Colic
Colic: Excerpt from The 5-Minute Pediatric Consult
William B. Carey, MD
Colic - BASICS
Colic - description
- A poorly defined and incompletely understood state of prolonged or excessive crying in young infants who are otherwise well
- No standard definition of this phenomenon
- Best definition available: >3 hours a day of irritability, fussing, or crying on >3 days in any 1 week during the 1st 3–4 months of life in an infant who is otherwise healthy and well fed. Some add the criterion of a duration ≥3 weeks.
- Crying is not qualitatively different, but quantitatively. It is considerably more than the average.
- Lack of a firm, standard definition means that varying groups of subjects have been studied and limits our certainty as to incidence and causes of prolonged crying and as to effectiveness of management plans.
Numerous pitfalls await the unprepared physician:
- Overdiagnosing the condition of the infant or caregiving inadequacies of parents
- Overtreatment of the infant with changes of feedings, medications, and various inappropriate procedures such as enemas and rectal manipulations. Despite the widely held, popular view that cow’s milk allergy is a principal reason for excessive crying, no study of acceptable double-blind design has demonstrated its occurrence in infants who are free of respiratory, GI, or cutaneous manifestations of allergy.
- Unnecessary laboratory tests
- Colic is defined as a pattern of recurring episodes of crying. Other explanations should be carefully considered 1st for an acute bout of crying.
- The physician should be wary of enthusiastic reports in the popular press or the medical literature that “at last there is a cure for colic.” Certainty is not easily achieved in an area where there is such a problem with definitions and with methodologic problems like achieving truly double-blind trials.
Colic - general prevention
No study has yet demonstrated any certain way of preventing this prolonged or excessive crying. Methods that are likely to be helpful are:
- Education of all parents about infant crying and soothing.
- Informing them of the expected average number of hours per day.
- Most parents do not know that 1 of the common reasons for an infant to cry is fatigue, and that stimulation at these times is not helpful.
- Dealing with various pertinent parental anxieties when they occur should be undertaken.
Colic - epidemiology
Incidence and prevalence estimates difficult due to lack of standard definition. Incidence figures of 10–15% typically cited in texts.
Colic - risk factors
Colic - genetics
No genetic influence has been discovered, but it has not been investigated. Temperamental traits are known to be largely inborn, however.
Colic - pathophysiology
- No single cause is always found.
- Typically, the problem lies in the interaction between factors in the infant and the environment at a unique time of biological vulnerability:
- In the infant there is a normal physiologic or temperamental predisposition to be more sensitive, irritable, intense, less rhythmical, or harder to soothe than average for the age.
- Parents generally have not yet learned how to read the infant’s individual needs correctly and respond appropriately. They may be manipulating the infant in ways that increase rather than decrease the amount of crying.
- This interaction takes place at a time in the 1st 3–4 months when the immature CNS makes the infant temporarily more vulnerable to the disorganizing effects of this poor fit.
- Colic generally occurs in the absence of any abnormality in the infant or the parents, but rather when the parents have not yet learned to interact harmoniously with the infant.
- There is no evidence that the bowel is at fault; flatus is more likely to be the result of the crying than the cause.
- Psychosocial risk factors, such as poor support for the mother and various stressors, are probably more common than in noncolicky infants, but they are not necessary.
- When such external factors are present, they seem to exert their effects by reducing the parent’s ability to respond appropriately to the infant.
- Physical problems in the infant, such as milk allergy or gastric reflux, probably account for no >10% of all prolonged crying at this time, and would exclude an infant from this diagnosis of colic, which requires that the infant be physically well.
Colic - DIAGNOSIS
Colic - signs & symptoms
Colic - history
- Define symptoms: Intensity, duration, and frequency of crying. Some parents complain more than others about the crying.
- Colic typically begins shortly after a baby comes home from a newborn nursery.
- It can last until 3–4 months of age if not successfully managed.
- If excessive crying lasts after 4 months, other diagnoses should be considered.
- Ask parents to describe a typical day:
- Description of a typical day or keeping a crying diary is helpful.
- This will give insights into the daily routine, feeding, rest, interpretive skills and responses of the parents.
- Ask parents to describe and demonstrate their soothing techniques.
- Information on the baby’s temperament can be obtained by asking the parents to describe the baby’s typical reaction patterns to stimuli.
- Medical history should include concerns about the pregnancy and the newborn period, anxieties related to parents’ own experiences as children or with previous children, and the quality of family supports and other stressors.
Colic - physical exam
- No findings are expected if the child has colic. However, examination should always be performed to reassure both parents and physician.
- Attempts at management over the telephone without a physical examination are likely to be unsuccessful.
Colic - tests
Colic - lab
No tests are indicated unless specifically suggested by history or physical examination.
Colic - differencial diagnosis
- Normal crying:
- Average, normal infants cry about 2 hours a day at 2 weeks of age, just under 3 hours at 6 weeks, and then decrease to ~1 hour by 12 weeks.
- Normal crying, like colic, tends to occur predominantly in the evening and can vary from day to day.
- Prolonged or excessive crying from physical causes:
- Faulty feeding techniques: Overfeeding or underfeeding and inadequate burping or sucking
- Physical problems in the infant: Acute disorders such as otitis media, intestinal cramping with diarrhea, corneal abrasion, and incarcerated hernia; or chronic ones such as gastroesophageal reflux
- Cow’s milk allergy, lactose intolerance, or transmission of irritating substances such as caffeine via breast milk
Colic - TREATMENT
Colic - general measures
- The most effective form of treatment at present is counseling the parents about the interaction.
