> Table of Contents > Colic, Infantile
Colic, Infantile
Daniel T. Lee, MD, MA
Arthur Ohannessian, MD
image 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 Three: crying lasts for:
    • >3 hr/day
    • >3 days/week
    • 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.
ETIOLOGY AND PATHOPHYSIOLOGY
The cause is unknown. Factors that may play a role include the following:
  • 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 him- or herself when dealing with stimuli
  • Increased gut hormone motilin, causing hyperperistalsis
  • Functional lactose overload (i.e., breast milk that has a lower lipid content can have faster transit time in the intestine, leading to more lactose fermentation in the gut and hence gas and distension) (1)[C]
  • Tobacco smoke exposure
RISK FACTORS
  • Physiologic predisposition in infant but no definitive risk factors have been established. However, emerging data suggest maternal smoking or exposure to nicotine replacement therapy during pregnancy is associated with higher incidence of infantile colic (2)[B].
  • Infants with a maternal history of migraine headaches are twice as likely to have colic (3)[B].
GENERAL PREVENTION
Colic is generally not preventable.
image DIAGNOSIS
PHYSICAL EXAM
  • A comprehensive physical exam is normal.
  • Because excessive crying may be a risk factor for shaken baby syndrome or other forms of child abuse (4)[B], be sure to examine the child carefully for signs of shaken baby syndrome or other types of child abuse.
DIFFERENTIAL DIAGNOSIS
Any organic cause for excessive or qualitatively different crying in infants such as:
  • Infections (e.g., meningitis, sepsis, otitis media, or UTI)
  • GI issues such as gastroesophageal reflux disease, intussusception, lactose intolerance, constipation, anal fissure, or strangulated hernia
  • Trauma, which includes foreign bodies, corneal abrasion, occult fracture, digit or penile hair tourniquet syndrome, or child abuse
DIAGNOSTIC TESTS & INTERPRETATION
Initial Tests (lab, imaging)
Clinical diagnosis; no testing is done unless clinical symptoms imply other cause (UTI, weight loss, etc.).
Diagnostic Procedures/Other
A thorough history and physical exam should be performed to rule out other causes. Otherwise, no diagnostic procedures or imaging is indicated.
image TREATMENT
GENERAL MEASURES
  • Soothe by holding and rocking the baby.
  • Use a pacifier.
  • Use of gentle rhythmic motion (e.g., strollers, infant swings, car rides).
  • Place near white noise (e.g., vacuum cleaner, clothes dryer, white noise machine).
  • Crib vibrators or car ride simulators have not proven to be helpful (5)[B].
  • Increased carrying or use of infant carrier has not been shown to improve colic (5)[B].
  • Burping does not significantly lower colic events and can cause significant increase in regurgitation episodes (6)[B].
  • Employ the 5 Ss (need to be done concurrently):
    • Swaddling: tight wrapping with blanket; may be especially beneficial in infants <8 weeks old (7)[B]
    • Side: laying baby on side
    • Shushing: loud white noise
    • Swinging: rhythmic, jiggly motion
    • Sucking: sucking on anything (e.g., nipple, finger, pacifier)
MEDICATION
  • None as no medication found to be beneficial and safe. Probiotics are safe and effective (see Complementary and Alternative Medicine).
  • Dicyclomine (Bentyl) has been proven beneficial, but the potential serious adverse effects (apnea, seizures, and syncope) have precluded its use. Furthermore, the manufacturer has made the medication contraindicated for infants <6 months (8)[B].
  • Simethicone has not been shown to be beneficial (8)[B].
  • Omeprazole has not been shown to be beneficial (9)[B].
ISSUES FOR REFERRAL
Excessive vomiting, poor weight gain, recurrent respiratory diseases, or bloody stools should prompt referral to a specialist.
COMPLEMENTARY & ALTERNATIVE MEDICINE
  • Recent data from a large randomized controlled study involving nine neonatal units in Italy found that prophylactic use of Lactobacillus reuteri was beneficial. At 3 months of age, the mean duration of crying time (38 vs. 71 minutes; p < .01), the mean number of regurgitations per day (2.9 vs. 4.6; p < .01), and the mean number of evacuations per day (4.2 vs. 3.6; p < .01) for the L. reuteri DSM 17938 and placebo groups, respectively, were significantly different (10)[A].
  • However, the effect of L. reuteri has not been as robust in infants already diagnosed with colic. A placebo-controlled study of 50 infants given L. reuteri had significantly reduced median daily crying times throughout the study (370 to 35 min/day vs. 300 to 90 min/day in placebo group). However, weight gain, stooling frequency, and incidence of regurgitation were similar in both groups (11)[B].
  • L. reuteri is available as over-the-counter drops, but it is not regulated by the FDA.
    • A 2013 systematic review found probiotics effective for breastfed infants but not formula-fed infants. Infant massage and crib vibrator were found to reduce colic symptoms by 50% in a small RCT (12)[B].
  • Anecdotal evidence that car rides, both real and simulated via podcast (https://www.youtube.com/watch?v=8KAXmIe-T_4), or running a vacuum cleaner near the baby may be effective.
  • Herbal teas and supplements may help but are not recommended because of limited, inconclusive evidence. Examples:
    • One study concluded that herbal teas containing mixtures of chamomile, vervain, licorice, fennel, and balm-mint used up to TID may be beneficial (4)[C]. However, the study used high dosages, raising clinical concerns that this therapy may impair needed milk consumption in infants and be impractical to administer. In addition, preparations used in the study may not be commercially available in the United States.
    • P.209

    • 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 United States, and the long-term health effects are unknown (13)[B].
  • A home-based intervention focusing on reducing infant stimulation and synchronizing infant sleep-wake cycles with the environment, as well as parental support, has been shown to be effective (14)[B].
