Baby colic is commonly defined as distress or crying in an infant, which lasts for more than three hours a day, for more than three days a week, for at least three weeks in an otherwise healthy infant. It is a common, benign, self-limiting condition and, 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.
- Baby colic is very common, occurring in round 10-30% of infants.
- It affects males and females equally.
- Breast-fed and formula-fed infants are equally affected.
- It is one of the most common reasons for parents to consult their doctor in the first three months of their baby's life.
- 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.
- Smoking and also nicotine replacement therapy during pregnancy have been shown to be risk factors for baby colic.
- There is an increased risk of infantile colic in preterm and small for gestational age infants.
- Baby colic may be associated with cow's milk allergy or lactose intolerance in some cases.
- 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.
- Food allergies have been advocated as a possible cause of infantile colic.
- Behavioural issues such as family tension, parental anxiety, or inadequate parent-infant interaction have also been explored as causative factors for infantile colic.
Infantile colic, defined according to Rome III criteria as episodes of irritability, fussing or crying that begin and end for no apparent reason and last ≥3 hours per day, ≥3 days per week, for ≥1 week.
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.
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.
- Abdominal examination, including hernial orifices and genitalia.
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.
- Strangulated hernia.
- Torsion of the testis.
- Non-accidental injury.
When the history is over a longer period of time, consider:
- Reflux oesophagitis.
- Lactose intolerance.
- Cow's milk protein allergy.
- Parenting skills and experience of parents.
- Maternal postnatal depression.
Gastro-oesophageal reflux disease is the most common differential diagnosis.
- The diagnosis is usually made using history and examination alone and does not normally require any further investigations.
- Normal weight gain is typical in these infants.
- An alternative diagnosis should be considered if failure to thrive is present.
- 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.
For the majority of cases simple reassurance is all that is required.
- 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.
- A hypoallergenic diet for breast-feeding mothers which excludes cow's milk products and other possible trigger foods may be helpful in some cases.
- Where a suspicion of cow's milk protein allergy exists there is some evidence that the use of an empirical time-limited trial of a completely hydrolysed formula is a reasonable option.
- If food intolerance is suspected in a baby with infantile colic (ie atopy risk, other signs or symptoms of food intolerance) then some experts recommend a short trial with an extensively hydrolysed cow's milk protein formula or, if breast-fed, with a maternal hypoallergenic diet (eliminating dairy foods, eggs, peanuts, tree nuts, wheat, soy and fish).
- Partially hydrolysed formulas are not recommended for the management of infantile colic.
- 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.
- Although some studies have shown that Lactobacillus reuteri may be effective as a treatment strategy for crying in exclusively breast-fed infants with colic, the evidence supporting probiotic use for the treatment of infant colic or crying in formula-fed infants remains unresolved.
- There is inconclusive evidence for spinal manipulation.
- There is limited evidence from the literature to recommend complementary therapies such as massage, acupuncture or chiropractic care in infantile colic.
- There is little scientific evidence to support the use of simeticone (eg, Infacol®) or dicyclomine hydrochloride.They are unlikely to be harmful however.
- There are no clear management guidelines for the treatment of baby colic and no evidence-based cures.
So, with such a dearth of good evidence, perhaps the more important question is whether we should be treating infant colic at all. 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 is likely to surpass the harm from colic itself.
For us to continue to perform drug intervention trials for this problem perhaps underscores our unwillingness to accept that colic is likely to represent a heterogeneous disorder with many complex inputs.
- 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.
Further reading and references
Savino F, Ceratto S, De Marco A, et al; Looking for new treatments of Infantile Colic. Ital J Pediatr. 2014 Jun 540:53. doi: 10.1186/1824-7288-40-53.
Savino F, Tarasco V; New treatments for infant colic. Curr Opin Pediatr. 2010 Dec22(6):791-7.
Milidou I, Henriksen TB, Jensen MS, et al; Nicotine replacement therapy during pregnancy and infantile colic in the offspring. Pediatrics. 2012 Mar129(3):e652-8. Epub 2012 Feb 20.
Milidou I, Sondergaard C, Jensen MS, et al; Gestational age, small for gestational age, and infantile colic. Paediatr Perinat Epidemiol. 2014 Mar28(2):138-45. doi: 10.1111/ppe.12095. Epub 2013 Nov 21.
Vandenplas Y, Alarcon P, Alliet P, et al; Algorithms for managing infant constipation, colic, regurgitation and cow's milk allergy in formula-fed infants. Acta Paediatr. 2015 May104(5):449-57. doi: 10.1111/apa.12962. Epub 2015 Mar 23.
Chau K, Lau E, Greenberg S, et al; Probiotics for infantile colic: a randomized, double-blind, placebo-controlled trial investigating Lactobacillus reuteri DSM 17938. J Pediatr. 2015 Jan166(1):74-8. doi: 10.1016/j.jpeds.2014.09.020. Epub 2014 Oct 23.
Vandenplas Y, Gutierrez-Castrellon P, Velasco-Benitez C, et al; Practical algorithms for managing common gastrointestinal symptoms in infants. Nutrition. 2013 Jan29(1):184-94. doi: 10.1016/j.nut.2012.08.008. Epub 2012 Nov 6.
Hall B, Chesters J, Robinson A; Infantile colic: a systematic review of medical and conventional therapies. J Paediatr Child Health. 2012 Feb48(2):128-37. doi: 10.1111/j.1440-1754.2011.02061.x. Epub 2011 Apr 7.
Hyman PE, Milla PJ, Benninga MA, et al; Childhood functional gastrointestinal disorders: neonate/toddler. Gastroenterology. 2006 Apr130(5):1519-26.
Management of infantile colic; BMJ. 2013 Jul 10347:f4102. doi: 10.1136/bmj.f4102.
Iacovou M, Ralston RA, Muir J, et al; Dietary management of infantile colic: a systematic review. Matern Child Health J. 2012 Aug16(6):1319-31. doi: 10.1007/s10995-011-0842-5.
Nocerino R, Pezzella V, Cosenza L, et al; The controversial role of food allergy in infantile colic: evidence and clinical management. Nutrients. 2015 Mar 197(3):2015-25. doi: 10.3390/nu7032015.
Critch J; Infantile colic: Is there a role for dietary interventions? Paediatr Child Health. 2011 Jan16(1):47-9.
Anabrees J, Indrio F, Paes B, et al; Probiotics for infantile colic: a systematic review. BMC Pediatr. 2013 Nov 1513:186. doi: 10.1186/1471-2431-13-186.
Cohen-Silver J, Ratnapalan S; Management of infantile colic: a review. Clin Pediatr (Phila). 2009 Jan48(1):14-7. Epub 2008 Oct 2.
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