Colic: Answers

CASE 1:

A worried and tired mom brings her 2 month old baby to your continuity clinic for advice.  You have been following Angel in your clinic since he was born at Term.  He has been healthy up to now, growing well even up to today’s weight.  But, mom is worried and has brought him in to clinic today as a walk-in because Angel has been crying every night from midnight until 5am for weeks.  He started having these episodes when he was one month old and has been having them five days a week since then.  During these crying episodes he turns “red in the face,” closes his eyes, tightens his fists, draws his legs up to his abdomen and cries with a loud and piercing cry that awakens mom from her sleep.  Mom has tried feeding him, bathing him, changing his diaper, rocking him to no avail.  Mom is 19 years old and this is her first child.  She lives with dad, who is 22 years old, and who is helpful and supportive but has tried helping to make Angel stop crying, also to no avail. Maternal grandmother also lives in the household and has tried helping to soothe the crying with no success.  Mom is worried that something is wrong with Angel.

QUESTIONS AND ANSWERS:

1)      What is the differential diagnosis in an infant with episodes of inconsolable crying? (Adapted from Barr and Roberts references below)

Gastrointestinal:
Constipation, cow’s milk protein intolerance, gastroesophageal reflux, lactose intolerance, intussusception, rectal fissure.

Infection:
Fever with possible meningitis, otitis media, sepsis, urinary tract infection, or viral syndromes.
 

Trauma:
Abuse, corneal abrasions, eye foreign body, bone fractures, hair tourniquets, ingrown eyelashes.

Cardiovascular:
Supraventricular tachycardia, prolonged QT, anatomic cardiac malformations.
 

CNS Abnormality:
Chiari I type malformation, infantile migraine, subdural hematoma.

Idiopathic:
Colic.

2)      What is the definition of colic?

Colic is often defined using the “rule of three,” which includes crying for more than three hours per day, for more than three days per week, for longer than three weeks.  This definition applies to infants who are well-fed and otherwise healthy.

Episodes are characterized by crying that typically begins in the late afternoon or evening, with crying in prolonged bouts.  They crying episodes are unpredictable and spontaneous and are unrelated to external factors.  The infant cannot be pacified with rocking or feeding.  During these crying episodes, infants may emit a high-pitched cry, their face may be flushed, they may clench their fists and draw up their legs toward their abdomen.

3)      What is the typical progression of colic?

Colic typically begins at two weeks of age and resolves by four months of age. 

4)      What is the cause of colic?

The cause is unknown.  It has been conjectured to be due to increased abdominal gas, allergy to human milk or cow’s milk protein, hyperperistalsis, parental anxiety, infant temperament, but none of these causes have panned out in studies.  Colic has been suggested to be neurodevelopmental (at the upper end of normal distribution of crying length in infants), which is supported by the fact that most infants outgrown colic by four months.

5)      How do you evaluate an infant with suspected colic?

Colic is a diagnosis of exclusion and is diagnosed by history and physical examination. 

History should include details about the onset, timing, quality, duration, characteristics of the crying along with associated environmental factors.  One should try to elicit whether or not there are any ameliorating factors.  Investigate the home environment, support for mom, and clues to ensure no concerns for trauma.  Questions about cyanosis, apnea, or difficulty breathing can help lead you to signs of cardiac or pulmonary conditions.  Emesis with and without feedings and its characteristics should be elicited to exclude reflux or obstruction.  Bowel movement characteristics can help rule out constipation and cow’s milk protein intolerance.  The infant’s weight, weight gain and overall growth should be normal in colic; thus abnormalities in these should steer you in a different direction.

On physical examination, an important consideration is to ensure the infant is not febrile or that the crying is not a sign of possible sepsis.  When examining an infant, look for level of alertness, appropriate activity for age, bruises, pain on palpation or bone deformities as a sign of fracture when considering trauma as a cause of crying.  Be sure to examine the infant for ingrown eyelashes, hair tourniquets, corneal abrasions, eye foreign bodies, or any other external causes of pain.  Abdominal examination for masses or anorectal fissure is important.  A thorough cardiac exam should help you to ensure the infant is not fussy and crying due to supraventricular tachycardia or other cardiac conditions.  Neurologic examination should be normal.

