eMedicine Specialties > Pediatrics: General Medicine > Gastroenterology

Colic

Updated: Oct 7, 2009

Introduction

Background

Colic is commonly described as a behavioral syndrome characterized by excessive, paroxysmal crying. Colic is most likely to occur in the evenings, and it occurs without any identifiable cause. During episodes of colic, an otherwise healthy neonate or infant aged 2 weeks to 4 months is difficult to console. They stiffen, draw up their legs, and pass flatus. Colic is one of the common reasons parents seek the advice of a pediatrician or family practitioner during their child's first 3 months of life.

The most widely used definition of colic was used by Wessel et al.¹ Their definition is based on the amount of crying (ie, paroxysms of crying lasting >3 h, occurring >3 d in any week for 3 wk).

Colic is a poorly understood phenomenon. It is equally likely to occur in both breastfed and formula-fed infants. Although potential adverse sequelae have been described, the disorder is generally believed to be self-limited and benign. Different feeding practices and crying may result in large amounts of air entering the gastric lumen, which suggests that excessive aerophagia may be associated with colic. Colonic fermentation is the second proposed source of excessive intestinal gas in infants. However, no experimental evidence supports either theory.

Increased levels of certain biochemical markers, such as motilin, alpha lactalbumin, and urinary 5-hydroxy-3-indole acetic acid (5-OH HIAA) have been associated in infants with colic. Data from one study suggested that psychosocial stress during pregnancy is associated with babies who develop colic.² Further research is needed to establish a causal relationship of these factors to colic.

Although anticholinergic drugs have proven effective, they are not recommended because of their serious adverse effects. Parental anxiety can be minimized if the physician discusses colic, offers insight on future expectations, and answers the parents' questions. Reassure the parents about the generally benign and self-limiting nature of the illness. A caring and compassionate healthcare provider remains the cornerstone in the management of colic, a problem for which effective therapy remains elusive.³

Pathophysiology

The term colic derives from the Greek word kolikos or kolon, suggesting that some disturbance is occurring in the GI tract. Researchers have also postulated nervous system, behavioral, and psychologic etiologies.

Frequency

International

Colic affects 10-30% of infants worldwide.

Mortality/Morbidity

Increased susceptibility to recurrent abdominal pain, allergic disorders and certain psychological disorders may be seen in some babies with colic in their childhood.

Sex

This condition is encountered in male and female neonates and infants with equal frequency.

Age

The colic syndrome is commonly observed in neonates and infants aged 2 weeks to 4 months.

Clinical

History

Colic remains a diagnosis of exclusion.
Crying by infants with or without colic is mostly observed in evening hours and peaks at the age of 6 weeks. The cause of this diurnal rhythm is not known. The amount of crying is not related to an infant's sex; the mother's parity; or the parents' socioeconomic status, education, or ages.
On acoustic analysis, colicky crying differs from regular crying. Compared with regular crying, colicky crying is more variable in pitch, more turbulent or dysphonic, and has a higher pitch. Mothers of infants with colic, unlike mothers of infants without colic, rate the cries as more urgent, discomforting, arousing, aversive, and irritating than usual.
Obtain a detailed history about the timing, the amount of crying, and the family's daily routine. The benign nature of colic should be emphasized.
Rule out causes of excessive crying in an infant, such as having hair in the eye, strangulated hernia, otitis, and sepsis.

Physical

Perform physical examination to confirm normalcy.
Infants with colic often have accelerated growth.
Weight gain is typical, whereas failure to thrive should make one suspicious about the diagnosis of colic.

Causes

GI causes may include but are not limited to gastroesophageal reflux, overfeeding, underfeeding, milk protein allergy, and early introduction of solids. Parental anxiety and parental stress has been a subject of many studies. Postpartum depression may lead to stress in parents, which may be transferred to the infant, resulting in excess crying.
Other causes include inexperienced parents or incomplete or no burping after feeding. Incorrect positioning after feeding may contribute to excessive crying. Note that colic is not limited to the first-born child, casting doubt on the theory about inexperienced parenting as the etiologic factor. Recent epidemiologic evidence suggests that exposure to cigarette smoke and its metabolites may be related to colic. Maternal smoking during pregnancy may be associated with colic.⁴
Some evidence has linked persistent crying in young infants to food allegy.⁵ An association between colic and cow's milk allergy (CMA) has been postulated.⁶ Data from one study suggested an association between low birth weight and increased incidence of colic.⁷
Recently, some reports have focused on intestinal microflora and its association with colic.⁸ Lower counts of intestinal lactobacilli were observed in infants with colic compared with infants without colic.⁹

