Infantile Colic

Aka: Infantile Colic, Colic in Infants

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II. Epidemiology

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

III. Etiology

  1. Unknown cause
  2. Two fold risk associated with maternal smokers
  3. 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)
  4. Not correlated with other studied factors
    1. Gender
    2. Gestational age
    3. Socioeconomic status
    4. Season

IV. History: Red Flags

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

V. Exam: Red Flags

  1. Consider causes of inconsolability
    1. See Inconsolable Crying in Infants
    2. Corneal Abrasion
    3. Hair Tourniquet
    4. Anal Fissure
  2. Red Flags
    1. Fever
    2. Lethargy
    3. Abdominal Distention
    4. Ecchymosis or other Trauma findings
      1. Nonaccidental Trauma (Child Abuse)

VI. Signs: Colic episode

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

VII. Diagnosis: Wessel Criteria (Rule of 3's)

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

VIII. Differential Diagnosis

  1. 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
  2. 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

IX. Management: General

  1. Describe condition to parent
  2. Explain that cause is unknown
  3. Reassurance that colic passes by age of 3-5 months
    1. Greatly improves even if it continues longer
  4. Discuss parental coping strategies
  5. 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]
  6. Have parent call or follow-up in 2 weeks
  7. 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
  8. 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]
  9. 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]

X. Management: Dietary changes

  1. 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
  2. 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]

XI. Course

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

XII. Reference

  1. Balon (1997) Am Fam Physician 55(1):235-46 [PubMed]
  2. Garrison (2000) Pediatrics 106:184-90 [PubMed]
  3. Johnson (2015) Am Fam Physician 92(7): 577-82 [PubMed]
  4. Iacovou (2012) Matern Child Health J 16(6): 1319-31 [PubMed]
  5. Lothe (1982) Pediatrics 70:7-10 [PubMed]
  6. Lucassen (2000) Pediatrics 106:1349-54 [PubMed]
  7. Lucassen (1998) BMJ 316:1563-9 [PubMed]
  8. Reijneveld (2000) Arch Dis Child 83(4):302-3 [PubMed]

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