Baby colic


Baby colic
Colic
Classification and external resources

Crying newborn
ICD-10 R10.4
ICD-9 789.7
MedlinePlus 000978
eMedicine ped/434
MeSH D003085

Colic (also known as infantile colic) is a condition in which an otherwise healthy baby cries or displays symptoms of distress (cramping, moaning, etc) frequently and for extended periods, without any discernible reason. The condition typically appears within the first month of life and often disappears rather suddenly, before the baby is three to four months old, but can last upto 12 months of life.[1] One study concludes that the chances of having colic is lower in breastfed babies.[2]

The crying often increases during a specific period of the day, particularly the early evening. Symptoms may worsen soon after feeding, especially in babies that do not belch easily.

The strict medical definition of colic is a condition of a healthy baby in which it shows periods of intense, unexplained fussing/crying lasting more than 3 hours a day, more than 3 days a week for more than 3 weeks.[3] However, many doctors consider that definition, first described by Morris Wessel, to be overly narrow and would consider babies with sudden, severe, unexplained crying lasting less than 3 hours/day as having "colic" (so-called "non-Wessel's" colic).[4] In reality, this extreme version of colic is more likely to be the final stage of a condition that has worsened for a few weeks.

Persistent infant crying is much more than a parenting nuisance. Crying and the exhaustion associated with it can trigger serious problems, such as relationship stress,[5] breastfeeding failure,[6][6] shaken baby syndrome (also known as abusive head trauma - the leading cause of child abuse fatalities),[7][8][9][10] postpartum depression (affecting 10-15% of new mothers and many new dads),[11][12][13][14][15][16][17][18] excess visits to the doctor/emergency room (1 in 6 children are brought to the doctor/emergency rooms for evaluation of persistent crying),[19] unnecessary treatment for acid reflux[20][21][22][22][23][24][25] and maternal smoking.[26] Crying and exhaustion may also contribute to Sudden Infant Death Syndrome (SIDS) and suffocation (from agitated babies flipping onto their stomachs, concerned parents placing fussy babies on the stomach to sleep, tired parents falling asleep with their baby in unsafe places, like couches or beds with bulky covers),[27][28][29] infant obesity,[30] maternal obesity[31] and even automobile accidents.[32]

Contents

Causes

For thousands of years, the number one belief of worried parents, grandparents and doctors has been that colicky crying was a sign of abdominal pain (e.g. intestinal spasm, overfeeding, trapped gas).[33] In fact, even the word "colic" is derived from the ancient Greek word for intestine (sharing the same root as the word "colon"). Today, it is fairly well established that there are a variety of causes of colic symptoms, the most common of which include: stomach gas (due to poor burping or milk flow issues), intestinal gas (pocketed in the intestinal tract), neurological overload (the overwhelmed and overstimulated baby that becomes exhausted) and even a muscular type of colic (perhaps due to muscle spasm and birth trauma). A gastrointestinal (GI) theory of colic seems logical because fussy babies often: grunt/pass gas/double-up/cry after eating; have noisy stomachs; improve with tummy pressure, warmth or massage; may improve with pain medication (e.g. paregoric, also dangerously referred to by its synonym camphorated tincture of opium containing 0.4 mg/mL of morphine which at times can be confused with a opium tincture which contains 10 mg/mL of morphine resulting in a mistake causing babies and adults alike with diarrhea to be wrongly prescribed 25 times the normal amount of morphine found in a regular dose of paregoric[34])[35] or sips of herbal teas used for stomach upset (e.g. mint, fennel).[36] However, 85-90% of colicky babies have no evidence of serious GI abnormality.[37]

Some have said that babies cry because they sense their mother's anxiety,[38] but this is highly unlikely. They simply do not have the ability to distinguish a mother's anxiety from depression, frustration, etc. In fact, even though parental anxiety is markedly reduced with successive children, it has been shown that a couple's later children are as likely to be colicky as their first.[39] It is plausible, however, that anxiety may have some relationship to crying through a more circuitous route. Anxious parents are often so unsure of themselves that they jump from one calming intervention to another without doing any technique long enough for it to be effective.

What is clear is that there are various causes of colicky babies other than the obvious gassy causes:

