Overview and Risk Factors
Infantile colic refers to excessive and persistent crying in a baby less than 3 months old. Although the condition is sometimes attributed to psychosocial causes, this chapter will focus solely on digestive contributors. Criteria developed by pediatrician Morris Wessel in 1954, and used as a diagnostic standard ever since, define colic as crying that occurs in an otherwise healthy baby for 3 or more hours a day, on 3 or more days a week, for 3 or more weeks. These criteria are somewhat controversial in that they may not adequately distinguish abnormal crying from normal behavior that occurs around 6 weeks of age.
Colic episodes are usually characterized by increased intensity, duration, and irregularity of crying that borders on screaming; hypertonicity; general inconsolability; and abrupt onset and conclusion.
Symptoms of colic may include flushing, constipation, tense abdominal distention, loss of appetite, and persistent crying and irritability.
Risk Factors
Risk factors for infantile colic are poorly understood. The condition does not appear to be related to gender or gestational age at birth and is not a sign of lactose intolerance. The following list identifies possible risk factors that have emerged in research studies, but whose validity has yet to be established:
- Parental smoking.
- Stressful home environment, including maternal prenatal anxiety and depression.
- Caucasian race.
- Residence in developed nations and/or locations farther from the equator.
- Feeding practices, which include swallowing of air, excessive feeding, and underfeeding.
- First-born birth order.
- Possible nutritional contributors are described in Nutritional Considerations.
Diagnosis and Treatment
Diagnosis
A detailed history is important, along with questions to determine the social factors at play with the parents and how they respond to their crying baby. It is essential to consider the possibility of parental abuse.
A complete physical exam should be performed, and colic should be a diagnosis of exclusion. Routine laboratory tests, stool samples, and imaging may help rule out malabsorption, intussusception, and bowel obstruction.
Treatment
Colic is self-limiting and will resolve with time. Offering reassurance to the family is helpful, and all interventions should be individualized to the family's needs. In addition to dietary factors described below, the following interventions may help decrease the severity and length of illness, although most evidence is inconclusive.
Parental counseling and support may be an effective strategy for reducing parental anxiety and infant crying.1
Feeding techniques that may reduce air-swallowing include breast-feeding at 1 breast (as opposed to equal feeding time at each breast);2 using a curved bottle with a plastic bag for feeding with formula or pumped breast milk; and keeping the infant in an upright position.
Two studies show the potential benefit of herbs. Fennel seed oil3 and a tea containing chamomile, fennel, licorice, vervain, and balm-milk4 both significantly improved colic with reference to the Wessel criteria. However, prolonged tea consumption at 32 ml/kg/d could adversely affect infants' nutrient intake,5 and caution is advised.
Reduction of stimulation may be helpful. Neurobehavioral assessments have shown that infants with the greatest responsiveness to external stimuli are more likely to be colicky, compared with other infants.6 This may explain the finding of a systematic review that stimulation reduction was a beneficial strategy for colicky infants.7
Lactase and simethicone have not generally been shown to be helpful. Sucrose is not sufficiently calming to justify its use.
Dicyclomine should not be used to treat infantile colic due to risk of serious adverse effects, including seizures and death.
Nutritional Considerations
Links between diet and infantile colic should be regarded as tentative, pending further research. Nevertheless, some evidence indicates that replacement of cow's milk and cow's milk-based formula with hypoallergenic formula, or elimination of cow's milk products from a breast-feeding mother's diet, may be helpful to certain patients. Also, in some cases, the maternal diet may influence colic as a result of the transmission of offending proteins or other compounds through breast milk. The key nutritional issues are as follows:
Cow's milk proteins. The possibility that cow's milk proteins may elicit colic symptoms is supported by at least 2 kinds of evidence. The first is the observation that colic symptoms often improve in infants who are either given formula free of cow's milk proteins or who are breast-fed by mothers who avoid cow's milk.8,9 The second is the high number of infants who experience colic symptoms when challenged indirectly with breast milk subsequent to maternal ingestion of whey capsules.9
In spite of the belief that the maternal intestinal wall provides a barrier to large molecules, it has been shown that cow's milk proteins are absorbed from the maternal gastrointestinal tract into the circulation and subsequently pass into breast milk. Passing on these proteins when breast-feeding is a suspected cause of colic.10
Disaccharidase deficiency or galactosemia may also cause colic symptoms.11 A 1-week trial of a hypoallergenic formula may be recommended for colicky infants,7,12 although this is not a proven strategy for reducing colic symptoms.
