas are more expensive and may provide a financial challenge to the parents; if no improvement in symptoms occurs within two weeks, the infant may be switched back to traditional formulas.
Some treatment approaches are directed at the correction of the infant's gut microflora. While several studies demonstrate a reduction in crying time among bottle-fed infants with colic who receive supplements of Lactobacillus reuteri, other studies have contradicted those findings. However, there seems to be more consistent evidence regarding the positive effects of L. reuteri supplementation among infants who are breastfed. Probiotic supplementation may be useful for colicky breastfed infants but less useful for bottle-fed infants.
Reducing stimulation may be effective for some infants with colic, much like its effectiveness in children with migraines. Techniques may include reducing the lighting in the room, turning down loud music and avoiding toys that make noise, keeping siblings and pets in another room, avoiding strong odors or perfumes, and rocking the baby gently may have beneficial effects. Feeding the infant in a darkened room may facilitate infant sleep.
Comparisons have been made between infants with colic who were treated with massage and those who were treated with rocking. While there are reductions in crying time for both treatment groups in one study, the greatest reduction was seen in infants undergoing regular massage by their mothers. However, other studies examining the effects of massage have been inconsistent in demonstrating effectiveness. While the effectiveness of massage may not be concrete, it is at least a safe intervention that may improve parental-infant bonding and can be used in any intervention for colic.
- Emergent management of Otitis media
- Bacterial meningitis imaging
- Pediatric aseptic meningitis
- Pediatric oesophageal reflux
Infantile colic is a benign and self-limiting condition that typically resolves spontaneously between three and four months of age. However, there are some indications that infants with colic may be at more risk for developing migraines without aura by age 18. There is also evidence linking excessive crying early in life with preschool adaptive problems, attention deficit hyperactivity disorder, and other behavioral problems, as well as being associated with maternal anxiety and depression. Thus, counseling parents regarding colic and helping them to develop coping mechanisms, as well as offering suggestions on the management of colic symptoms, seems prudent.
Pearls and Other Issues
In the absence of other obvious causes, infants who meet the Rome IV criteria can be confidently diagnosed with colic. These criteria, which are modifications of the original "Rule of 3s" include inconsolable crying or fussiness for 3 or more hours per day, during 3 or more days for 1 or more weeks. Etiologies are likely multifactorial, and treatment recommendations vary based on those potential etiologies. However, the strongest evidence for effective treatment recommendations includes eliminating potential allergens (cow's milk being the most common) from the diets of mothers who are breastfeeding and switching bottle-fed infants to hydrolyzed formulas. Weaker levels of evidence also support supplementing breastfed infants with Lactobacillus reuteri but do not endorse supplementing formula-fed infants with those probiotics.
Enhancing Healthcare Team Outcomes
Infantile colic is managed by a number of healthcare professionals including the family practitioner, pediatrician, pediatric gastroenterologist, emergency department physician, nurse practitioner, and obstetrician. Infantile colic is a distressing challenge for parents and is a reason for 10% to 20% of pediatrician visits during the early weeks of an infant's life. Colic is estimated at affecting 20% of infants worldwide. The condition typically presents in the second or third week of life, peaks around 6 weeks, and usually resolves between 12-16 weeks. Inconsolable crying, irritability, and screaming without an obvious cause characterize colic. Today, the Rome IV criteria are often used to make the definition of infantile colic more consistent for research purposes. The criteria are as follows:
- Episodes of fussing or crying that start and stop without obvious causes
- Episodes lasting 3 or more hours daily, 3 or more days a week for 1 or more weeks
- Episodes without evidence for failure to thrive
While benign and self-limiting, the condition is frustrating for parents and has been linked to maternal postpartum depression and shaken baby syndrome. Since treatments for colic are controversial and inconsistent, the role of the clinician as a counselor and educator to parents is critical.
The pediatrician, pediatric gastroenterologist, nurse practitioner, and primary care provider should minimize parental anxiety by discussing colic and ensuring that it is a benign disorder. Infants should be brought back frequently to assess growth as well as screen the caregiver for depression. Parents should also be educated to put the infant back in the crib by the interprofessional team so as to avoid shaking or hurting the infant with unproven remedies. Finally, the pharmacist should warn parents against the use of dicyclomine and other related agents as the risks outweigh any potential benefit.
The outcome for most infants with colic is excellent.