Patient information: Colic (excessive crying) in infants

COLIC OVERVIEW

Colic is the term is used to describe infants who cry excessively for no apparent reason during the first three months of life. Colic is one of the most distressing problems of infancy. It is distressing for the infant, the parents, and for the healthcare provider. The cause of colic is not well understood, but it resolves in most infants by 3 to 4 months of age. Nonetheless, many parents need reassurance and support to get through this difficult stage of an infant's life.

COLIC DEFINITIONS

A child with colic usually cries for more than three hours per day, more than three days per week, for more than three weeks.

Colic occurs in 8 to 40 percent of all infants. It occurs with equal frequency in the following groups:

• Males and females
• Breast- and bottle-fed infants
• Full-term and preterm infants
• The first and second child (and other siblings as well)

Normal crying patterns — All infants cry more during the first three months of life than during any other time. There is no standard definition for "excessive" crying, although it is normal for infants to cry for up to two hours per day. Infants without colic cry, although generally less frequently and for a shorter time than infants with colic.

Colic — Colic may include more than excessive crying, at least in some infants.

• Onset — Each episode of colic has a clear beginning and end, and the onset is unrelated to what was happening before the episode started; the infant may have been happy, fussy, feeding, or even sleeping. The crying episode begins suddenly and often occurs in the evening hours.
• Differs from normal crying - Colic episodes are more intense, louder, and higher pitched than "normal" crying. Infants with colic may sound as if they are in pain or are screaming.
• Increased muscle tone - Infants with colic may have physical symptoms (table 1).
• Difficult to soothe - Infants with colic are difficult or impossible to soothe, no matter what the parents do. There may be periods of quiet, but infants often remain fussy. Crying may end after the infant passes gas or a bowel movement.

For all infants, colic is a temporary problem. It resolves by three months of age in 60 percent of infants and by nine months in 90 percent of infants.

OTHER CAUSES OF EXCESSIVE CRYING

There are a number of reasons, other than colic, that an infant may cry excessively; these can range from simple problems such as hunger to more serious problems such as infection. A list of these is included in the table (table 2).

A parent should first check for manageable causes of crying:

• Hunger — Try feeding the baby to see whether hunger is the problem. Although most young infants (younger than 3 months) feed every two to four hours, all babies go through periods when they will want to feed more frequently (usually during growth spurts).
• Pain — Check to see if the baby is uncomfortable because of illness or physical injury. Feel the skin to determine if the baby is overheated or too cold. Check to see if the clothing or diaper is too tight or if a hair is wrapped around a finger, toe, or the penis (called a hair tourniquet).
• Fatigue or overstimulation — Babies often cry when they become tired or overstimulated from playing or being handled. Swaddling the baby snugly (figure 1), offering a pacifier, or a change of scene (such as a stroller or car ride) may help the baby to fall asleep.
• Food sensitivities — Infants can have an allergy or sensitivity to foods in their mother's diet or a component of their formula. Foods such as milk, eggs, nuts, and wheat in a mother's diet have a direct effect on the composition of her breastmilk; these foods can occasionally cause food reactions and digestive problems such as abdominal pain, cramping, and diarrhea. Formula-fed infants can be sensitive or allergic to a protein in cow's milk-based formulas. Lactose (a type of sugar found in cow's milk) intolerance has little to no effect on the development of colic.

Food sensitivities may be suspected if an infant cries or spits up a large amount within an hour of feeding or if a baby has constipation or diarrhea. Symptoms of cow's milk allergy include eczema, wheezing, diarrhea, or vomiting. (See "Patient information: Gastroesophageal reflux in infants".)

If these causes have been eliminated and the baby continues to cry excessively, parents should speak with their healthcare provider. Most infants who cry excessively do not have a serious underlying medical problem; a healthcare provider can help to make this determination. (See 'When to seek help' below.)

COLIC DIAGNOSIS

The diagnosis of colic is often made after it has run its typical three- to four-month course. If you are concerned about your infant's crying, call your child's doctor or nurse to discuss your concerns and possible management strategies.

Home monitoring — You can monitor your infant's crying by keeping a written record of the following information. You can share this information with your child's doctor or nurse to help determine the cause of crying as well as the best ways to manage it.

• When does crying occur and how long does it last? Crying that occurs directly after feeding may be caused by gastroesophageal reflux (heartburn) or swallowed air. (See "Patient information: Gastroesophageal reflux in infants".)

