The most important aspect
of the management of colic
is to reduce psychological
pressure on the parents,
write Emma Jane
McDermott and
Alf Nicholson
Forum
Child Health
Colic in infancy – a
continuing enigma
COLIC IS NOT SERIOUS unless you are the infant’s parents!
The true incidence of excessive crying/fussing in infancy
(colic) is unknown. Whether parents seek medical attention
for their crying infant will depend on a number of factors,
including whether the child is first-born, cultural attitudes
towards crying and the level of support given to the mother.
Excessive crying represents the upper end of the spectrum
of crying behaviour that is found in normal infants. Individual differences in crying are likely to reflect differences in
the way the central nervous system works rather than differences in the way the gastrointestinal tract works.
The excessive crying typically begins at about two weeks
of age and reaches a peak sometime in the second month
and then declines to baseline levels at about four months of
age. Crying tends to cluster during the late afternoon and
evening hours. It tends to occur in prolonged bouts and
these bouts are resistant to all kinds of soothing attempts,
including feeding.
During such bouts, infants may clench their fists, flex their
legs, arch their backs and grimace giving the impression
that they are in pain. The crying bout may include regurgitation and the passage of gas per rectum. These crying bouts
tend to begin and end without warning.
Crying in normal infants
There is a characteristic crying pattern in almost all
infants and in almost all cultures studied to date. This pattern in normal infants shows a peak at four to six weeks of
age and a decline from eight to 12 weeks of age. The peak
of crying in normal infants may be earlier in formula-fed
infants compared to breast-fed infants. This pattern of
crying is a normal developmental phenomenon and is found
in Western culture but also in other cultures where caregiving is radically different.
Definition of colic
While it is often difficult to determine when an infant
should be considered to have colic, the most widely used
definition is that proposed by Wessel and colleagues and
which is known as the ‘rule of threes’:
Table 1
Conditions that
may mimic colic
Condition
Strength of
evidence
Estimated
prevalence
• Cow’s milk protein
intolerance
strong
< 5%
• Isolated fructose
intolerance
strong
very rare
• Maternal drug effects
(esp. fluoxetine HCl: Prozac)
strong
rising
• Reflux oesophagitis
moderate
rare
• Anomalous left coronary
artery
strong
very very rare
• Lactose intolerance
very weak
probably not
related
• An infant should be considered to have colic if he/she
cries for more than three hours a day for more than three
days a week for three weeks.
However this definition has its limitations in that the
actual duration of crying may be difficult to quantify and
very few parents are prepared to wait three weeks until an
official announcement proclaiming that their infant has
colic is made!
Features of colic
Infants do not complain of ‘colic’ – they cry and therefore
the interpretation of crying as being due to colic or not is
made by the parents. The crying of colic is a non-specific
sign of discomfort or distress in the infant and is termed
expressive crying. In contrast, older infants tend to have
communicative crying which is tied to the maternal response
and is more intentional.
It is important to note that most cases of colic cannot be
accounted for by pre-existing maternal personality characteristics, postnatal depression or non-optimal caregiving.
Because of inexperience, first-time mothers may bring their
FORUM September 2004 41
Forum
Child Health
crying infants for medical attention more often but there is
no difference in the amount of crying in first-born and laterborn infants.
Thus most cases of colic are unlikely to be due to problems in either the mother or infant. Differences in caregiving
(such as the amount of contact, the frequency and type of
feeding) may modify both the duration and pattern of crying.
Identifying infants with organic disease
Always enquire about a history of recent fever as the presence of fever in an under three month old may indicate the
possibility of a serious bacterial infection (urinary tract
infection, septicaemia or meningitis). Organic diseases that
may mimic colic are highlighted in Table 1.
Pointers towards an organic cause include:
• Those infants with high-pitched crying
• Infants who regularly arch their backs during crying bouts
• When the crying pattern does not fit a pattern of evening
clustering.
A late onset of increased crying in the third month of life
or following a switch from breast to formula milk may implicate cow’s milk protein intolerance.
Infants do produce more colonic gas during the first three
months of life due to incomplete absorption of lactose, but
evidence that this excess gas causes colic or that treatment
for this excess gas is effective is extremely weak.
Natural history of colic
There is little doubt that if caregivers can make it through
the period of colic, the prognosis for the infant is likely to
be excellent. The pattern of crying does recede by three
months of age in most infants but they may still be perceived differently by their parents – they may be seen as
having a difficult or demanding temperament or be seen as
being vulnerable to illness up to three years of age.
The management of colic
Basic principles to outline to parents include:
• Try to never let your baby cry
• In attempting to discover why your infant is crying consider three possibilities:
– the infant is hungry and wants to be fed
– the infant wants to suck, although he is not hungry
– the infant wants to be held
– the infant is bored and wants stimulation
– the infant is tired and wants to sleep
• If the crying continues for more than five minutes with one
response, try another
• Decide on your own in what order to explore the above possibilities
• Do not be concerned about overfeeding your infant. This
will not happen
• Do not be concerned about spoiling your infant. This also
will not happen.
As a family doctor, to manage colic it is important to take
the problem seriously and to ensure that feeding is adequate
and appropriate for the infant. One should conduct a
detailed examination of the infant. Assess parental competence, confidence and levels of anxiety, and the level of
stress in the household and what support structures are in
place. Spend time reassuring and explaining the problem to
parents and do not be afraid to advise admission to hospital if necessary to alleviate a very stressful situation at home.
