Infantile colic

What is baby colic?¹²

The diagnostic criteria for infantile colic are set out by the Rome foundation in the Rome IV criteria:

• The infant must be <5 months of age when the symptoms start and stop.

• There are recurrent and prolonged periods of infant crying, fussing, or irritability reported by caregivers that occur without obvious cause and cannot be prevented or resolved by caregivers.

• There is no evidence of infant failure to thrive, fever, or illness.

Fussing is defined as intermittent distressed vocalisation, also defined as not quite crying but not awake or content either. The previous definition which mandated at least three hours of crying or fussing per day for three or more days in seven days has been removed for clinical purposes as it was felt to be too strict. It is still used for clinical research.

Infantile colic is a common, benign, self-limiting condition; despite much research on the subject, the underlying cause is still not clear.

Baby colic can cause considerable distress for parents and paediatricians. Despite 40 years of research, its pathogenesis is incompletely understood and treatment remains an open issue.

Who gets baby colic? (Epidemiology)¹

• 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%.

• It affects males and females equally.

• Breastfed and formula-fed infants are equally affected.

• It is one of the commonest reasons for parents to consult their doctor in the first three months of their baby's life.

What causes baby colic? (Aetiology)¹

Despite decades of research, the actual cause of infantile colic remains unknown.

• Infantile colic may be caused by the impact of abnormal gastrointestinal motility and pain signals from sensitised pathways in the gut viscera.

• There is some evidence that smoking and nicotine replacement therapy (NRT) during pregnancy are associated with a higher risk of colic; the evidence for NRT is of low to moderate quality only.³⁴

• There is an increased risk of infantile colic in preterm and small-for-gestational-age infants.^{5 6}

• Baby colic may be associated with cow's milk allergy or lactose intolerance in some cases.⁷

• The composition of intestinal microbiota, especially an inadequate amount of lactobacilli and an increased concentration of coliforms, has been suggested in some studies to influence the pathogenesis of baby colic.⁸

Baby colic symptoms¹

The symptoms seen in infants described as having colic are all nonspecific and baby colic must be a diagnosis of exclusion when the clinician is satisfied that the child is otherwise healthy. Commonly described features of colic include:

• Inconsolable crying - typically, high-pitched and occurring frequently in the afternoon or evening.

• Redness of the face.

• Drawing up of the knees.

• Flatus.

A history should include:

• Feeding - breast/bottle.

• Weight gain.

• Bowel habit - stool consistency/colour/blood.

• Vomiting or reflux.

• Timing of crying.

• Duration of crying.

An examination should include:

• General examination, including weight which should be plotted on a centile chart.

• Abdominal examination, including hernial orifices and genitalia.

Differential diagnosis

Inconsolable crying and distress may indicate pain or other physical discomfort and other possible causes of pain should be sought in an acute situation, although many parents usually present with a history of inconsolable crying in an infant who appears to be thriving and content.

In an acute situation when faced with a distressed infant, consider:

• Physical discomfort - cold, wet, hungry.

• Severe nappy rash.

• Corneal abrasion from the infant's nails.

• Intussusception.

• Volvulus.

• Strangulated hernia.

• Torsion of the testis.

• Safeguarding issues.

• A hair tourniquet, where a hair has become wrapped around a toe, causing pain and risking tissue necrosis.⁹

When the history is over a longer period of time, consider:

• Reflux oesophagitis.

• Lactose intolerance.

• Constipation.

• Cow's milk protein allergy.

• Parenting skills and experience of parents.

• Maternal postnatal depression.

Gastro-oesophageal reflux disease is the most common differential diagnosis.

Investigating baby colic

• The diagnosis is usually made using history and examination alone and does not normally require any further investigations.

• Infants who exhibit atypical features, or in whom the diagnosis is in doubt, should be referred for a specialist opinion either as an emergency or to an outpatient clinic, depending on the clinical presentation.

Baby colic treatment and management

For the majority of cases simple reassurance is all that is required.

General support¹¹⁰

• The parents of infants with colic often require support, as they will be anxious as to the cause of the crying and their apparent inability to help the child.

• A caring and compassionate healthcare professional is extremely important in the management of colic.

• General advice to the parents may be all that is needed in terms of feeding regimes, temperature of the child's room, and clothing worn by the child, together with an explanation of the likely course of the condition.

• Parents may be advised to share childcare with each other and friends/grandparents until this stage has passed, in order to prevent physical/mental exhaustion.

Dietary approaches

• A hypoallergenic diet for breastfeeding mothers which excludes cow's milk products and other possible trigger foods may be helpful in some cases. For bottle fed babies the equivalent would be a trial of a hypoallergenic milk.⁷

• There is no proven role for the use of soy-based formulas or of lactase therapy in the management of baby colic and these interventions are not recommended.¹¹

• There is some evidence that Lactobacillus reuteri probiotics have some effectiveness for breastfed babies, but may be effective as a treatment strategy for crying in exclusively breastfed infants who were born by normal delivery; there is very limited evidence for those who are bottle fed or born by caesarean.⁸

Physical therapies

• There is no high quality data for any benefits of manipulation therapy such as chiropractic, osteopathy, or cranial manipulation.¹⁰¹²

Medication¹³

• Simethicone has moderate-to-low evidence showing no benefit or negative effect.

• There is no evidence for the use of proton pump inhibitors for reducing crying time and fussing.

• Three national guidelines have unanimously recommended the use of education, parental reassurance, advice and guidance and clinical evaluation of mother and baby. Consensus on other advice and treatments did not exist.

A great deal of accumulated clinical experience tells us that children with colic incur no serious long-term effects from the disorder and that symptoms abate with time. The potential harm associated with diagnostic testing and treatment of infants may surpass the harm from colic itself.

Outlook of a baby with colic (prognosis)

• The prognosis is excellent.

• Most infants with colic recover spontaneously by 3-4 months of age.

• However, it remains a frustrating problem for parents and caregivers because it is difficult to treat and may result in significant psychosocial consequences.