  • Use of music may help (15,16)[C].
  • Chiropractic treatment has shown no benefit over placebo.
  • Infant massage has not been shown to be helpful.
image ONGOING CARE
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 breastfeeding:
    • Continue breastfeeding. Switching to formula probably will not help.
    • Possible therapeutic benefit from eliminating milk products, eggs, wheat, and/or nuts from the diet of breastfeeding mothers (5)[B]
    • Along with eliminating the preceding foods from the maternal diet, removing soy, nuts, and fish may be beneficial.
  • 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.
    • If no intervention or dietary change has improved the situation, consider a 1-week trial of hypoallergenic formulas such as whey hydrolysate (e.g., Good Start) or casein hydrolysate (e.g., Alimentum, Nutramigen, Pregestimil) (5)[B],(8)[C].
    • The American Academy of Pediatrics concluded that there is no proven role for soy formula in the treatment of colic (17)[C].
    • Adding fiber to formula also has not been shown to be helpful (5,15)[B].
  • Supplementing with sucrose solution may be helpful, but the effect may be short-lived (<1 hour) (5,8)[B].
  • Despite the proposed mechanism of functional lactose overload, 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 the spectrum of crying behavior.
  • Avoid over- or underfeeding.
  • Instruct in better feeding techniques such as improved bottles (low air, curved) and sufficient burping after feeding.
  • Colic information at American Family Physician: www.aafp.org/afp/2004/0815/p741.html
PROGNOSIS
  • Usually subsides by 3 to 6 months of age, often on its own
  • Despite apparent abdominal pain, colicky infants eat well and gain weight normally.
  • A handful of studies indicate temper tantrums may be more common among formerly colicky infants as studied in toddlers up to 4 years old (18,19)[C].
  • Colic has no bearing on the baby's intelligence or future development.
REFERENCES
1. Douglas P, Hill P. Managing infants who cry excessively in the first few months of life. BMJ. 2011;343:d7772.
2. Milidou I, Henriksen TB, Jensen MS, et al. Nicotine replacement therapy during pregnancy and infantile colic in the offspring. Pediatrics. 2012;129(3):e652-e658.
3. Romanello S, Spiri D, Marcuzzi E, et al. Association between childhood migraine and history of infantile colic. JAMA. 2013;309(15):1607-1612.
4. Reijneveld SA, van der Wal MF, Brugman E, et al. Infant crying and abuse. Lancet. 2004;364(9442): 1340-1342.
5. Garrison MM, Christakis DA. A systematic review of treatments for infant colic. Pediatrics. 2000;106(1, Pt 2):184-190.
6. Kaur R, Bharti B, Saini SK. A randomized controlled trial of burping for the prevention of colic and regurgitation in healthy infants. Child Care Health Dev. 2015;41(1):52-56.
7. 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(4):512-517.
8. Wade S, Kilgour T. Extracts from “clinical evidence”: infantile colic. BMJ. 2001;323(7310): 437-440.
9. Moore DJ, Tao BS, Lines DR, et al. Double-blind placebo-controlled trial of omeprazole in irritable infants with gastroesophageal reflux. J Pediatr. 2003;143(2):219-223.
10. Indrio F, Di Mauro A, Riezzo G, et al. Prophylactic use of a probiotic in the prevention of colic, regurgitation, and functional constipation: a randomized clinical trial. JAMA Pediatr. 2014;168(3):228-233.
11. Savino F, Cordisco L, Tarasco V, et al. Lactobacillus reuteri DSM 17938 in infantile colic: a randomized, double-blind, placebo-controlled trial. Pediatrics. 2010;126(3):e526-e533.
12. Huhtala V, Lehtonen L, Heinonen R, et al. Infant massage compared with crib vibrator in the treatment of colicky infants. Pediatrics. 2000;105(6):E84.
13. Alexandrovich I, Rakovitskaya O, Kolmo E, et al. The effect of fennel (Foeniculum vulgare) seed oil emulsion in infantile colic: a randomized, placebo-controlled study. Altern Ther Health Med. 2003;9(4):58-61.
14. Keefe MR, Lobo ML, Froese-Fretz A, et al. Effectiveness of an intervention for colic. Clin Pediatr (Phila). 2006;45(2):123-133.
15. Clemons RM. Issues in newborn care. Prim Care. 2000;27(1):251-267.
16. McCollough M, Sharieff GQ. Common complaints in the first 30 days of life. Emerg Med Clin North Am. 2002;20(1):27-48.
17. O'Connor NR. Infant formula. Am Fam Physician. 2009;79(7):565-570.
18. Canivet C, Jakobsson I, Hagander B. Infantile colic. Follow-up at four years of age: still more “emotional.” Acta Paediatr. 2000;89(1):13-17.
19. Rautava P, Lehtonen L, Helenius H, et al. Infantile colic: child and family three years later. Pediatrics. 1995;96(1, Pt 1):43-47.
20. 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(12):1183-1188.
21. Gelfand AA, Thomas KC, Goadsby PJ. Before the headache: infant colic as an early life expression of migraine. Neurology. 2012;79(13):1392-1396.
Additional Reading
&NA;
  • Anabrees J, Indrio F, Paes B, et al. Probiotics for infantile colic: a systematic review. BMC Pediatr. 2013;13:186.
  • Johnson JD, Cocker K, Chang E. Infantile colic: recognition and treatment. Am Fam Physician. 2015;92(7):577-582.
  • 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(1):e124-e130.
Codes
&NA;
ICD10
R10.83 Colic
Clinical Pearls
&NA;
  • 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.
  • Usually subsides spontaneously by 3 to 6 months of age
  • Provide advice, support, and reassurance to parents.
  • Prevent caregiver burnout by advising parents to get proper rest breaks, sleep, and help in caring for the infant.