- Main points:
- The infant is not sick.
- Crying may be persistent, but there is no evidence of a physical problem.
- There is no proof the infant is having pain, just distress. Avoid iatrogenic problems caused by suggesting that something is wrong with the infant.
- The infant is probably overaroused and tired.
- Education about infant crying.
- Parents need to know how much normal infants cry and how they vary in sensitivity, irritability, and soothability.
- The way parents react to their infants can affect the amount of crying.
- Parents often do not understand that a common reason for infant crying is fatigue and a need to be left alone.
- The excessive crying can be reduced.
- Parents have to learn to tune in more sensitively to infants’ needs and to be more appropriately and effectively responsive to them.
- Basic strategy:
- Soothe more, as by a pacifier, repetitive sound, swaddling, swinging, or a hot water bottle, and stimulate less by decreasing the picking up, holding, and feeding the infant when it is not appropriate.
- Contrary to popular opinion, there is no evidence that there is a better behavioral outcome at the present or later from the parents’ always responding immediately to every cry.
- A quiet environment, correction of any faulty feeding techniques, and a minimum of unnecessary handling without changing the composition of the feedings. Pertinent psychosocial issues should be dealt with.
- Expression of optimism by the pediatrician about the immediate outcome is justified and in itself improves chances of success. Simply saying that the colic will be gone by 3–4 months of age is not comforting and may be quite the opposite.
- Extra carrying does not help.
- Drugs, such as phenobarbital or diphenhydramine, are seldom necessary.
- Some observers have reported beneficial effects when used for 1 or 2 weeks in conjunction with counseling, but these results have not as yet been subjected to double-blind studies.
- Simethicone has not been shown to be helpful. Herbal teas should not be recommended because of their varied and often unknown contents.
- Formula changes are frequently attempted by physicians hoping for a simple solution, but they rarely are effective. Sometimes they seem to be helpful for a few days, only to cease being so soon after that.
- Almost any procedure done with conviction is likely to be followed by a temporary reduction in crying because of the placebo effect.
- The normal trend toward diminished crying over time has given some forms of treatment an undeserved reputation of effectiveness.
Colic - FOLLOW UP
Colic - prognosis
Without intervention, this prolonged crying usually diminishes somewhere around 3–4 months. Some recent studies have reported a variety of possible long-term outcomes such as continued aversive temperaments, more behavior problems, and diminished parental self-confidence. More investigations with attention to methodologic details are needed to clarify these matters. Particularly deserving attention is the possible pathogenic role of the physician in incorrectly informing the parents that there is something physically wrong with the infant.
Colic - complications
- Excessive crying does not turn into any other condition, but the factors that caused it may contribute to sleep problems and other behavioral concerns in the infant after the colic has gone.
- Parents are usually exasperated by it.
- The most serious outcome is that, owing to parental exasperation, the infant may be physically abused.
- The infant is likely to be overfed.
Colic - patient monitoring
- It is important to keep in close touch with parents of an excessively fussy baby. Telephone contact every 2–3 days is essential until improvement. Re-examination is rarely needed.
- Standard pediatric textbooks state that little can be done to change the pattern. However, several studies report that colic can be sharply reduced within 2–3 days if management such as that described above is used. Some infants take longer, but virtually all respond to suitable management.
Colic - bibliography
- Blum, NJ, Taubman B, Ttretina LL, et al.: Maternal ratings of infant intensity and distractibility. Arch Pediatr Adolesc Med. 2002;156:286–290.
Carey WB. “Colic”: Prolonged or excessive crying in young infants. In: Cara We, Crocker AC, ColBman WL, et al. eds. Developmental-Behavioral Pediatrics. 4th ed. Philadelphia: WB Saunders; 2008.- Carey WB. The effectiveness of parent counseling in managing colic. Pediatrics. 1994;94:333–334.
Lester BM, Barr RG. Colic and Excessive Crying. 105th Ross Conference on Pediatric Research. Columbus, OH: Ross Products Division, Abbott Laboratories; 1997.St. James-Roberts I. Summary: What do we know? What are the implications of the findings for practitioners? What do we need to know? In: Barr RG, St. James-Roberts I, Keefe MR, eds. New Evidence on Unexplained Early Infant Crying: Its Origins, Nature and Management. Skillman, NJ: Johnson & Johnson Pediatric Institute; 2001: 327–333.- Van ijzendoorn MH, Hubbard FOA. Are infant crying and maternal responsiveness during the first year related to infant-mother attachment at 15 months? Signal. Newsletter World Asso Infant Ment Health. 2001;Jan-Jun:1–12.
- Wessel MA, Cobb JC, Jackson EB, et al. Paroxysmal fussing in infants, sometimes called “colic.” Pediatrics. 1954;14:421–434.
Colic - CODES
Colic - icd9
780.92 Excessive crying of infant (baby)
Colic - FAQ
- Q: What is wrong with my baby? What can we do to relieve the pain? Why is he/she so gassy? How do you know that it is not due to an allergy? Shouldn’t we strengthen the formula? You mean it’s all my fault? Will this ever stop? What will he/she be like later?
- A: All the answers are to be found above.
Book Source Details
- Book Title: The 5-Minute Pediatric Consult
- Author(s): M. William Schwartz MD; et al.
- Year of Publication: 2008
- Copyright Details: The 5-Minute Pediatric Consult, Copyright © 2008 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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More About This Book:
Title: The 5-Minute Pediatric Consult
Authors: M. William Schwartz MD; et al.
Publisher: Lippincott Williams & Wilkins
Copyright: 2008
ISBN: 0-7817-7577-9
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