• Does the crying begin at the same time every day? Does the infant cry at other times of the day?
• What seems to trigger an episode of crying? What helps to stop crying?
• What do you do when the baby cries? You can hurt your child if you yell, shake, or hit.
• What does the cry sound like? Infants with colic often have a higher pitched, louder, and more intense sounding cry.
• How and what do you feed the baby? As mentioned above, overfeeding, underfeeding, and feeding inappropriate foods can cause colic.
• Is the crying getting better, worse, or is it about the same?
• How do you feel when the baby cries? Lving with a colicky infant is hard; some parents feel overwhelmed and incapable of caring for their infant, while others blame the infant for being difficult.
• How has colic affected your family? Colic affects all members of a household, and it is important to consider input from everyone.
• Why do you think the baby cries? Discuss your thoughts and concerns about your infant with your child's doctor or nurse.

COLIC MYTHS AND FACTS

There are a number of myths about the causes and treatments of colic. Myths often develop to explain problems that are not well understood. You can learn to separate myths from facts through education and support from respected sources, including healthcare providers.

• Babies do not cry to manipulate you.
• It is not possible to spoil a baby by holding or comforting them.
• Rice cereal does not improve colic. Infants should be given only breast milk or formula until they are 6 months old, unless told otherwise by a healthcare provider. (See "Patient information: Starting solid foods during infancy".)

• Studies show that simethicone (Mylicon®) and lactase (the enzyme that helps to digest lactose, the sugar in milk) do not help with colic.
• Sedatives, antihistamines (diphenhydramine [Benadryl®]), and motion-sickness medications (dicyclomine [Bentyl®]) are not safe or effective for colic. Dicyclomine can temporarily stop breathing or cause seizures or coma.

COLIC MANAGEMENT

The goals of treatment for colic are to decrease the infant's crying, help your family cope, and prevent long-term difficulties in your family's relationships. Many doctors recommend trying several strategies at once (table 3).

Parental support — Parents of infants with colic often feel frustrated, angry, exhausted, guilty, and helpless because of their child's crying. These feelings are normal, and do not indicate that you are incapable or unworthy of caring for your child.

Take a break — It is normal for you to need a break from a child who cries excessively. If you are alone and need a break, leave the infant in a safe place for a few minutes; the infant should be placed on his or her back in a crib or bassinet with side rails. Loose blankets, pillows, and toys that could potentially suffocate the child should be removed.

Single parents can get support and information from Parents Without Partners (www.parentswithoutpartners.org).

Taking a break allows you to call a friend or relative for help, get away from the crying, and can prevent you from potentially harming your child. Shaking, smothering, or slapping will not stop an infant's crying but can seriously injure or even kill the child. In the United States you can call 24 hours a day, 7 days a week and speak with a professional counselor at 1-800-4-A-CHILD (422-4453).

Shaken baby syndrome is the term used to describe the injuries suffered by infants who are violently shaken, often by a parent or other adult, who has become overwhelmed by excessive crying. Infants do not have sufficient strength in their neck to limit head movement, and shaking causes the head to move suddenly and uncontrollably. As the head moves backwards and forwards, the brain hits the inside of the skull, causing serious damage and even death. (See "Patient information: Head injury in children and adolescents".)

Dietary and feeding technique changes

Bottle-fed infants — A number of devices (nipples, bottles) have been designed to decrease the amount of air swallowed during feeding. You may try positioning your infant in a vertical (sitting up) position while feeding. You may also try a curved bottle or collapsible bag, in combination with frequent burping. These techniques can reduce the amount of air swallowed, which may reduce colic in some infants.

Some studies suggest that infants with colic improve when their formula is switched to a soy-based or hypoallergenic formula. However, the results of these studies are inconclusive. Consult with your infant's doctor or nurse to determine if a formula change might be helpful.

Some doctors suggest a trial of a different formula for one week (for bottle-fed infants). The original formula should be restarted if there is no change; low allergy (hypoallergenic) and soy-based formulas are more expensive than traditional formula and do not need to be continued if crying does not improve after a one-week trial of the new formula.

Breast-fed infants — Mothers who breastfeed may try consuming a hypoallergenic diet to reduce their infant's colic. A hypoallergenic diet eliminates potentially aggravating food groups, including milk, eggs, nuts, and wheat.

To try a hypoallergenic diet, stop eating a single food group for a one-week trial period while you monitor the infant's crying. You can restart the food if you do not see improvement. This type of diet appears to be more effective for infants whose mothers have eczema, asthma, or allergic rhinitis, or if the infant has symptoms of cow's milk allergy (including eczema, wheezing, diarrhea, or vomiting). There is some evidence that having an infant empty one breast completely before switching sides may reduce colic.