Differential Diagnoses

Bronchiolitis	Otitis Media
Gastroesophageal Reflux	Pneumonia
Intussusception	Protein Intolerance
Meningitis, Aseptic	Soy Protein Intolerance
Meningitis, Bacterial

Workup

Laboratory Studies

Laboratory studies are usually not indicated in colic unless the physician suspects another condition, such as gastroesophageal reflux.
If the patient's stools are excessively watery, testing them for excess reducing substances (Clinitest) may be worthwhile. If results are positive, this may be an indication of an underlying GI problem, such as acquired (postinfectious) lactose intolerance. Stool may be tested for occult blood to rule out cow's milk allergy (CMA).
Irritability and crying may be associated with gastroesophageal reflux disease because of the pain associated with esophagitis.

Treatment

Medical Care

Ruling out common causes of crying is the first step in treating an infant with persistent crying (ie, colic).
Recommend that the parents not exhaust themselves and encourage them to consider leaving their baby with other caretakers for short respites.
Drug treatment generally has no place in the management of colic, unless the history and investigations reveal gastroesophageal reflux.
Consistent follow-up and a sympathetic physician are the cornerstones of management.
Many benign but unproven treatment modalities are available for colic.
Although GI factors do not seem to cause colic in most patients, clinicians continue to treat infants with colic based on this hypothesis.
Dicyclomine hydrochloride is an anticholinergic drug that has been proven in clinical trials to be effective in the treatment of colic. However, because of serious, although rare, adverse effects (eg, apnea, breathing difficulty, seizures, syncope), its use cannot be recommended.
Wessel and colleagues suggested an association between family and infantile tension. Some families with infants with colic may have more problems in their family structure, family functioning, and affective state, compared with families with infants without colic.
A maternal low-allergens diets (ie, low in dairy, soy, egg, peanut, wheat, shell fish) may offer relief from excessive crying in some infants.
Lactobacillus reuteri endogenous to the human GI tract was found to relieve colic symptoms in breastfed infants within one week of treatment. This was compared with simethicone, which suggests that probiotics may have a role in treatment of infantile colic.⁸ Further studies are needed before this can be recommended as a routine therapy for colic in infants.
Oral hypertonic glucose and sterile water were compared for treatment of colic in infants in a randomized trial. In the group receiving glucose, 30% had significantly less colic than the placebo group.¹⁰
Evidence for the efficacy of spinal manipulation in treating infantile colic is inconclusive. Physicians should be cautious about recommending spinal manipulations in infants.^11,12
Some psychodynamic factors may possibly play a role from the prenatal to the postnatal period. Some studies demonstrated that behavioral management was effective in reducing excessive crying. Dealing with family problems and extending help to mothers is an integral part of this management.
Commercial products, including car-ride simulators, infant swings, lambskin or sheepskin blankets, and womb-sound recordings, have not been proven effective and may be expensive.
Remind parents about the importance of feeding a hungry baby, changing wet diapers, and comforting a baby who is cold and crying as a result of these factors. Soothing music accompanied with parental attention (including eye contact, talking, touching, rocking, walking, and playing) may be effective in some infants and is never harmful.
Encourage parents to discuss their feelings and concerns with each other to obtain support. Emphasize the responsibility of the whole family in the care of a baby with colic.

Diet

Eliminate cow's milk protein only in cases of suspected intolerance to the protein (eg, positive family history, eczema, onset after the first month of life, association with other GI symptoms such as vomiting or diarrhea).
The symptoms of allergy to cow's milk protein generally start later than those of colic (mean age, 13 wk), though early onset is also well known.
In infants with suspected allergy to cow's milk protein, a protein hydrolysate formula, such as Pregestimil or Nutramigen (Mead Johnson) or Alimentum (Ross Pharmaceuticals) is indicated.
Uncommonly, amino acid–based formulas such as Neocate (Nestle) or Elecare (Ross Pharmaceuticals) may be needed to manage suspected cow's milk allergy (CMA), although evidence may be lacking for management of infants with colic. Cost and availability of such formulas also tend to be prohibitive for routine use in infants with excessive crying.
Use of soy-based formula is not recommended because many infants allergic to cow's milk protein may also develop intolerance to soy protein.