Allergy-causing and gas-producing foods. A breast-feeding mother who eats a hypoallergenic diet may improve her infant's colic.5 Breast-feeding mothers with atopy may find that colic symptoms increase on days that dairy products are consumed.13 A survey of breast-feeding women revealed that the foods mothers found to be most strongly linked to colic in their infants were cruciferous vegetables (broccoli, cabbage, cauliflower), onions, and chocolate.14
However, evidence is increasing that many other foods may exacerbate colic. In a randomized controlled trial in which many of these foods (eg, cow's milk, eggs, peanuts, tree nuts, wheat, soy, and fish) were excluded from the diets of breast-feeding women with colicky infants, a reduction in colic symptoms was observed, compared with women who continued eating these foods.15
Fructose malabsorption. Rarely, patients with colic may have isolated fructose malabsorption and respond to a fructose-free diet.16
Orders
Parental smoking cessation.
Nutrition consultation: to advise breast-feeding mothers in the use of a dairy-free or hypoallergenic diet, as appropriate, and arrange follow-up.
Social work consultation: to assess home environment, and arrange follow-up to assess the possibility of ill feelings toward the infant, care provider burnout, and maternal depression or anxiety.
What to Tell the Family
In the absence of other medical issues, colic typically resolves within 4 months, and is always self-limited. Reassurance of the family is important. Dietary changes, including a dairy-free or hypoallergenic diet for breast-feeding mothers or the use of a nondairy or hypoallergenic formula, may be given a therapeutic trial. If switching to a soy-based formula, it is essential to use a baby formula, not common soy milk sold in grocery stores.
All household smokers should stop smoking for the present and future health of the baby and other family members.
Caregivers should understand that they may not be able to console the infant on every occasion, and that caring for a colicky baby is very stressful. They should be encouraged to ask for help if anxiety, depression, or feelings of frustration or anger toward the baby arise. Reducing stimulation, including the stimulation of a family's repeated efforts to console the baby, may result in decreased colic symptoms.
References
1. Taubman, B. Parental counseling compared with elimination of cow's milk or soy milk protein for the treatment of infant colic syndrome: a randomized trial. Pediatrics. 1988;81:756-761.
2. Evans K, Evans R, Simmer K. Effect of the method of breast feeding on breast engorgement, mastitis and infantile colic. Acta Paediatr.1995; 84:849-852.
3. Alexandrovich I, Rakovitskaya O, Kolmo E, Sidorova T, Shushunov S. The effect of fennel (Foeniculum vulgare) seed oil emulsion in infantile colic: a randomized, placebo-controlled study. Altern Ther Health Med. 2003;9:58-61.
4. Weizman Z, Alkrinawi S, Goldfarb D, Bitran C. Efficacy of herbal tea preparation in infantile colic. J Pediatr. 1993;122:650-652.
5. Garrison MM, Christakis DA. A systematic review of treatments for infant colic. Pediatrics. 2000;106(pt 2):184-190.
6. St James-Roberts I, Goodwin J, Peter B, et al. Individual differences in responsivity to a neurobehavioral examination predict crying patterns of 1-week-old infants at home. Dev Med Child Neurol. 2003;45:400-407.
7. Lucassen PL, Assendelft WJ, Gubbels JW, et al. Effectiveness of treatments for infantile colic: systematic review. BMJ. 1998;316:1563-1569.
8. Jakobsson I, Lindberg T. Cow's milk as a cause of infantile colic in breast-fed infants. Lancet. 1978;312:437-439.
9. Jakobsson I, Lindberg T. Cow's milk proteins cause infantile colic in breast-fed infants: a double-blind crossover study. Pediatrics. 1983;71:268-271.
10. Clyne PS, Kulczycki A Jr. Human breast milk contains bovine IgG. Relationship to infant colic? Pediatrics. 1991;87:439-444.
11. Kerner JA Jr. Formula allergy and intolerance. Gastroenterol Clin North Am. 1995;24:1-25.
12. Sicherer SH. Clinical aspects of gastrointestinal food allergy in childhood. Pediatrics. 2003;111:1609-1616.
13. Evans RW, Fergusson DM, Allardyce RA, Taylor B. Maternal diet and infantile colic in breast-fed infants. Lancet. 1981;1:1340-1342.
14. Lust KD, Brown JE, Thomas W. Maternal intake of cruciferous vegetables and other foods and colic symptoms in exclusively breast-fed infants. J Am Diet Assoc. 1996;96:46-48.
15. Hill DJ, Roy N, Heine RG, et al. Effect of a low-allergen maternal diet on colic among breastfed infants: a randomized, controlled trial. Pediatrics. 2005; 116:e709-715.
16. Wales JK, Primhak RA, Rattenbury J, Taylor CJ. Isolated fructose malabsorption. Arch Dis Child. 1990;65:227-229.
