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Colic in babies

MODULE SUMMARY

Infant colic is a common condition, affecting around 1 in 5 babies.1 Although benign and self-limiting, colic can have a significant impact on parent and child.2,3 This CPD module brings you up-to-date with the latest thinking on the possible causes of colic, its diagnosis and current management guidelines. 

 

LEARNING OBJECTIVES

After studying this module you should:

  • Appreciate the possible causes and contributing factors that may lead to colic
  • Be able to assess both infant and parent/carer to exclude more serious causes
  • Offer advice on coping with a colicky baby

NEXT STEPS

  • Read the clinical review: if you don't have a printed version, click here to download a pdf
  • Complete the online assessment
  • Receive CPD credit

AUTHOR(S)

Written by Tara Ralph B (hons)
Reviewed by Simon Carvell MB ChB, MRCGP - practising GP with special interest in medical education

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    The content of this website is subject to editorial review however you should seek independent validation where required. Content on the website is correct at the time of publishing, and will be reviewed every 2 years aligned to medical best practice.

     

    Pre-learning reflection

    Please take a moment to answer these pre-learning questions.  Once completed, click 'next step' below to start this module.  These answers will be logged on your CPD certificate which will be emailed to you on completion as evidence of your learning.


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    Infant colic is common but self-limiting

    Despite wide variation in reported occurrence,4 worldwide prevalence of infant colic is estimated to be around 20%1

    Colic normally starts soon after birth, peaks at around six weeks, and resolves by three to six months5

    • A meta-analysis of 28 diary studies of 8,690 infants found that colic was more frequent in the first 6 weeks of age (17-25%) than at 8-9 weeks (11%) and 10-12 weeks (0.6%)6
    • Mean duration of fussing and crying also reduced over time, from 117-133 minutes in the first 6 weeks to 68 minutes by 10-12 weeks6

    Colic occurs equally in breastfed and bottle-fed babies, and equally in girls and boys1,5

     

     

       

     

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    Diagnostic criteria focus on nature of crying

    Until recently, the standard diagnostic criteria for colic was the 'rule of three': crying for more than three hours per day, more than three days a week for longer than three weeks.

    The latest diagnostic criteria (ROME IV) has shifted focus from an arbitrary amount of crying to the excessive and inconsolable nature of the crying7

    Parents typically report crying episodes tend to occur in the late afternoon or evening and last several hours5,8

    Other features of colic include:8

    • Redness of the face
    • Clenched fists
    • Drawing-up of knees
    • Arched back

     

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      The precise cause of colic remains a mystery

      The pathogenesis of colic is poorly understood, but several mechanisms have been suggested

      Physiological causes include:

      • Abnormal bile acid levels and composition, impairing the absorption of fat and other nutrients
      • Alternations in the gut microbiome
      • Immature gut motility
      • Intolerance to cow's milk protein or lactose5

      A recent study of 55 infants found a link between melatonin circadian rhythms and infant colic10

      • Melatonin circadian rhythms begin around the third month of life, typically the same time that colic symptoms start to decrease
      • However, this was a small study and further research is needed to understand the hormone's role in colic

         

       

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      The precise cause of colic remains a mystery

      Psychosocial causes include:11,12

      • Family tension and parental anxiety
      • Inadequate parent-child interaction
      • Overstimulation of the child
      • Misinterpretation of crying

      It has also been suggested that colic may be a normal development phenomenon, reflecting part of the normal distribution of infant crying7,12



       

       

         

       

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      The impact on parent and child can be significant

      Colic can be deeply distressing for parents/carers, leading to stress, anxiety, sleep deprivation and depression. Possible effects include:

      • Increased risk of postpartum depression: inconsolable infant crying of more than 20 minutes a day has a stronger association with maternal depressive symptoms than overall daily fussing and crying
      • Child maltreatment: excessive crying may be a factor in triggering physical abuse3

      Colic can also lead to premature cessation of breastfeeding or premature weaning onto solid foods11

         

       

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      Each case should be assessed thoroughly

      Symptoms are typically non-specific, so it is important to establish that the baby is otherwise heath

      Assessment should therefore include a detailed history and examination of both the infant and the parent/carer, summarised in Table 111

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      Table 1. History and examination of infant and parent/carer11

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      A cry diary may help identify a pattern

      If parents cannot provide clear feedback on the pattern of crying, it may be helpful to suggest a cry diary

      However, some parents may feel additional pressure to complete the diary, so it may not be suitable in all cases7

      A cry diary template can be downloaded from the Health Professional Academy's infant colic resource page

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      Example of a cry diary

       

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      Colic is a diagnosis of exclusion

      Although an underlying organic cause is identified in less than 5% of children who present with inconsolable crying,6 signs of organic disease can be non-specific in infants

      A diagnosis of colic should only be made after first excluding other possible causes5

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      Table 2. Differential diagnoses for infant colic11

       

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      Parental reassurance and support are key

      Treatment focuses on helping parents to get through this challenging period in their baby's development13

