GI

Colic

Infantile Colic 

Colic is defined as crying in an otherwise healthy infant for 3 hours/day for 3 days/week lasting 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

The etiology of colic is largely unknown and debated.  Theories often center on infant discomfort due to 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 very recent study (2013) found significant differences in the intenstinal microbiota of infants who went on to develop colic. Another 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.

Differential Diagnosis

Colic is usually confirmed in retrospect once it has resolved, but often physicians must evaluate for the possibility of several other conditions which can also present with persistant infant discomfort and irritability. 

  • Injury including fractured clavicle or other bone (possible abuse)
  • Incarcerated hernia
  • Milk intolerance
  • Corneal abrasion or foreign body
  • Hair tourniquet (around finger, toes, penis)
  • Cardiac arrythymias
  • Infantile reflux
  • Constipation
  • Infection (UTI, pneumonia, sepsis, meningitis, ear infection, etc) 

Evaluation and Management

A complete history and physical examination, including weight, height, and head circumference, should be performed in order to rule out other underlying 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:

  • Alleviate the common concern that the infant's behavior is due to something the parents have done.
  • REST- reassurance, empathy, support, time away
  • 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.” Encourage parents to get some sleep.
  • Holding the baby will not spoil the infant.
  • 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.

References

  1. Barr RG. Changing Our Understanding of Infant Colic. Arch Pediatr Adolesc Med. 2002;156(12):1172-1174.
  2. Barr RG. Colic and Crying Syndromes in Infants. Pediatrics. 1998; 102(5 Suppl.):1282-1286.
  3. de Weerth, Carolina, et al. Intestinal Microbiota of Infants With Colic: Development and Specific Signatures. Pediatrics 131.2 (2013): e550-e558.
  4. Perry, Rachel, Katherine Hunt, and Edzard Ernst. Nutritional supplements and other complementary medicines for infantile colic: a systematic review. Pediatrics 127.4 (2011): 720-733.
  5. Lucassen, P. L. B. J., et al. Systematic review of the occurrence of infantile colic in the community. Archives of disease in childhood 84.5 (2001): 398-403.
  6. Karp H. The "fourth trimester": A framework and strategy for understanding and resolving colic. Contemporary Pediatrics. February 2004
  7. Savino F et al.  Lactobacillus reuteri versus simethicone in the treatment of infantile colic: a prospective randomized study.  Pediatrics  Jan 2007
  8. Cohen-Silver J, Ratnapalan S.  Management of Infantile Colic: A Review.  Clinical Pediatrics January 2009
  9. 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.
  10. Clifford Tammy J et al. Sequelae of Infant Colic. Archives of Pediatrics and Adolescent Medicine Dec 2002 
  11. Duro, D et al.  Association between infantile colic and carbohydrate malabsorption from fruit juices in infancy. Pediatrics 2002: 109(5): 797-805.
  12.  Freedman S. The Crying Infant: The Frequency of Serious Underlying Disease.  Pediatrics March 2009
  13. Cohen et al. Colic.  Pediatrics in Review July 2012