Colic Treatment & Management

Rule 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, shellfish) 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 or placebo, which suggests that probiotics may have a role in treatment of infantile colic. ^{[6, 15]}

In a more recent study, 167 infants with colic who were fed formula or breast milk were randomly assigned to receive either L reuteri DSM 17938 (10⁸ colony-forming units) or placebo daily for 28 days. ^[16]  No benefit was noted in babies who were exclusively fed breast milk or formula; however, a gradual improvement in colic was noted in both groups. No change was noted in fecal microbial diversity, Escherichia coli colonization or calprotectin levels in the intervention group. The largest prevention trial enrolled 589 infants, starting in their first week of life; they received L reuteri DSM 17938 or placebo for 90 days. ^[17]  A 50% reduction in crying time and regurgitation and more frequent bowel movements were noted in the L reuteri group compared with the placebo group. No differences in weight gain were noted, and no adverse events were related to the supplementation. The study concluded that L reuteri DSM 17938 at a dose of 10⁸ colony-forming units per day reduced the onset of functional GI disorder, reduced private and public cost of care, and was well tolerated and safe.

Results on the effectiveness of probiotics for the prevention and treatment of colic are thus far inconclusive, based on a 3 systematic reviews. ^{[18, 19, 20]} . Eight prevention and nine randomized, controlled trials using probiotics have been performed. Of these, 6 used Lactobacillus rhamnosus GG, 9 used L reuteri, and 2 used Bifidobacterium Lactis as a probiotic. Of those using L reuteri, 1 prevention and 6 treatment trials showed consistent benefit in breast-fed babies. A meta-analysis of these studies found that infants treated with L reuteri had a reduced risk of crying time at 14 days and 21 days compared with placebo in breast-fed babies but not in formula-fed babies; the difference was less apparent at 4 weeks, and this was based on 6 studies that involved 423 infants. ^[20]  Further studies are needed before this can be recommended as a routine therapy for colic in infants due to a lack of clarity involving its mechanism of action and its effect on long-term health. ^[21]

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. ^[22]

Evidence for the efficacy of spinal manipulation in treating infantile colic is inconclusive. Physicians should be cautious about recommending spinal manipulations in infants. ^{[23, 24]}

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.

An excellent review of various studies with nutritional supplements and other complementary medicines has recently been published. ^[25] Many of these studies have design flaws, biases, and poor descriptions of adverse effects. It is a common misconception that natural means safe. This review concludes that there may be encouraging results for fennel extract, mixed herbal tea, and sugar solutions.

More randomized control studies and rigorous methodologies need to be applied to the studies before any recommendations can be made about the use of natural supplements and nutritionals.

Commercial products, including car-ride simulators, infant swings, lambskin or sheepskin blankets, and womb-sound recordings, have not been proven effective, may not be without adverse effects, and can 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.

Dietary changes may include the following:

• 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.