Colic

7 Interesting Facts of Colic

  1. Colic is a common condition of infancy with a reported incidence between 5% and 20% of otherwise healthy infants aged between 3 weeks and 3 months 
  2. The symptoms of colic include excessive crying more than 3 hours per day for more than 3 days per week for longer than 3 weeks in otherwise healthy, thriving infants 
    • The intense crying has a diurnal pattern, clustering in the afternoon and/or evening; the infant appears to be in pain during paroxysms
  3. The diagnosis of colic is evident if the infant is growing well and has normal physical examination results with no evidence of an organic cause for excessive crying 
  4. A careful history and physical examination are adequate to determine if an infant has an alternate organic cause for excessive crying 
    • Fewer than 5% of infants evaluated for excessive crying have an organic cause 
    • Serious illness is unlikely in an infant with normal history and physical examination results who does not cry beyond the initial assessment 
  5. Laboratory and radiographic examinations add little to the diagnostic work-up 
  6. Treatment of colic is mainly supportive
    • Caregivers of colicky infants should receive stress-reducing techniques, support, education, and reassurance
    • No medications are effective in treating colic
      • A trial of antireflux medication is reasonable only if diagnosis of concurrent gastroesophageal reflux disease exists
    • Mothers of breastfed infants should be encouraged to continue breastfeeding and to eliminate their intake of highly allergenic foods. A brief trial on protein hydrolysate formula is reasonable 
    • A trial of protein hydrolysate formula is clearly indicated if cow’s milk allergy is suspected; mothers should eliminate soy and cow’s milk proteins from their diet
    • There is no clear evidence that probiotics are more effective than placebo at preventing infantile colic; however, daily crying time appeared to reduce with probiotic use compared with placebo 
  7. There are no known long-term adverse outcomes associated with colic

Pitfalls

  • Colic is a diagnosis of exclusion
    • It is imperative to pursue alternate diagnoses to rule out urgent causes of excessive crying if a child is truly inconsolable or ill-appearing on examination
  • A first episode of severe crying should not be easily dismissed as colic
  • Urinary tract infection can present with fussiness without fever
    • Clinicians should have a low threshold for obtaining catheterized urine in infants with continued unexplained crying
  • Fluorescein examination of the cornea should be done on afebrile infants with unexplained, persistent crying
  • Excessive crying can be the cause or result of child abuse
  • Formula changes are controversial, and data are lacking to support manipulation of formula without concern for cow’s milk/soy protein intolerance or family history of atopy and/or cow’s milk/soy protein intolerance 
  • Many drug treatments have been studied, but none have proved to be markedly effective 
  • Colic is a self-limiting behavioral disorder of infants that is characterized by excessive crying spells lasting more than 3 hours per day, at least 3 days per week, and continuing for more than 3 weeks. The paroxysmal crying spells have no known organic etiology and start around 3 weeks of age, peak at 6 weeks, and resolve by the fourth month of life 

Clinical Presentation

History

  • Colicky infants have unpredictable, spontaneous attacks of excessive crying or fussiness that typically last a few hours in the late afternoon or evening and are resistant to usual soothing techniques
    • The high-pitched, piercing, screaming spells reported are often associated with drawing up of legs to the abdomen, tight abdomen, flatulence, flushed face, furrowed brow, and clenched fists 
    • Crying spells have no discernible precipitants
  • Review of systems should not identify any of the following:
    • Changes in feeding
    • Changes in bowel habits
    • Vomiting, diarrhea, constipation, or bloody stools
    • Feeding difficulties
    • Seizure-like activity
    • Concerns for abuse
    • Apnea, cyanosis, or difficulty breathing
    • Fever
    • Central nervous system irritability
    • Abnormal weight gain and development for age
    • Family history of cow’s milk/soy protein intolerance or atopic disease (eg, eczema or wheezing)
    • History of recent immunizations
  • History of prematurity or perinatal problems increases concern about neurologic causes for the crying