There are unfortunately no lab tests or imaging studies that will lead you to a diagnosis of colic.

CASE 2:  A 24-year old mom of a 6 week old girl comes to your clinic for a walk-in visit.  Mom is both breastfeeding and formula-feeding and asks if she should avoid any foods in her diet, such as broccoli or cow’s milk, to help ameliorate the baby’s colic?  Mom also wonders if she should change the formula as it may be “upsetting her stomach?”

CASE 3:  An experienced 34-year old mother brings her 2 month old baby boy to see you for his 2 month well child check and immunizations.  On conversing with her, she mentions that they are not getting much sleep at night, because the baby is fussy with “gas pain.”  She has tried Simethicone drops and Gripe water and wonders if it actually works? or if there is any other medicine she can give him?  She has been also feeding the baby chamomile tea once a day for his fussiness and colic, per grandmother’s recommendations, and wonders if that’s OK or helpful?

6)   What are the treatment options for colic? Which treatment options for colic have been shown to be effective?

Does Use of a Low Allergen Diet by Breastfeeding Mothers Reduce the Symptoms of Infant Colic?

Per the Pediatrics 2000 article …“There are conflicting answers to this question. One study, randomized both breastfeeding and bottle-feedingmother-infant pairs to hypoallergenic or control diets. In breastfeedingpairs (67%), the hypoallergenic diet was a maternal diet free of milk, egg, wheat, and nut products; the control diet was a maternal diet that included all of these products. In bottle-feeding pairs (33%), the hypoallergenic diet was a hypoallergenic infant formula; the control diet was a cow milk-containing infant formula.  In a combined analysis, the authors found that the mean daily duration of colic symptoms was reduced by 25% over 8 days in 61% of infants in the hypoallergenic group as compared with 43% of infants in the control group.  No significant differences were found between the results of the breastfed and bottle-fed groups.   In another randomized trial, elimination ofnot have a significant effect on the symptoms of colic; however, the symptoms of colic were more frequent on days during which the mother ate fruit or chocolate, regardless of the group to which she had been randomized.  Rates of colic were higher on cow's milk days than on milk-free days in infants of mothers who reported atopic disorders (eczema, asthma, or allergic rhinitis). Data regarding utilization of hypoallergenic diets by breastfeeding mothers are inconclusive, but suggest that there may be some therapeutic benefit. Further studies are warranted to better evaluate these therapies.”

Does the Use of Hypoallergenic Formulas Reduce the Symptoms of Colic? in Bottle-fed Infants?

Per the Pediatrics 2000 article …”Two RCT reported significant improvements in colic while infants were receiving hypoallergenic formula.  The use of hypoallergenic infant formulas appears to have abeneficial effect on the symptoms of infant colic, although better studiesare needed.”

Does Use of Soy-Based Formulas Reduce the Symptoms of Colic in Bottle-fed Infants?

Per the Pediatrics 2000 article … “In 1 RCT, the mean weekly duration ofcolic symptoms during treatment with soy formula was 8.7 hours, as compared with 18.8 during the control periods.  The other RCT of soy formula in infants did report the data in a manner that allows foranalysis of treatment effect. This trial used infants admitted to the hospital for colic as their case definition, which is likely a considerably different sample population from those children seen for colic symptomsin an outpatient setting.  Soy formula may be an effective treatment of infant colic, but further research is clearly needed in this area as well.” 

Does Carrying the Infant More Often Reduce the Symptoms of Colic?

Per the Pediatrics 2000 article … “Neither of 2 RCTs showed that increased infant carrying resulted in any reduction of the symptoms ofant colic. In one trial, parents were given Snugli (Evenflo Company, Inc, Vandalia, OH) infant carriers and were told to both carry the infant more often and to reduce stimulation. Again, no significant effect was observed. Neither of the studies were double-blinded, a common weakness in trials of behavioral interventions.  Current data does not support supplemental carrying as an effective intervention for infant colic.”

Does Decreasing Infant Stimulation Reduce the Symptoms of Colic?

Per the Pediatrics 2000 article … “In 1 RCT, 93% of infants whose parents were advised to reduce stimulation improved, as opposed to 50% of those in the control group.”  These findings are statistically significant, but the study has several methodologic weaknesses.”