  • Fussiness peaks at about 6 weeks and reliably ends by 3–4 months, yet infants continue to experience plenty of burps, flatus, bowel movements, etc. well beyond 4 months of age [40]
  • Premature babies—with very immature intestines—have no more colic than full term-ers (despite the fact that their intestines are much more immature). And, when they do get colic it doesn't start until they reach their due date. (In other words, a baby born three months early has the same 10-15% chance of developing colic as a full term baby. Despite eating, defecation, burping and flatulating every day, he/she will have almost no fussing during the first three months.[41]
  • Contrary to the belief that babies cry from swallowed air, X-ray studies reveal that when babies start wailing, they have much less air trapped in their stomachs than they do after the colic is over and they are calm and relaxed.[42] (Babies gulp air while crying. So they have more air in the stomach after crying, but it is totally innocuous.)
  • "Burp" drops (simethicone) are no better at reducing crying than drops of distilled water.[43][44]
  • Car rides and vacuum cleaner sounds may calm fussing, yet have no power to lessen GI pain (just as adults never use a car ride or vacuum to sooth a stomachache).
  • In 90% of cases, colic is unrelated to a baby's diet.[45][46] However, in 10% of cases colic is triggered by stomach discomfort from food allergy and requires altering the diet of a breastfeeding mom or switching a baby to a hypoallergenic formula (e.g. Pregestimil).[47][47] The most problematic foods for fussy babies seem to be cow's milk based formula and, for breastfeeding babies, dairy products in the mother's diet. Other, less common allergens are wheat, soy and nuts. Breastfed babies may also become fussy from stimulants in the mother's diet (see section on treatment).[48][49][50] Parents and doctors commonly switch fussy babies to a soy formula; however, it is not clear that soy reduces colic.[51]

Also, unlike older children and adults who have GI discomfort from lactose intolerance, there is little evidence that this causes crying among infants.[52][53][54]

Some reports have associated colic to changes in the bacterial balance in a baby's intestine. They suggest treating the crying with daily doses of probiotics, or "good bacteria" (such as Lactobacillus acidophilus or Lactobacillus reuteri). In a 2007 study,[55] 83 colicky babies given the probiotic Lactobacillus reuteri had reduced crying time. After one week, treated babies had 19% less crying time (159 min/day vs. 197 min/day). By 4 weeks, treated babies had 74% less crying (51 min/day vs. 197 min/day). In a 2010 study conducted with the same probiotic strain, similar benefits were seen in colicky infants.[56] However, another study found no reduced colic in over 1000 babies who were given a mixture of four other probiotic strains from birth.[57]

In 2009, a University of Texas study observed that colicky babies had a higher incidence of mild intestinal inflammation and a specific intestinal bacteria, Klebsiella.[58] But, a commentary in the same journal, noted that the inflammation and bacteria were most likely just an exaggerated variation of normal.[59]

Over the past 15 years, many thousands of fussy babies have been given medicine in the belief that their colic was caused by painful acid reflux, so-called gastro-esophageal reflux disease (GERD). From 1999-2004, the use of a popular class of liquid antacid (proton pump inhibitor, or PPI) in young children increased 16 fold.[60] And, from 2000-2003 there was a 400% increase in the number of babies treated with anti-reflux medicines. By all accounts this rate of increase has continued—or accelerated—from 2003 to the present.

In truth, most babies have mild reflux, but we simply call it "spitting up." Over the past 5 years, several studies have proven that GERD rarely causes infant crying. Even crying during feeding and crying accompanied by writhing and back arching is rarely related to acid reflux, unless the baby also has:

  • 1) poor weight gain (less than ½ ounce/day)
  • 2) vomiting more than 5 times/day; or
  • 3) other significant feeding problems.

A multicenter study, organized by researchers at Pittsburgh Children's Hospital, concluded that GERD medicine is no better than plain water at reducing infant crying. Surprisingly, 50% of fussy babies improved on medicine, but so did 50% of fussy babies given the placebo. In the meantime, research has shown that proton pump inhibitors can cause decreased bone density in adults.[61] No research has been done on bone density or growth in children given PPIs and this use is not approved by the FDA and should be considered experimental.According to Dr Arsalan Khattak Menicol drops are advised from 2 to 3 times.

Red Flags

Babies who continue crying may simply be hungry, uncomfortable or ill. Parents who are unable to soothe their baby's crying must call their healthcare provider to make sure the baby is not sick. Fortunately, only 5% of colic cases are caused by illness (most commonly by intestinal allergy, described above).[62]

Parents should be especially suspicious of illness or pain as the cause of their baby's fussing if the cry is accompanied by at least one of the following ten "red flag" symptoms:[63]

  • Persistent moaning or weak crying
  • High-pitched, shrill cry (sharp and more dramatic than usual)
  • Vomiting (vomit that is green or yellow, bloody or occurring more than 5/day)
  • Change in stool (constipation or diarrhea, especially with blood or mucous)
  • Fussing during eating (twisting, arching, or crying that begins during or just after a feed)
  • Abnormal temperature (a rectal temperature less than 97.0 DEGF or over 100.2 DEGF)
  • Irritability (crying all day with few calm periods in between)
  • Lethargy (excess sleepiness, lack of smiles or interested gaze, weak sucking lasting over 6 hours)
  • Bulging soft spot on the head (even when the baby is sitting up)
  • Poor weight gain (gaining less than 1/2 ounce a day)

Babies with persistent crying or any "red flag" symptoms should be checked by a healthcare professional to rule out illness. The top ten medical problems to consider in irritable babies with "red flag" symptoms are:[63]