There is no evidence that stopping breastfeeding and starting formula is of any benefit in babies who have colic. There are a number of benefits to breastfeeding and breast milk that are not available with formula. (See "Patient information: Deciding to breastfeed".)

Carrying — Some parents find that carrying their infant in their arms, a sling, or a front carrier can decrease the infant's and parents' anxiety. Although studies have not proven carrying to be effective for all infants, it is worth trying if your infant has not responded to other treatments. Using a sling or front carrier frees your hands and arms and allows you to move around while monitoring your infant.

Change in environment — There are many other techniques that may help to reduce crying: a pacifier, ride in the car, change of scenery, infant swing, and warm baths have been suggested and may help to soothe an infant with colic.

Limiting the infant's movement swaddling (figure 1) may be soothing. Placing the infant near a white noise machine or clothes drier may soothe an infant who is sensitive to noise.

Herbal remedies — Herbs such as chamomile, fennel seed, and balm-mint are thought to have anti-spasmodic properties and have been used in infants with colic. Although a few studies have shown improvement in infants given a tea made with a specific mix of herbs, parents should be cautious about trying this type of treatment.

Gripe water is a mixture of herbs, primarily dill, and water that has been promoted for its ability to cure colic. However, various types of gripe water have been found to contain dangerous ingredients, including glass particles and alcohol. A homeopathic remedy, colocynthis (found in cocyntal and Hyland® colic tablets), is unlikely to cause harm, but has not been proven to be effective for treatment of colic.

Talk to your doctor or nurse BEFORE giving your infant any herbal remedy; herbal remedies may not be appropriate and could be dangerous in some cases.

Infant massage — Infant massage has been recommended to parents of infants with colic, although no studies have proven it to be of clear benefit. A full description of infant massage can be found at the La Leche League Web site, www.lalecheleague.org (search for "massage for colic").

WHEN TO SEEK HELP

Call your child's doctor or nurse during the day or night if any of the following occur:

• The baby has cried for more than two hours
• The parent is afraid he or she may hurt the baby, or if the parent has shaken the baby
• If crying could be the result of an injury or fall
• The baby has a fever of ≥100.4ºF (38ºC). Parents should call their infant's healthcare provider or go to an emergency department immediately. Table 4 describes how to take a child's temperature (table 4). (See "Patient information: Fever in children".)

• The infant refuses to eat or drink anything for more than a few hours, vomits excessively, has bloody stools, or has a change in behavior, including lethargy or decreased responsiveness

A parent should call their child's healthcare provider's office during normal office hours if any of the following occur:

• You cannot soothe your baby's crying or you have questions or concerns about how to manage your crying baby
• Excessive crying continues after the infant is older than 4 months
• The infant fails to gain weight

LONG-TERM OUTCOMES OF COLIC

Colic can take a toll on families. Some researchers have suggested that colic interferes with child-parent interactions and can have a long-term effect on the family and child.

Long-term studies have examined the possible relationships between colic and later childhood, including temperament, sleep patterns, family functioning, asthma, and cognitive development. However, no significant relationship between colic and these features of later childhood have been proven.

WHERE TO GET MORE INFORMATION

Your child's healthcare provider is the best source of information for questions and concerns related to your child's medical problem. Because no two people are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your child's situation.

This discussion will be updated as needed every four months on our web site (www.uptodate.com/patients). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.

Some of the most pertinent include:

Patient Level Information:
Patient information: Gastroesophageal reflux in infants
Patient information: Starting solid foods during infancy
Patient information: Head injury in children and adolescents
Patient information: Deciding to breastfeed
Patient information: Fever in children

Professional Level Information:
Clinical features and etiology of colic
Evaluation and management of colic

A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable.

• National Library of Medicine

      (www.nlm.nih.gov/medlineplus/healthtopics.html)

• American Academy of Pediatrics

      (www.aap.org)

• American Academy of Family Physicians

       (www.familydoctor.org)

• The Nemours Foundation

     (http://kidshealth.org/parent/growth/growing/colic.html)

• The Mayo Clinic

     (www.mayoclinic.com)

We are saddened by the untimely death of Steven Parker, MD, who passed away in April. UpToDate wishes to acknowledge Dr. Parker's many contributions to developmental and behavioral medicine and, in particular, his work as our co-section editor for developmental and behavioral pediatrics.

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