Colic

 

Case

The parents of a 4 week old boy come to your office with the chief complaint that their infant boy is crying excessively.  The baby seems inconsolable with food or rocking. This is the parents’ first child and they seem very anxious. How would you approach this problem?

 

Definition . 

Colic is defined as crying in an otherwise healthy infant for ³ 3 hours/day for ³ 3 days/week lasting ³ 3 weeks, in the absence of conditions that could cause prolonged crying (hunger, organic disease, neglect).  Most colic-related crying begins between 2-6 weeks of age and declines until 4 months of age.  Crying most often occurs in the afternoon and evening. Colic is thought to represent the extreme of normal; therefore, many physicians will accept the definition that colic is any crying by infants that is considered excessive by the parents. 

 

Etiology

There is a paucity of large randomized trials on colic; therefore, the etiology of colic is largely unknown.  Theories often center on gastrointestinal sources, including an inability of the infant to handle colon gas, intolerance of certain foods (allergies, hypersensitivities), motility abnormalities, and an immature GI tract.  A recent study showed that colic may be associated with carbohydrate malabsorption in some infants. Other studies point to environmental or parental factors, such as poor parental response to infant needs, maternal/paternal misinterpretation of normal crying, or increased sensitivity to surroundings. Neural etiologies, such as inability of the CNS to handle stimuli and abnormalities of circadian cycles, have also been implicated.  On 11-year follow-up, there has been no association between colic and feeding type, atopy, asthma, allergic rhinitis, or wheezing.

 

Symptoms

  1. Excessive crying and the appearance of being in pain. Crying may be of sudden onset and last for greater than 15 minutes. 
  2. Difficulty in consoling the infant.
  3. Poor sleeper.
  4. Acts like they are starving and will then suck vigorously for few seconds, only to spit the nipple out and scream.
  5. Passes a lot of gas
  6. Difficulty with defecating despite soft stools.

 

Signs of Colic

  1. General physical exam is usually normal.
  2. Draws legs up and abdomen seems distended.
  3. Arching his/her body.
  4. Seems to react to every stimulus.

 

Differential Diagnosis

  • Injury including fractured clavicle or other bone (possible abuse)
  • Incarcerated hernia
  • Milk intolerance
  • Corneal abrasion or foreign body
  • Hair tourniquet
  • Cardiac arrythymias
  • Infantile reflux
  • Constipation

 

Evaluation and Management

A complete history and physical examination to emphasize that the child is normal. This should include weight, height, and head circumference measurements to rule out chronic or infectious disease.  A history of periods of normal behavior will help reassure that paroxysms of crying is not due to organic disease or formulas. The complete assessment will also reassure the parents that their child is growing and developing normally and that you care and are listening to their issues.  Reassure the parents that this is a common finding and emphasize that it will get better by 3-4 months.

 

The following list some approaches to colic used by many practitioners:

 
  • REST- reassurance, empathy, support, time away
    • Alleviate the common concern that the infant's behavior is due to something the parents have done.
      • Encourage parents to get outside help from relatives, friends, and baby-sitters. There is no reason for both parents to be with inconsolable baby at one time.  Reassure parents that it is okay for one or both to “take a break.”
    • Holding the baby will not spoil the infant. 
    • Motion seems to help, especially rocking, swinging gently, and going for rides in the car.  Many babies improve with swaddling.
    • Emphasize that we do not know of any long-term sequelae of colic and when the symptoms resolve, their child will be no different from any other child.
    • Try feeding or sucking first to console the infant.
    • Decrease visual stimulation.
      • If the symptoms are prolonged i.e.( lasting more than 4-5 months, there is blood in the stools, and the child feeding poorly and is not thriving), further evaluation of an underlying cause must be considered.

       

      Avoid the following approaches:

       

      • Unless there is a strong family history of atopy or the stools are bloody or mucoid, changing formulas will not help. If there is some suggestion of atopy, changing to protein hydrolyzed formula may help. Look for signs of rash or hives to enhance ideas that this is due to atopy.
      • Drugs are not helpful and some have even been shown to be dangerous. There appears to be a placebo effect when any medication is started. Avoid anticholinergics, antihistamines, narcotics, and sedatives. Herbal tea may help.
      • Simethicone has been tried and most studies show that it is not helpful.

       

      References

      1. Castro-Rodriguez, JA et al. Relation between infantile colic and asthma/atopy: a prospective study in an unselected population. Pediatrics 2001 Oct; 108(4): 878-82.
      2. Clifford Tammy J et al. Sequelae of Infant Colic. Archives of Pediatrics and Adolescent Medicine Dec 2002 
      3. Duro, D et al.  Association between infantile colic and carbohydrate malabsorption from fruit juices in infancy. Pediatrics 2002: 109(5): 797-805.
      4. Fleisher DR. Coping with colic. Contemporary Pediatrics 1998; 15(6): 144-155.
      5. Lehtonen, LA, and Rautava, PT. Infantile Colic: Natural History and Treatment. Current Problems in Pediatrics. March 1996.
      6. Barr RG. Colic and Crying Syndromes in Infants. Pediatrics. 1998; 102(5 Suppl.):1282-1286.
      7. Treem, WR. Infant Colic. Pediatric Clinics of North America. October 1994.
      8. Karp H. The "fourth trimester": A framework and strategy for understnding and resolving colic Contemporary Pediatrics. February 2004
      9. Savino F et al.  Lactobacillus reuteri versus simethicone in the treatment of infantile colic: a prospective randomized study.  Pediatrics  Jan 2007
      10. Cohen-Silver J, Ratnapalan S.  Management of Infantile Colic: A Review.  Clinical Pediatrics January 2009
        11.  Freedman S. The Crying Infant: The Frequency of Serious Underlying Disease.  Pediatrics March 2009