About the author: This article was written by Samuel Nurko MD, MPH, Associate Professor of Paediatrics, Havard Medical School & Director of the Centre of Motility and Functional Gastrointestinal Disorders, Children’s Hospital Boston, USA
Proceedings from Danone Scientific Symposium: Functional gastrointestinal disorders and common nutritional deficiencies in early childhood, Munich, 2010
Opinions expressed by the author are not necessarily those of the publisher or editorial staff
Colic or excessive crying is one of the most frequent problems presented to paediatricians by new parents. It affects 16 to 26% of newborns in the first three months of life, and it remains a frustrating problem for both parents and caregivers. Infantile colic is a syndrome characterised by paroxysmal, excessive and inconsolable crying without identifiable cause in an otherwise healthy infant during the first three to four months of life and can be alarming and stressful for parents. Whilst most clinical intervention studies define infantile colic according to Wessel’s rule of threes (more than 3 hours per day on more than 3 days per week for more than 3 weeks), using 24 hour cry diaries in practice, most providers rely on parental reports to define crying as excessive. Although excessive crying in many infants in population-based studies tends to resolve spontaneously within the first three months of life, a sub-group of infants show persistent colic symptoms after three months of age.
The etiology of infantile colic remains unclear. Many paediatricians view persistent crying predominantly as a transient developmental problem. Infantile colic has been attributed to infants’ difficult temperament, inadequate or inappropriate mother-infant interaction or mothers’ anxiety, abnormal gastrointestinal function, or allergic problems. The main causes suggested in the literature are cows’ milk allergy, abnormal colonic micro flora, increased infant responsiveness, difficult infant temperament, disturbed infant–parent interaction and maternal and paternal depression. It has also been suggested that infantile colic merely represents the extreme end of the normal spectrum of infantile crying behaviour. Recent studies also indicate that exposure of the child to tobacco smoking by the mother during pregnancy and after delivery, and smoking by the father were associated with excessive crying. Maternal and paternal depressions have alsobeen associated with infant colic. The maternal and paternal influence on colic can be seen by a recent study of 104 children that showed that infants with severe and persistent excessive crying of infancy almost invariably show normal sleeping, feeding and crying behaviour when admitted to the hospital.
There is an extensive differential diagnosis of organic disorders that may present as colic, including central nervous system problems, GI pathology, infections, trauma, musculoskeletal and other problems (corneal abrasion). However most infants with colic do not require any testing, and it has been shown that history and examination are the most important predictor of organic pathology. In a recent review of 237 patients that presented with severe colic to an emergency room, 12 (5.1%) children had serious underlying etiologies with urinary tract infections being most prevalent. History and/or examination suggested an etiology in 66.3% of cases.
Treatments Based on the proposed etiopathogenesis of colic multiple treatments have been considered. Treatment often focuses on reassuring the parents as well as helping them to develop a predictable feeding and sleep routine for their infant. There are some effective interventions that have been described. The main treatments available are dietary, behavioural and pharmacological, although few have had rigorous scientific evaluation in the form of randomised controlled trials. One of the main problems in studying this population is the fact that there tends to be a symptomatic improvement with time, so it may be difficult to establish the difference between a time effect and a specific intervention.
Dietary treatments Cows’ milk protein allergy - Multiple trials have studied the effect of eliminating cows’ milk protein. Hypoallergenic formulas with or without the addition of other nutritional components like prebiotics have been shown to produce a significant improvement in clinical scores when compared with placebo. The effect of soya has not been consistent, lowering the lactose content of the formula has had no effect, nor did the enrichment of the formula with fibre. Conflicting results data regarding utilisation of hypoallergenic diets by breastfeeding mothers have been published, but suggest that there may be some therapeutic benefit.