There is a group of infants with colic that are classified as
42 FORUM September 2004
‘Wessel’s plus’; these infants fulfil Wessel’s criteria for colic
but in addition have other cues that cause concern (ie. have
not responded to trials of therapy or have additional risk factors such as a fragile family). These so-called ‘Wessel’s plus’
infants tend to display clenched fists, flexed legs, back
arching, distended abdomens, regurgitation with crying and
a pained face when crying. In this ‘Wessel’s plus’ group
(especially if associated diarrhoea and/or vomiting), a trial
of elimination of cow’s milk protein (either from the mother’s
diet if breastfeeding or from the infant’s diet by changing to
a special formula) may be indicated.
Treatments for colic – critical appraisal
Over the years, numerous remedies ranging from behavioural to pharmacological have been studied as treatments
for colic with very few having rigorous evaluation in the form
of randomised controlled trials. The differences in case definition, along with the wide variation in outcome measures,
both limit comparison of results between trials and make
meta-analysis inappropriate.
Does the use of soya-based formulae reduce the
incidence of colic in bottle-fed infants?
There has been only one RCT on this and it was very
flawed, thus soya milk is not proven to reduce colic. Therefore, there is no evidence that lowering the lactose content
of formula has any effect in reducing crying in infantile
colic.
Does treatment with lactose enzymes reduce the
symptoms of infant colic?
Only two RCTs have been carried out on this and there is
no evidence that lactose is an effective therapy for colic.
Does the use of a low antigen diet by breastfeeding
mothers reduce colic in their infants?
The data is still inconclusive and more study is required.
Do hypo-allergenic formulae in infants reduce the
symptoms of colic?
There is some evidence for a modest beneficial effect of
a hypo-allergenic formula.
Does treatment with simethicone, dicyclomine or
methylscopolamine reduce colic?
Simethicone has been studied in three RCTs and only in
one was a possible benefit evident. Thus simethicone therapy cannot be recommended in colic. Dicyclomine does
show a clear benefit in reducing excessive crying but, due
to excess adverse effects, albeit very rare, in under seven
week old infants (seizures, apnoea and coma), it has now
been withdrawn and is contraindicated in under six month
olds. Methylscopolamine is neither safe nor effective in
infant colic.
Behavioural modifications – do they reduce colic?
Increased carrying does not reduce crying. Specific management techniques (early response to the crying, gentle
soothing motion, avoidance of over-stimulation, use of a
dummy, prophylactic holding and carrying and even car ride
simulators) in combination with general reassurance were
no more effective than general reassurance only.
Do herbal teas reduce the symptoms of infant colic?
One RCT compared herbal tea containing chamomile, licquorice, fennel and balm-mint to a placebo tea with the
same taste, odour and appearance and, when given three
times a day, that those on herbal tea had significantly less
crying.
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Child Health
Is a trial of elimination of cow’s milk protein worthwhile?
In those infants who are deemed to have ‘Wessel’s plus’
criteria, in particular those with clenched fists, flushed
faces, tense distended abdomens, regurgitation with crying,
pained faces when crying and associated diarrhoea, a trial
of elimination of cow’s milk protein is indicated. This
involves changing over to a special formula or elimination
of cow’s milk protein from the mother’s diet if breastfeeding.
Prognosis
Crying and fussing do reduce significantly after three
months of age and this relates to the maturing central nervous system of the infant and coincides with a changing role
for the cry signal – from expressive crying to communicative
crying. Therefore, the most important aspect of the management of colic is to reduce psychological pressure on the
caregivers, especially the mother. This is best achieved by
using the following principles:
• Acknowledge the reality of the parents’ concern, regardless of the amount of crying
• Inform parents about normal patterns of crying in under
three month old infants and that crying peaks at four to
six weeks of age
• It is helpful to assess the supports for the mother and see
that these support persons (eg. grandparents) are also
educated about the best way to handle and perceive crying
• Ask the mother to keep a diary of crying
• Ask a practice nurse or public health nurse to support the
family and regularly weigh the infant
• Arrange for regular ‘respite’ periods for the mother, if
possible
• In severe cases, especially if the increased crying is occurring in the context of a fragile or otherwise challenged
family, refer for a paediatric opinion and perhaps consider
admission to take the heat out of the situation.
A difficult clinical challenge
Colic continues to be a mysterious and difficult clinical
challenge for both parents and doctors. Studies point to
colic being a condition of excess crying in the first three
months in normal infants. All young infants display crying
which peaks at four to six weeks of age.
As doctors, one should firstly never ignore or downplay
parental concern about colic, and the infant with colic
should be regularly monitored. Also do not focus solely on
the infant as the more likely consequences of colic are the
effects on the infant’s parents. Drug therapy is ineffective
and dietary changes are rarely indicated.
f
Emma Jane McDermott is a specialist registrar in paediatrics,
previously at Our Lady of Lourdes Hospital, Drogheda and
currently in the US, and Alf Nicholson is consultant
paediatrician at Our Lady of Lourdes Hospital, Drogheda
References
1. Wessel MA et al. Paroxysmal fussing in infancy, sometimes called ‘colic’.
Paediatrics 1954; 14: 421-434
2. Barr RG et al. The crying of infants with colic: a controlled empirical
description. Paediatrics 1992; 90: 14-21
3. Gormally SM, Barr RG. Of clinical pies and clinical cues: proposal for a
clinical approach to complaints of early crying and colic. Ambul Child
Health 1997; 3: 137-153
4. Raiha H et al. Family functioning three years after infantile colic. J Dev
Behav Pediatr 1997; 18: 290-294
5. Lucassen PLBJ et al. Effectiveness of treatments for infantile colic:
systematic review. BMJ 1998; 316 (7144): 1563-1569
6. Garrison MM, Christakis DA. A systematic review of treatments for infant
colic. Paediatrics 2000; 106 (1): 184-189
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