  • Infections (e.g. ear infection, urine infection, meningitis, appendicitis)
  • Intestinal pain (e.g. food allergy, acid reflux, constipation, intestinal blockage)
  • Trouble breathing (e.g. from a cold, excessive dust, congenital nasal blockage, oversized tongue)
  • Increased brain pressure (e.g., hematoma, hydrocephalus)
  • Skin pain (e.g. a loose diaper pin, irritated rash, a hair wrapped around a toe)
  • Mouth pain (e.g. yeast infection)
  • Kidney pain (e.g. blockage of the urinary system)
  • Eye pain (e.g. scratched cornea, glaucoma)
  • Overdose (e.g. excessive Vitamin D, excessive sodium)
  • Others (e.g. migraine headache, heart failure, hyperthyroidism)

Effect on the family

Infant crying can have a prominent effect on the stability of the family. Crying and the fatigue that typically accompanies it can inflict enormous emotional strain causing parents to feel they are providing inadequate care, triggering anxiety, stress, resentment and low self-esteem.[64]

Persistent infant crying has been associated with severe marital discord, postpartum depression, Shaken Baby Syndrome, SIDS/suffocation, early termination of breastfeeding, frequent visits to doctors, maternal smoking and over a quadrupling of excessive laboratory tests and prescription of medication for acid reflux.

Parents are at especially high risk of experiencing a serious reaction to their infant's crying; at-risk parents include teens, drug addicts, military families, foster parents, parents of premies and parents of multiples. Families living in dense housing projects, such as apartment blocks, may also suffer strained relationships with neighbors and landlords if their babies cry loudly for extended periods of time each day.

Treatment

Currently, the first approach most commonly recommended in healthy babies (without any "red flag" symptoms) is to use non-medicinal, noninvasive treatments like burping, stomach massage and gas release techniques as well as symptomatic and emotional support[65][66].

Some reports have associated colic to changes in the bacterial balance in a baby's intestine. They suggest treating the crying with daily doses of probiotics, or "good bacteria" (such as Lactobacillus acidophilus or Lactobacillus reuteri). In one study,[67] 83 colicky babies given Lactobacillus reuteri had reduced crying time. After one week, treated babies had close to 20% less crying time (159 min/day vs. 197 min/day). By 4 weeks, treated babies had 74% less crying (51 min/day vs. 197 min/day). Overall, there was a 95% positive response to the Lactobacillus reuteri probiotic drops in colicky infants.

In past decades, doctors recommended treating colicky babies with sedative medications (e.g. Phenobarbital, Valium, ethanol), analgesics (e.g. opium) or anti-spasm drugs (e.g. scopolamine, Donnatal, dicyclomine), but all of these have been stopped because of potential serious side-effects, including death.

There is a broad body of evidence showing that symptoms can be eased through soothing measures, such as pacifiers,[68][69] strong white noise[70][71][72][73][74] and jiggly rocking[75][76][77][78] are effective in calming babies during crying bouts. These techniques form the core of the "5 S's" approach:

  1. - Swaddling[79][80][81][82][83][84](safe swaddling carefully avoiding overheating, covering the head, using bulky or loose blankets,[85] and allowing the hips to be flexed[86][87][88]);
  2. - Side or stomach (holding a baby on the back is the only safe position for sleep, but it is the worst position for calming a fussy baby);
  3. - Shhh sound (making a strong shush sound near the baby's ear or using a CD of womb sound/white noise);[89][84][90][91][92]
  4. - Swinging the baby with tiny jiggly movements (no more than 1" back and forth) always supporting the head and neck;[93][84][94][75][95][76][96][78][97][98]
  5. - Sucking (Letting the baby suckle on the breast, your clean finger or a pacifier)

The most common medical causes of colic are food related. In a breastfed baby, the doctor may suggest eliminating all stimulant foods (e.g. coffee, tea, cola, chocolate, decongestants, diet supplements, etc.) from a mother's diet for a few days to evaluate for improvements in the baby's condition. If food allergy is suspected, the doctor may suggest a hypoallergenic formula for a formula fed infant or, if the mother is breastfeeding, a period of elimination of allergenic foods (e.g. dairy, nuts, soy, citrus, etc.) from her diet in order to observe changes in the baby's condition.[48][49] If the crying is related to a cow's milk allergy benefits are usually seen within 2–7 days. Mothers can then choose to add back small amounts of the suspected offending food a little bit at a time as long as persistent crying does not reappear. If crying reappears, the offending foods may need to be avoided for many months.[99][50]

Persistently fussy babies with poor weight gain, vomiting more than 5 times a day, or other significant feeding problems should be evaluated by a healthcare professional for other illnesses (e.g. urinary infection, intestinal obstruction, acid reflux).[23]

Claims are sometimes made as to the effect of chiropractic intervention to relieve their infants' colic. One explanatory theory behind such treatment is that the pain infants appear to be experiencing may be spinal in origin (perhaps acquired in the birth process), rather than gastro-intestinal. A single study by chiropractors[100] in 1999 used dimethicone drops as a placebo, comparing them to spinal manipulation; this suggested a similar level of effectiveness but no independently administered randomised control trial evidence supports such claims.

See also

References

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