Does Massage Reduce the Symptoms of Colic?

Per the Pediatrics in Review 2007 article … “A 2006 Cochrane Database Systematic Review of the effectiveness of infant massage in promoting physical and mental health in infants concluded that there is evidence of benefits on mother-infant interaction, infant sleeping, and crying but noted that more rigorous RCTs are needed before infant massage can be recommended routinely for treating colic.”

Is Simethicone an Effective Treatment for Infant Colic?

Per the Pediatrics 2000 article … “Out of 3 RCTs of simethicone for the treatment of colic, only 1 showed any possible benefit. The 2 other trials of simethicone both found no significant benefit.  None of the 3 trialsreported adverse effects of therapy in either treatment or placebogroups.  Existing data do not demonstrate conclusive benefit of simethicone as a treatment for infant colic.” 

Does Treatment With Dicyclomine Reduce Symptoms in Infants With Colic?

Per the Pediatrics 2000 article … “In all 3 RCTs of dicyclomine, it performed significantly better than placebo. In both of the RCTs that reported adverse effects, there was a difference of 8% in the incidence of adverse effects between the dicyclomine and placebo groups, with the most commonly reported including drowsiness, constipation, and diarrhea.  However, these figures reflect only 6 adverse events (1 of occurred in the placebo group), and the differences were not statistically significant. According to published case reports, the more severe adverse effects (such as apnea, seizures, and coma) from dicyclomine appear to be most common in infants <7 weeks old.  Some authors have argued that the beneficial effects of dicyclomine outweigh the relatively low incidence of adverse effects.68 However, Merrell Dow, the manufacturer, no longer considers infant colic an indication for dicyclomine and has contraindicated its use in infants <6 months old.” 

Does Treatment With Methylscopolamine Relieve the Symptoms of Colic?

Per the Pediatrics 2000 article … “The 1 RCT conducted ofamine in infant colic found that it had no significant impact on the symptoms of infant colic, but that adverse effects were more common in infants receiving the active treatment.  Methylscopolaminedoes not appear to be an either effective or safe treatment for infant colic.”

Do Herbal Teas Reduce the Symptoms of Infant Colic?

Per the Pediatrics 2000 article … “One RCT compared an herbal teaaining chamomile, vervain, licorice, fennel, and balm-mint to aacebo tea with the same taste, odor, and appearance. Infants were offered the tea at the onset of every episode, with a maximum dose of150 mL, up to 3 times a day. After 7 days of treatment, 57% of the infants receiving the herbal tea no longer met the Wessel criteria forcolic, as opposed to 26% of the infants in the placebo group (RR = 0.57; 95% CI = .37-.89). No significant differences were seen in the average number of night wakings (1.9 in treatment group, 2.2 in placebo group), and no adverse effects were reported in either group. As promising as these results are, however, the mean tea consumption of 32 mL/kg/d raises concerns about the potential nutritional effects if prolonged treatment leads to a decreased intake of milk.”

Conclusions on TREATMENT:

Per the Pediatrics 2000 article … “An evidence-based approach to colic reduce the stimulation level in the infant's environment.  It seems likely that a subgroup of infants with colic has symptomscaused at least in part by allergy; these infants will have a significant reduction in symptoms within a few days of initiating a hypoallergenic diet.  In bottle-fed infants, hypoallergenic formula may be superior to soy formulas, as several studies have commented that the majority of infants who did not respond to soy formula later responded to hypoallergenic formula.   However, there have been no clinical trials to date directly comparing hypoallergenic to soy formulas in infants with colic. There is some evidence for the effectiveness of herbal tea in the relief of colic symptoms, and the organic nature of the treatment may appeal to many parents. The evidence for reduction in stimulation is somewhat less clear, but the intervention requires few, if any, resources to implement and was not associated with any adverse effects.”   

7)  What reassurance can you provide the family about colic?

Above all, parents of infants with colic need reassurance that their infant is healthy.  Stress to them that colic is self-limited, and that their infant will suffer no long-term effects from it.

Colic can be stress-inducing in families of infants who are suffering from it, and as a Pediatrician, you should watch families for signs of increasing stress that could be harmful to the baby.