Other dietary and naturopathic interventions The administration of herbal tea has also been shown to decrease crying in colicky infants. A randomised controlled trial (RCT) found that, at seven days, herbal tea eliminated colic in more infants than placebo. Hypoallergenic formulas with added prebiotics have also found to be effective in the treatment of colic. However, it is not clear if those modified formulas are more effective than regular hypoallergenic formulas, as no randomised trials comparing hypoallergenic formulas with or without prebiotics are available. Sucrose has been found to be effective in some randomised trials, particularly in breastfed infants but the response seems to be very short lived. The role of intestinal micro flora has been growing in importance and lower counts of intestinal lactobacilli have been observed in colicky infants, in comparison with infants with no colic. Since then a randomised trial in breastfed infants with colic showed that supplementation with lactobacillus was more effective than simethicone.
Pharmacologic There are no specific pharmacologic interventions. Among the RCTs dealing with pharmaceutical interventions for infant colic, 3 studied simethicone, 3 dicyclomine, and 1 scopolamine. Out of 3 RCTs of simethicone for the treatment of colic, only 1 showed any possible benefit. In all 3 RCTs of dicyclomine, it performed significantly better than placebo*. The 1 RCT conducted of methylscopolamine in infant colic found that it had no significant impact on the symptoms of infant colic, but that adverse effects were more common in infants receiving the active treatment. Studies in which hypoallergenic formula has been compared with simethocone have shown the hypoallergenic diet to be more effective. Even though gastroesophageal reflux has been considered an etiologic factor of colic, multiple randomised studies of anti-reflux medications, have shown there is no role for the use of anti-reflux medication in patients with colic, and their use should be discouraged.
*N.B. In the UK NICE state that “Dicycloverine (dicyclomine) should not be used in the treatment of colic due to side effects such as breathing difficulties and coma.” Behaviour Controlled trials have shown no benefit for carrying the infants or car-riding. The role of more intense behavioural interventions is also not clear. In one study focused parental counselling was compared with reassurance, and found no difference. There may be some benefit in reducing infant stimulation, and in creating interventions that support infant-parent relationship. There is some suggestion that behavioural interventions help reduce parental anxiety.
Comparison between different treatments A landmark recent study compared different treatment modalities for children with colic. They randomised 175 children with colic to 5 groups: Tea, sucrose, massage spinal therapy, a formula with protein hydrolysate or a control group. There was a significant reduction in crying hours per day in all intervention groups. The difference between mean duration of total crying (hours/day) before and after the intervention infants in hydrolysed formula group was found higher than massage, sucrose and herbal tea group. The difference between mean duration of total crying (hours/day) before and after the intervention infants in massage group was found lower than other intervention groups.
Conclusion In conclusion, colic is a benign condition that can be diagnosed clinically without any testing in the majority of patients. The etiology is probably multifactorial. It usually requires reassurance and simple interventions. It is self-limited. There are some effective treatments, especially for those children with more severe symptoms. Dietary interventions are probably the most effective, but additional studies are still needed to better identify those children that require more intervention.
For a downloadable factsheet to use with parents ‘Coping with Colic’
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Related References
A. Zwart P, Vellema-Goud MG, et al. Characteristics of infants admitted to hospital for persistent colic, and comparison with healthy infants. Acta Paediatr 2007 Mar; 96(3):401-5.B. Garrison MM, Christakis DA. A systematic review of treatments for infant colic. Pediatrics 2000; 106 (1 Pt 2):184-90.
C. Barr RG, Paterson JA, et al. Prolonged and unsoothable crying bouts in infants with and without colic. J Dev Behav Pediatr 2005; 26(1):14-23.
D. Arikan D, Alp H, et al. Effectiveness of massage, sucrose solution, herbal tea or hydrolysed formula in the treatment of infantile colic. J Clin Nurs 2008; 17(13):1754-61.
E. Cohen-Silver, J and Ratnapalan S:, Management of Infantile Colic: A Review Clinical Pediatrics 2009; 48 : 14-17
F. Freedman SB, Al-Harthy N, et al. The crying infant: diagnostic testing and frequency of serious underlying disease. Pediatrics 2009 Mar;
123(3):841-8.