Physical examination

  • Physical examination findings are normal
  • General
    • Afebrile, alert, vigorous, pink, well perfused, and possibly fussy but consolable
    • Infants in the midst of a colicky crying episode will be at least briefly consolable to feeding or gentle rocking
  • Growth parameters
    • Head circumference, length, and weight should all be normal for age on the infant’s own specific growth curve

Causes

  • There is no known etiology for colic
  • Colic is thought to be the upper end of normal developmental behavior in infants

Risk factors and/or associations

Age
  • Infants in the age range of 3 weeks to 3 months 
Other risk factors/associations
  • Situational
    • Excessive tiredness
    • Hunger
    • Overstimulation
    • Parental anxiety
    • Chaotic environment
  • More common in the following:
    • Children of older parents
    • Firstborn children
    • Families with fewer children
    • Infants of mothers with migraines 
    • Households where parents smoke 
    • Low-birth-weight infants 
    • Infants who are overfed/underfed or who have high-carbohydrate/high-fat diet
    • Infants with poor feeding technique, including poor positioning, inadequate burping, or habitual air swallowing
  • Breastfed infants may have decreased incidence of colic 

Diagnostic Procedures

Primary diagnostic tools

  • Follow history and physical examination with a period of observation for 1 to 2 hours until crying stops and child has tolerated a feeding 
    • If the crying stops spontaneously, the child may be observed at home for possible colic
    • If the crying persists, further work-up is warranted
  • Repeat vital signs with accurate temperature measurement after the period of observation and feeding trial
  • Growth assessment parameters
    • Abnormal growth parameters point to gastrointestinal, central nervous system, or infectious complications; systemic organic disease must be ruled out
  • Laboratory testing adds little to the diagnostic work-up in most patients; additional laboratory testing or imaging is indicated only with truly inconsolable infants, febrile infants, ill infants, or infants whose history or physical examination raise concerns for alternate organic etiology at presentation
    • Specific testing should be based on individual clinical signs and symptoms and concern for a specific alternate etiology
  • Colic is a diagnosis of exclusion
    • Abnormal findings such as sustained tachycardia over 220 beats per minute, fever, signs of increased intracranial pressure, tender abdomen, or bilious emesis suggest an alternative cause; appropriate urgent clinical action is required, based on clinical findings

