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Colic, Infantile

Basics

  • Defined as excessive crying (>3 hr/day, >3 days/week, >3 weeks) in healthy infants.
  • Wessel criteria (“Rule of Three”) and Rome IV criteria used clinically.
  • Peaks around 6 weeks of life, usually resolves by 3-5 months.
  • Equal prevalence by sex, feeding type, birth order.

Epidemiology

  • Common between 2 weeks and 4 months.
  • Affects approximately 10-25% of infants.
  • May be more prevalent in industrialized countries and white infants.

Etiology & Pathophysiology

  • Unknown exact cause; multifactorial:
  • Gastroesophageal reflux
  • Milk protein or lactose intolerance
  • Intestinal immaturity and carbohydrate malabsorption causing gas and distension
  • Altered gut microbiota
  • Air swallowing, feeding practices (over/underfeeding)
  • Parental anxiety, family stress, and parent-infant interaction mismatch
  • Environmental stimuli hypersensitivity
  • Increased gut motilin levels causing hyperperistalsis
  • Tobacco smoke/nicotine exposure
  • Possible early childhood migraine manifestation

Risk Factors

  • Maternal smoking or nicotine exposure during pregnancy.
  • Maternal history of migraines doubles infant’s colic risk.
  • No definitive infant physiological risk factors identified.

General Prevention

  • No established preventive measures.

Diagnosis

History

  • Evaluate crying pattern per Wessel or Rome IV criteria.
  • Episodes usually afternoon/evening, spontaneous, and distinct from normal crying.
  • Associated features: facial flushing, pallor, tense abdomen, back arching, limb tension.
  • Infant difficult to console during episodes but otherwise normal.

Physical Exam

  • Normal comprehensive exam.
  • Rule out signs of abuse (shaken baby syndrome).

Differential Diagnosis

  • Infectious: meningitis, otitis media, thrush, UTI.
  • Feeding issues: tongue-tie, inadequate feeding.
  • GI: reflux, intussusception, constipation, anal fissure, hernia.
  • Trauma or abuse.

Diagnostic Tests

  • Clinical diagnosis.
  • Tests only if other pathology suspected (e.g., UTI, failure to thrive).

Treatment

General Measures

  • Soothing techniques: holding, rocking, pacifier, rhythmic motion (swing, stroller), white noise.
  • Warm baths.
  • 5 S’s approach: Swaddling, Side/stomach position, Shushing, Swinging, Sucking.
  • Encourage calm demeanor in caregivers.
  • Frequent burping not clearly beneficial.
  • Avoid crib vibrators or similar devices.

Medications

  • No universally effective medication.
  • Probiotics may reduce crying in breastfed infants (Lactobacillus reuteri DSM 17938, Bifidobacterium strains).
  • Avoid dicyclomine (contraindicated in infants <6 months due to severe adverse effects).
  • Simethicone, PPIs, H2 blockers not effective.

Referral

  • Refer if poor weight gain, excessive vomiting, respiratory issues, or bloody stools.

Complementary & Alternative Medicine

  • Probiotics with some evidence in breastfed infants.
  • White noise and car ride simulations may help.
  • Herbal teas (chamomile, fennel) show limited evidence.
  • Music may be beneficial.
  • Massage, chiropractic, craniosacral therapy, acupuncture not proven effective.

Ongoing Care

  • Frequent outpatient visits for reassurance and monitoring feeding/growth.
  • Support for caregiver stress and coping.

Diet

  • Breastfeeding mothers may consider eliminating milk products if infant allergic symptoms present.
  • For formula-fed infants, use of hypoallergenic formulas may be trialed if no improvement.
  • Vertical feeding position and special bottles to reduce air swallowing.

Patient Education

  • Educate caregivers that colic is not due to parenting failure.
  • Emphasize normal development and reassure about self-limited nature.
  • Encourage caregiver rest and support.
  • Provide resources and coping strategies.

Prognosis

  • Usually resolves by 3-5 months.
  • No impact on infant intelligence or long-term development.
  • Possible association with increased temper tantrums in toddlers.

Complications

  • None direct to infant.
  • Increased risk of caregiver burnout, postpartum depression, and child abuse.

Clinical Pearls:

  • Colic is a diagnosis of exclusion.
  • Use the 5 S’s soothing technique concurrently.
  • Support and reassurance of caregivers is critical.
  • Avoid medications with serious side effects (e.g., dicyclomine).
  • Probiotics may be beneficial but evidence is limited.