Medication

Simethicone is a nonabsorbable medication that changes the surface tension of gas bubbles, allowing them to coalesce and disperse and releasing the gas for easier expulsion. Experimental evidence does not support its use in colic.

Sedatives, such as phenobarbital, chloral hydrate, and alcohol (gripe water) should never be used, however tempting. Herbal remedies have been used in many cultures. The common ingredients include chamomilla, bitter apple, and fenugreek. Only a handful of studies of herbal products have been conducted, and additional studies of their safety and efficacy are needed.

Follow-up

Further Outpatient Care

Consistent follow-up and a sympathetic physician are the cornerstones of management in patients with colic.

Patient Education

Parental anxiety can be minimized if the physician discusses colic, offers insight on future expectations, and answers parental questions.
Reassure the parents about generally the benign and self-limiting nature of the illness.

Miscellaneous

Medicolegal Pitfalls

Colic is a common problem. The keys to the diagnosis are normal findings on physical examination in an infant gaining weight.
Do not miss potentially serious diagnoses, including the following:
- Corneal abrasion
- Hair wrapped around toes or fingers
- Strangulated hernia
- Torsion of the testis/appendix of the testis
- Bronchiolitis
- Gastroesophageal reflux
- Intussusception
- Meningitis, aseptic
- Meningitis, bacterial
- Otitis media
- Pneumonia
- Sepsis
- Urinary tract infection

References

Wessel MA, Cobb JC, Jackson EB. Paroxysmal fussing in infancy, sometimes called "colic". Pediatr. 1954;14:721.
Sondergaard C, Olsen J, Friis-Hasche. Psychological distress during pregnancy and the risk of infantile colic:a follo-up study. Acta Paediatrica. 2003;92(7):811-816. [Medline].
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Canivet CA, Ostergren PO, Jakobsson IL, Dejin-Karlsson E, Hagander BM. Infantile colic, maternal smoking and infant feeding at 5 weeks of age. Scand J Public Health. May 2008;36(3):284-91. [Medline].
Heine RG. Gastroesophageal reflux disease, colic and constipation in infants with food allergy. Curr Opin Allergy Clin Immunol. Jun 2006;6(3):220-5. [Medline].
Taubman B. Parental counseling compared with elimination of cow's milk or soy milk protein for the treatment of infant colic syndrome: a randomized trial. Pediatrics. Jun 1988;81(6):756-61. [Medline].
Sondergaard C, Skajaa E, Henriksen T B. Fetal Growth and Infantile Colic. Arch Dis Child Fetal Neonatal Ed. 2000;83:F44-F47.
[Best Evidence] Savino F, Pelle E, Palumeri E, Oggero R, Miniero R. Lactobacillus reuteri (American Type Culture Collection Strain 55730) versus simethicone in the treatment of infantile colic: a prospective randomized study. Pediatrics. Jan 2007;119(1):e124-30. [Medline].
Savino F, Cresi F, Pautasso S, et al. Intestinal microflora in breastfed colicky and non-colicky infants. Acta Paediatr. Jun 2004;93(6):825-9. [Medline].
Akcam M, Yilmaz A. Oral hypertonic glucose solution in the treatment of infantile colic. Pediatr Int. Apr 2006;48(2):125-7. [Medline].
Olafsdottir E, Forshei S, Fluge G, Markestad T. Randomised controlled trial of infantile colic treated with chiropractic spinal manipulation. Arch Dis Child. Feb 2001;84(2):138-41. [Medline].
Wiberg JM, Nordsteen J, Nilsson N. The short-term effect of spinal manipulation in the treatment of infantile colic: a randomized controlled clinical trial with a blinded observer. J Manipulative Physiol Ther. Oct 1999;22(8):517-22. [Medline].
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Forsyth BW, McCarthy PL, Leventhal JM. Problems of early infancy, formula changes, and mothers'' beliefs about their infants. J Pediatr. Jun 1985;106(6):1012-7. [Medline].
Frodi A. When Empathy Fails: Aversive Infant Crying and Child Abuse. New York, NY: Plenum Publishers; 1985:263.
[Best Evidence] Hill DJ, Roy N, Heine RG, et al. Effect of a low-allergen maternal diet on colic among breastfed infants: a randomized, controlled trial. Pediatrics. Nov 2005;116(5):e709-15. [Medline].
Kurtoglu S, Uzum K, Hallac IK. 5-Hydoxy-3-indole acetic acid levels in infantile colic:Is serotoninergic tonus responsible for this problem?. Acta paediatrica. 1997;86:764-765. [Medline].
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Pinyerd BJ. Strategies for consoling the infant with colic: fact or fiction?. J Pediatr Nurs. Dec 1992;7(6):403-11. [Medline].
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Rao MR, Brenner RA, Schisterman EF, Vik T, Mills JL. Long term cognitive development in children with prolonged crying. Arch Dis Child. Nov 2004;89(11):989-92. [Medline].
Ruiz-Contreras J, Urquia L, Bastero R. Persistent crying as predominant manifestation of sepsis in infants and newborns. Pediatr Emerg Care. Apr 1999;15(2):113-5. [Medline].
Savino F, Castagno E, Bretto R. A prospective 10-yaer study on children who had severe infantile colic. Acta Paediatrica. 2005;94 ( S 449):129-132. [Medline].
Shenassa E D, Brown Mary-Jean. Maternal Smoking and Infantile Gastrointestinal Dysregulation:The Case of Colic. Pediatr. 2004;114(4):e497-e505.
St James-Roberts I. What is distinct about infants' "colic" cries?. Arch Dis Child. Jan 1999;80(1):56-61; discussion 62. [Medline].
Weissbluth M. Colic. In: Gellis and Kagan's current pediatric therapy. 14^th ed. Philadelphia, Pa: WB Saunders.
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Keywords