Differential Diagnosis

Most common

  • Corneal abrasion
    • Physical examination findings can range from a normal-appearing cornea (without use of fluorescein) to an erythematous conjunctival reaction, tearing, photophobia, and refusal to open eye
    • Fussiness resolves immediately with application of a topical anesthetic
    • Fluorescein examination will reveal trauma, abrasion, and/or foreign body
  • Otitis media
    • Infection of the middle ear space can cause ear pain, poor feeding, fussiness, and fever
    • Examination will find erythematous, bulging, and immobile tympanic membrane
  • Cow’s milk/soy protein intolerance
    • Milk protein allergy is an abnormal immune reaction to the proteins in cow’s milk or soy milk. It is characterized by vomiting, diarrhea, abdominal pain, blood in stool, malabsorption, and potentially poor weight gain, which worsen with time
    • Onset of symptoms is after 1 month of life, whereas colic typically presents earlier in life
    • Family history of atopy (eg, eczema or wheezing) or milk protein allergy may be present
    • Blood in the stool is common but not required for diagnosis
    • History and physical examination will confirm diagnosis, but a brief clinical trial of elemental formula (or maternal elimination diet if infant is breastfed) is required to solidify the diagnosis
  • Gastroesophageal reflux
    • Infant gastroesophageal reflux disease is the regurgitation of feedings that is associated with other pathologic symptoms such as cough, apnea, crying after feedings, and weight loss
    • History and physical examination are usually sufficient to confirm this diagnosis
    • Esophageal pH probe or esophagogastroduodenoscopy may be needed to confirm this diagnosis
  • Constipation
    • In the case of functional constipation, hard stool will be palpable on rectal examination
    • History and physical examination are usually sufficient to confirm this diagnosis
    • If abdominal radiograph is obtained, it will show a large stool burden
  • Immunization reaction
    • Continuous crying immediately after vaccination for up to 3 hours is not uncommon; intermittent fussiness may persist for 1 to 2 days after vaccination 
      • Children with recent diphtheria and tetanus toxoids and pertussis vaccination can have an extremely painful local reaction or exhibit generalized fussiness after vaccine administration
  • Urinary tract infection
    • Infants with urinary tract infection may present with fussiness early in the illness
    • Fever (with no other source for infection), poor feeding, abdominal pain, vomiting, and possibly foul-smelling urine can develop
    • Diagnosis can be confirmed by obtaining a catheter specimen for urinalysis, microscopic examination, Gram stain, and culture
  • Tourniquet syndromes (hair/fiber)
    • Fiber or hair becomes tightly wrapped around penis, toe, finger, or external female genitalia
    • Examination will find distal swelling, tenderness, and erythema of affected area, with stark indented delineation where hair or fiber is strangling the distal aspect of the affected area
  • Pyloric stenosis
    • Pyloric stenosis is the gradual development of hypertrophied pyloric musculature resulting in gastric outlet obstruction in infants aged 3 weeks to 3 months
    • Infants are historically very hungry with worsening of forceful/projectile, nonbilious vomiting
    • Poor weight gain and failure to thrive precede clinical signs of dehydration
    • Infants with colic will not have projectile vomiting, but if diagnosis is in question, pyloric hypertrophy can be confirmed on ultrasonography
  • Sepsis/bacteremia
    • Blood-borne infection in neonates can initially present with nonspecific symptoms such as irritability and poor feeding
    • Later in the disease process, fever or hypothermia is universal and child appears ill on examination
    • Child will develop signs of poor perfusion (delayed capillary refill) if bacteremia progresses to sepsis
    • Temperature instability and ill appearance or inconsolability on examination differentiate from colic
  • Child abuse/trauma
    • Child abuse is inflicted, nonaccidental trauma
    • Historical features that are concerning for abuse include the following:
      • Any injuries that do not fit stated mechanism
      • Changing historical account of injury mechanism
      • Injuries in multiple stages of healing
      • Delay in seeking medical care
      • Injury that is inconsistent with child’s developmental capability
    • History and physical examination findings will most often point to the diagnosis of physical abuse, but they can be normal
    • Findings such as bruising, burns, oral lacerations, fractures, subdural hematomas, or retinal hemorrhages are not consistent with the diagnosis of colic
  • Intussusception
    • Intussusception is a bowel obstruction that presents in young children with lethargy, bloody stools, and vomiting
    • The pain is acute, severe, and unremitting
    • Abdominal mass can be palpable on examination. Blood may be found on rectal examination
    • History and physical examination will differentiate intussusception from colic
  • Supraventricular tachycardia
    • Supraventricular tachycardia is a narrow, complex tachycardia presenting in children
    • Young children present with fussiness and difficulty feeding and breathing
    • Supraventricular tachycardia is evident upon assessment of vital signs with a heart rate “too fast to count” and sustained heart rate greater than 220 beats per minute with no beat-to-beat variability
  • Meningitis (Related: Bacterial meningitis in children)
    • Meningitis is inflammation in the cerebrospinal fluid space; the infection in neonates can present with nonspecific symptoms such as irritability, vomiting, and poor feeding early in the disease process
    • Later in the disease process, fever, lethargy, apathy, high-pitched cry, and hypotonia develop
    • Signs of meningeal irritation, such as resistance to movement, are elicited on examination
    • A bulging fontanelle is consistent with meningitis
    • If the diagnosis is unclear from history and physical examination, a lumbar puncture with cerebrospinal fluid analysis will confirm
  • Incarcerated hernia
    • Differentiated from colic by examination findings consistent with the presence of a nonreducible inguinal mass that may extend into the scrotum in boys
  • Testicular torsion
    • Swollen, tender scrotum with absent cremasteric reflex is evident on examination
    • Ultrasonography is diagnostic, with minimal-to-absent blood flow to affected testicle