      The mainstay of treatment is:

      • parental reassurance that colic is benign and self-limiting5
      • directing parents to support resources, such as NHS Choices, NCT and self-help group Cry-sis11

      Advice to look after their own well-being, seek additional support and to rest when possible is also important

      • parents/carers should consult their GP if:11
      • symptoms haven't improved after 4 months
      • symptoms suddenly get worse
      • their baby doesn't grow at the expected rate

       

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      Soothing techniques may be helpful

      It may be possible to reduce crying by trying different soothing methods - some babies respond better to some techniques than others

      Parents may find the following helpful3,11-14

      • Holding the baby during a crying episode
      • Wearing baby in a sling
      • Gentle motion, such as rocking, pushing them in a pram or going for a drive
      • Background noise, such as the vacuum cleaner or washing machine
      • White noise
      • A warm bath
      • Baby massage
      • Reducing stimulation

       

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      Pharmaceutical treatments may help some children

      Several over-the-counter products are available that may help some children

      Although there is insufficient evidence to recommend their use, these products are unlikely to be harmful11,13

      Treatments include:

      • Lactase drops - lactase is an enzyme that helps to break down lactose in the milk, making it more digestible
      • Simeticone drops - these help to release bubbles of trapped air in the baby's digestive system
      • Probiotics - there is some evidence that Lactobacillus reuteri can reduce crying in breast-fed babies,15  there is insufficient evidence to support their use

       

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      Summary

      • Infant colic, while self-limiting and benign, can cause significant distress to parents/carers
      • The non-specific nature of symptoms requires careful assessment and diagnosis is based on exclusion of other more serious causes
      • Simple reassurance and advice on effective coping strategies are important in reducing parental stress and anxiety
      • Other treatment options are available, although there is insufficient evidence to recommend their use

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      Assessment - Signs and symptoms

      Now that you have reviewed the learning, please complete the following multiple choice questions to test what you've learnt and receive your CPD certificate. 

       
      Which of the following is NOT a typical sign or symptom of colic?
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      Assessment - Signs and symptoms

      When do colic symptoms typically reach their peak?
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      Assessment - Causes and contributing factors

      Which of the following may cause or contribute to infant colic? Click all that apply
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      Assessment - Assessment and diagnosis

      Which of the following are red flag symptoms in a baby presenting with excessive crying? (Choose all that apply)
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      Assessment - Treatment

      Which of the following are recommended in the management of colic? (Choose all that apply)
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      Post-learning reflection

      Please take a moment to answer these post-learning questions.  These answers will be logged alongside your pre-learning responses on your CPD certificate which will be emailed to you on completion as evidence of your learning.



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      References and further reading

      1 Vandenplas Y et al. Prevalence and health outcomes of functional gastrointestinal symptoms in infants from birth to 12 months of age. JPGN 2015; 61: 531-537.
      2. Radesky J et al. Inconsolable infant crying and maternal postpartum depressive symptoms. Pediatrics 2013; 131: e1857-e1864.
      3. McKenzie SA. Fifteen-minute consultation: troublesome crying in infancy. Arch Dis Child Educ Pract Ed 2013; 98: 209-211.
      4. Lucassen PLBJ et al. Systematic review of the occurrence of infantile colic in the community. Arch Dis Child 2001; 84: 398-403.
      5. Johnson JD et al. Infantile colic: recognition and treatment. American Family Physician 2015; 92:577-582.
      6. Wolke D et al. Systematic review and meta-analysis: fussing and crying durations and prevalence of colic in infants. Journal of paediatrics 2017; 185:55-61.
      7. Zeevenhooven J et al. The New Rome IV Criteria for functional gastrointestinal disorders in infants and toddlers. Pediatr Gastroenterol Hepatol Nutr 2017; 20:1-13.
      8. NHS Choices. Colic. 2015. Available at: https://www.nhs.uk/conditions/colic/. Accessed March 2018.
      9. Camilleri M et al. Exploring hypotheses and rationale for causes of infantile colic. Neurogastroenterol Motil. Published online 2017; DOI: 10.1111/nmo.12943.
      10. Ince T et al. The role of melatonin and cortisol circadian rhythms in the pathogenesis of infantile colic. World Journal of Pediatrics 2018.
      11. NICE Clinical Knowledge Summary: infantile colic. June 2017. Available at: https://cks.nice.org.uk/colic-infantile. Accessed March 2018.
      12. Akhnikh S et al. The excessively crying infant: etiology and treatment. Pediatric Annals. Published online 2014. DOI:10.3928/00904481-20140325-07.
      13. NCT. Coping with colic symptoms in babies. Available at: https://www.nct.org.uk/parenting/coping-colic. Accessed March 2018.
      14. Sezici E, Yigit D. Comparison between swinging and playing of white noise among colicky babies: A paired randomised controlled trial. J Clin Nurs 2018; 27:593-600.
      15. Sung V et al. Lactobacillus reuteri to treat infant colic: a meta-analysis. Pediatrics 2018; 141:e20171811

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