Infantile Colic

See Also

Inconsolable Crying in Infants

Epidemiology

Very common (25% of infants)
More common in bottle-fed Infants

Etiology

Unknown cause
Two fold risk associated with maternal smokers
Thoroughly studied with inconclusive results
1. Hyperperistalsis
2. Cow's Milk Allergy (may account for 10-15% of colic)
3. Lactose Intolerance
4. Parent or Infant relationship disturbance
5. Neurophysiologic response of immature infant (gastrointestinal immaturity)
6. Alteration in fecal microflora
7. Colon inflammation (Fecal Calprotectin does increase in colic)
Not correlated with other studied factors
1. Gender
2. Gestational age
3. Socioeconomic status
4. Season

History
Red Flags

Intermittent explosive Diarrhea
1. Hirschprung Disease
Blood Diarrhea
1. Cow's Milk Allergy
Recurrent, forceful Vomiting
1. Pyloric Stenosis
2. Pediatric Gastroesophageal Reflux
Inguinal or Scrotal Swelling
1. Testicular Torsion
2. Incarcerated Hernia

Exam
Red Flags

Consider causes of inconsolability
Red Flags
1. Fever
2. Lethargy
3. Abdominal Distention
4. Ecchymosis or other Trauma findings
  1. Nonaccidental Trauma (Child Abuse)

Signs
Colic episode

Infant has unpredictable episodes with paroxysms of pain, often in evening
1. Not provoked by environment
2. Not relieved with soothing or feeding
High pitched screaming
Facial Flushing
Clenched fists
Infant pulls legs up to Abdomen

Diagnosis
Wessel Criteria (Rule of 3's)

Unexplained fussiness or crying
1. Otherwise healthy infant
2. Critical that organic causes are ruled out
  1. See Inconsolable Crying in Infants
Resolves by 3 months (to 5 months) of age
Lasts (cumulative) more than 3 hours per day
Occurs more than 3 days per week
Persists longer than 3 weeks

Differential Diagnosis

Normal crying in infants without colic
1. Overall, Infants cry 2.2 hours/day on average
2. Crying duration peaks at 6 weeks and then decreases
Assess for other etiology of excessive crying
1. See Inconsolable Crying in Infants
2. See Red Flags as above
3. Consider Inadequate Breast or Bottle Feeding

Management
General

Describe condition to parent
Explain that cause is unknown
Reassurance that colic passes by age of 3-5 months
1. Greatly improves even if it continues longer
Discuss parental coping strategies
Consider potentially soothing measures: Harmless and potentially helpful (Five S's)
1. Side or Stomach position
2. Shushing sounds
3. Swinging
4. Sucking (Breast Feeding)
5. Swaddling
  1. Not recommended as no benefit when studied
  2. van Sleuwen (2006) J Pediatr 149(4): 512-7 [PubMed]
Have parent call or follow-up in 2 weeks
Few medications may have benefit
1. Probiotics may decrease crying time (by as much as 50%)
  1. Lactobacillus reuteri (e.g. Gerber Soothe) 5 drops per day 30 minutes before morning feeding
  2. Best efficacy is for Breast fed infants with colic
  3. Savino (2010) Pediatrics 126(3): e526-33 [PubMed]
  4. Sung (2014) BMJ 348:g2107 [PubMed]
2. Consider hypertonic, 12% sucrose water (e.g. Sweet-Ease)
  1. May be used occasionally for calming effect (infant sedation)
  2. http://prc.coh.org/SucAnal.pdf
Most medications studied either do not help colic or have insufficient evidence for efficacy and safety
1. Avoid Dicyclomine (Bentyl) due to risk of apnea
2. Avoid Phenergan
3. Avoid Simethicone (no more effective than Placebo)
  1. Metcalf (1994) Pediatrics 94:29-34 [PubMed]
4. Avoid Omeprazole (ineffective)
  1. Moore (2003) J Pediatr 143(2): 219-23 [PubMed]
5. Avoid Tylenol for relief of colic
6. Avoid herbal tea preparations
  1. May result in Malnutrition from less milk intake
7. Avoid sucrose (reduces crying for only minutes)
8. Avoid Scopolamine (ineffective)
9. Avoid lactase enzyme (ineffective)
10. Avoid Herbals (peppermint, fennel, chamomile, vervain, lemon balm, licorice) - insufficient evidence
  1. Perry (2011) Pediatrics 127(4): 720-33 [PubMed]
Physical stimulation does not appear helpful
1. No evidence to support car-ride simulators
2. No evidence to support carrying infant more
3. No evidence to support decreased infant stimulation
4. No evidence to support Behavior Modification
5. Insufficient evidence to support massage, Acupuncture
6. Insufficient evidence to support chiropractic or osteopathic manipulation (and unknown safety)
  1. Dobson (2012) Cochrane Database Syst Rev (12):CD004796 [PubMed]

Management
Dietary changes

Bottle Feeding: Changing Formula
1. Many infants are unlikely to benefit from change (variable effect on colic)
2. Changing to a hydrolyzed formula is most likely of formula changes to be effective
  1. Preparations
    1. Partially hydrolyzed: Gentlease, Good Start Gentle/Soothe, Total Comfort
    2. Extensively hydrolyzed: Nutramigen, Pregestimil, Alimentum
    3. Completely hydrolyzed: Elecare, Nutramigen AA, Neocate
  2. Disadvantages
    1. Very expensive ($1-3 per powder ounce)
      1. Often not covered by WIC and other assistance programs
    2. Poorly palatable
      1. Consider gradually mixing with regular formula over 4-5 days
  3. Protocol
    1. Transition gradually from regular formula and continue trial for 2 weeks
3. Study of colicky infants in Denmark
  1. Improved when switched to Soy Formula: 18%
  2. Improved with no change (Control Group): 29%
  3. Improved on Casein Hydrolysate (Nutramigen): 53%
4. Changing formula is benign option for parent (but unlikely to benefit)
  1. See also Infant Nutrition Components
  2. Avoid multiple formula changes
  3. Options
    1. See hydrolyzed formula change as above
    2. Consider Lactose-Free Formula trial for 2 weeks
  4. Changes formula manufacturers have tried
    1. Change in Linoleic Acid
    2. Change in Whey to Casein Protein ratio
  5. Changes not shown to be effective
    1. Soy Formula does not appear effective (and may be an allergen)
      1. Garrison (2000) Pediatrics 106:184-90 [PubMed]
    2. Fiber-enrichment does not appear effective
Breast Feeding: Dietary changes (low-allergen) in the Breast Feeding mother
1. Follow a low-allergen diet until infants is 3-6 months old
  1. Avoid cow's milk
  2. Avoid eggs
  3. Avoid wheat
  4. Avoid soy
  5. Avoid tree nuts and peanuts
  6. Avoid fish
2. Efficacy
  1. Low allergen diet may reduce colic in some infants
  2. Hill (2005) Pediatrics 116:709-15 [PubMed]

Course

Onset as early as 2 weeks
Resolves by 3-5 months

Reference