Treatment Goals

  • Decrease colic symptoms
  • Minimize social and psychological stress on the family

Disposition

Admission criteria

  • If infant is truly inconsolable and diagnosis is unclear; rarely indicated
  • Admit to a safe environment if there exist any concerns about caregivers’ ability to cope effectively with a fussy infant

Recommendations for specialist referral

  • Consult child abuse specialist for concerns about findings from history, physical examination, or work-up for nonaccidental trauma

Treatment Options

Treatment of colic is mainly supportive, using a confirm, reassure, and support model 

  • Acknowledge the difficulties of parenting a colicky infant
  • Possible adjunct treatment options are case-dependent and may include the following:
    • Teaching routine soothing techniques
    • Using antireflux medication for infants with concurrent colic and gastroesophageal reflux disease
    • Changing formula or hypoallergenic diet in breastfeeding mothers if concerns exist for cow’s milk/soy milk protein intolerance
    • Adding probiotics to infant’s diet
      • There is no clear evidence that probiotics are more effective than placebo at preventing infantile colic; however, daily crying time appeared to reduce with probiotic use compared with placebo 
      • No other dietary supplements or complimentary medicines are proven to be safe or effective in treating colic 
    • Using simethicone (historically used to treat colic without any clinically proven benefit) 
    • Avoiding overfeeding or excessive hunger
    • Avoiding overstimulation
  • Many drug treatments have been studied, but none have proved to be markedly effective 

Nondrug and supportive care

  • The main therapeutic interventions in colic include the following:
    • Educate about normal crying, sleep routine, and healthy feeding/diet
      • Dietary changes are usually not indicated unless the infant has signs of cow’s milk/soy protein intolerance 
        • Formula switching is controversial in the absence of known cow’s milk/soy protein intolerance. Some evidence does support recommending a change of diet to protein hydrolysate formula in children with colic for a 1-week trial period 
          • Switching to soy-based formula is not suggested because infants with cow’s milk protein allergy are usually also sensitive to soy milk protein base
        • A change in diet to protein hydrolysate formula or elimination of cow’s milk proteins from the mother’s diet in breastfed infants is indicated if cow’s milk/soy protein colitis is suspected 
          • The use of exclusive hypoallergenic-labeled elemental (amino acid–based) infant formulas should be limited to infants with well-defined clinical indications 
        • There is no clear evidence that probiotics are more effective than placebo at preventing infantile colic; however, daily crying time appeared to reduce with probiotic use compared with placebo 
      • Mothers who are breastfeeding should be encouraged to continue, but may consider eliminating milk, eggs, wheat, shellfish, and nuts from their diet (low-allergen diet) 
    • Reassure parents that their infant is healthy and will outgrow the fussy behavior with no long-term effects
    • Ensure parents have coping mechanisms in place until the infant grows out of the behavior
    • Discuss treatment options such as soothing techniques and the avoidance of harmful techniques (eg, gripe water)

Comorbidities

  • It has been shown that there may be problems with family functioning and communication, as well as increased parental anxiety and fatigue in families that care for colicky infants 

Complications

  • Rarely, cases of child abuse have been associated with colic 
  • Caring for an infant with colic is associated with maternal depression; however, long-term maternal mental health is not affected 

Prognosis

  • Infants with colic do not have any definitive long-term adverse outcomes in health or temperament 

Prevention

  • Parental smoking cessation can decrease the incidence of colic 

References

Barr RG: Changing our understanding of infant colic. Arch Pediatr Adolesc Med. 2002;156:1172-4

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