colic syndrome, evening colic, infantile colic, 3-month colic, incessant crying, nonstop crying, periodic crying, episodic crying, sepsis, otitis, strangulated hernia, maternal smoking, cow's milk allergy, CMA, treatment, diagnosis

Contributor Information and Disclosures

Author

Prashant G Deshpande, MD, Attending Pediatrician, Department of Pediatrics, Christ Hospital Medical Center and Hope Children's Hospital, Oak Lawn, Illinois; Chairman, Department of Pediatrics, Palos Community Hospital, Palos Heights, Illinois; Assistant Clinical Professor Of Pediatrics, University Of Illinois at Chicago
Prashant G Deshpande, MD is a member of the following medical societies: American Academy of Pediatrics and American Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Chris A Liacouras, MD, Director of Pediatric Endoscopy, Department of Pediatrics, Division of Gastroenterology and Nutrition, Associate Professor, Children's Hospital of Philadelphia and University of Pennsylvania
Chris A Liacouras, MD is a member of the following medical societies: American Gastroenterological Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Stefano Guandalini, MD, Director, University of Chicago Celiac Disease Program, Section Chief of Gastroenterology, Hepatology and Nutrition; Professor, Department of Pediatrics, University of Chicago Comer Children's Hospital
Stefano Guandalini, MD is a member of the following medical societies: American Gastroenterological Association, European Society for Paediatric Gastroenterology, Hepatology & Nutrition, and North American Society for Pediatric Gastroenterology and Nutrition
Disclosure: Nothing to disclose.

CME Editor

Steven M Schwarz, MD, FAAP, FACN, AGAF, Professor of Pediatrics, Children's Hospital at Downstate, SUNY-Downstate Medical Center
Steven M Schwarz, MD, FAAP, FACN, AGAF is a member of the following medical societies: American Academy of Pediatrics, American College of Nutrition, American College of Physician Executives, American Gastroenterological Association, American Pediatric Society, Gastroenterology Research Group, New York Academy of Medicine, North American Society for Pediatric Gastroenterology and Nutrition, and Society for Pediatric Research
Disclosure: TAP Pharmaceuticals Honoraria Speaking and teaching; Curemark, LLC Consulting fee Board membership; Centocor, Inc. Grant/research funds Independent contractor

Chief Editor

Carmen Cuffari, MD, Associate Professor, Department of Pediatrics, Division of Gastroenterology/Nutrition, Johns Hopkins University School of Medicine
Carmen Cuffari, MD is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, North American Society for Pediatric Gastroenterology, Hepatology and Nutrition, and Royal College of Physicians and Surgeons of Canada
Disclosure: Nothing to disclose.

Further Reading