Colic (infantile) 

• Key points
  • Crying is normal physiological behaviour in young infants
  • With typical history and normal examination, no investigations are required
  • Parental education and close follow-up are vital to managing the unsettled or crying infant
  • Excessive crying is associated with higher rates of parental post-natal depression 
• Background
  • At 6–8 weeks age, a baby cries on average 2-3 hours per 24 hours. 
  • “Colic” is an out-dated term used to describe excessive crying.
  •  The parents are often distressed, exhausted, and confused and often have received conflicting advice.                                                                                                                          
• Assessment
  • Clinical characteristics of normal crying
    • Increases in the early weeks of life and peaks around 6-8 weeks of age and usually improves by 3-4 months of age
    • Usually worse in late afternoon or evening but may occur at any time
    • May last several hours
    • Infant may draw up legs as if in pain, but there is no good evidence that this is due to intestinal problems
  • Red flags
    • Sudden onset of irritability and crying
    • Parental post-natal depression (PND) may be a factor in presentation
    • Excessive crying is a strong risk factor for abusive head trauma (previously known as shaken baby syndrome)
  • Consider if crying is acute onset
    • Raised intracranial pressure (ICP)
    • Injury eg clavicle fracture, non-accidental injury
    • Incarcerated inguinal hernia  
    • Urinary tract infection
    • Hair tourniquet
    • Corneal foreign body/abrasion 
• Common non-pathological causes of crying
  • Excessive tiredness — consider if the infant’s total sleep duration per 24 hours falls more than an hour short of the “average” for their age
    • Average sleep requirements:
      • at birth: 16 hours
      • at 2–3 months: 15 hours
      • a 6 week old baby generally becomes tired after being awake for 1.5 hours
      • a 3 month old baby generally becomes tired after being awake for 2 hours 
    • Hunger — more likely if there is poor weight gain   

Differential diagnoses to consider

• • Non-IgE cow milk / soy protein allergy 
    • Both can be found in human breast milk if in the mother’s diet
    • Goat milk protein is as allergenic as cow milk protein
    • Suspect if there is:
      • significant feeding problems that persist day and night
      • frequent vomiting
      • diarrhoea with blood or mucus
      • poor weight gain
      • wide-spread eczema
    • Clinical diagnosis by trialing eliminating cow / soy milk for 2 weeks:
      • modifying the mother’s diet 
      • or changing to an extensively hydrolysed formula (requires paediatrician consultation) 
      • and requires resolution of symptoms or re-emergence of symptoms on rechallenge
  • Lactose overload / malabsorption   
    • Consider lactose overload if infant has very frequent breastfeeds and frothy, watery diarrhoea with perianal excoriation 
    • Primary lactose intolerance is extremely rare
  • Gastro-oesophageal reflux disease (GORD) 
    • No causal relationship between gastro-oesophageal reflux (GOR) and infant crying and irritability has been demonstrated
    • Gastro-oesophageal reflux disease is rare
    • Proton pump inhibitors have been shown to be ineffective in reducing crying 

Acute management

• 

Investigations

• If the history is typical and examination normal, no investigations are required

Management

• Exclude medical cause
  • Parental education and reassurance. It is often helpful to explain to caregivers the potential causes of crying that have been excluded and the reasons for excluding each condition
• Assess parental emotional state and mother-baby relationship:
  • invite the parent/s to talk about how stressful it is to care for a baby who cries persistently
  • ascertain whether the parent is worried that she/he is depressed
  • screen for postnatal depression using the Edinburgh Postnatal Depression Scale

Parental Education

• Most importantly, listen to parents and validate their concerns.
• If you have an infant who is happily vomiting and is growing well, provide reassurance to parents that their baby is physically healthy and a ‘happy chucker’.
• For infants who are crying and irritable
  • discuss normal sleep and crying patterns (PURPLE Crying Curve, below)
  • baby could be ‘physically healthy, but a high crier’; and settling techniques

• Engage in a partnership with the parent/s
  • This includes acknowledging their concerns
  • taking time to observe the baby-parent interactions and offering follow-up
  • Observing the baby feed is helpful for parents who are concerned about their baby’s feeding

• Explain normal crying and sleep patterns
  • Use the normal crying curve to explain the natural history of infant crying (taken from Purple Crying – see parent information below)
  • Use a sleep/cry diary to explain the infant’s cry/sleep/feeding patterns
  • Encourage parents to recognise signs of tiredness (frowning, clenched hands, jerking arms or legs, crying, grizzling) 

• Assist parents to help their baby deal with discomfort and distress
  • Establish pattern to feeding/settling/sleep
  • Aim to settle the baby for daytime naps and night-time sleep in a predictable way (eg, quiet play, move to the bedroom, wrap the baby, give the baby a brief cuddle, then settle in the cot while still awake)
  • Avoid excessive stimulation – noise, light, handling. Excessive quiet should also be avoided. Most babies find a low level of background noise soothing.
  • Darken the bedroom for daytime sleeps
  • Carry baby in a papoose in front of the chest
  • Baby massage/rocking/patting
  • Gentle music
  • Respond before baby is too worked up
  • Give the primary carer permission to rest once a day without the need to carry out household chores. Have somebody else care for the baby for brief periods to give the parent/s a break
  • Provide printed information as parents are unlikely to remember much given their state of mind at the time

• Medications and other treatment options
  • Medication is not indicated, this includes:
    • Anti-reflux medications — ineffective in reducing crying compared with placebo
    • Anticholinergic medications — due to risk of serious adverse events eg apnoeas, seizures
    • Colic mixtures (eg gripe water) – no proven benefit
    • Simethicone (eg Infacol™) – no effect on crying compared with placebo
    • There is limited evidence to support probiotic use
      • Only in exclusively breastfed infants under 3 months, the probiotic Lactobacillus reuteri DSM17938 (BioGaia™) has been shown to be effective with excessive crying (colic)
      • To be given as 5 drops per day orally to the infant for 21 days only
      • It should not be given to formula-fed infants
      • The probiotic has not been shown to be effective in both breastfed and formula-fed infants in Victoria, Australia
      • Probiotic effects are strain-specific; Lactobacillus reuteri DSM17938 is the only probiotic strain with some evidence of efficacy in exclusively breastfed infants with excessive crying (colic)
      • Formula changes are usually not helpful unless there is proven cow milk allergy. Weaning from breast milk has no benefit
    • Spinal manipulation is not indicated and has associated risks 
• Consider consultation with local paediatric team when
  • Medical cause of crying identified or suspected
  • Baby clinically unwell   
  • Admission to hospital — if infant considered at risk of non-accidental injury or parental exhaustion