2018-19 TOW #9: Colic

Next week we are covering a bread and butter topic in outpatient pediatrics, the ever-so-challenging diagnosis of colic, or excessive crying. Dealing with an especially fussy infant as you’re just learning to be a parent can be among the most challenging experiences a parent can face. Think about the stress you’ve felt listening to an infant crying on a plane, then imagine a parent having to deal with it every day for hours at a time! We want to harness evidence and empathy to help families through this.

Here are the materials:

Take-home points about colic:

  1. Epidemiology: how do we define colic and how many babies have it? Colic was defined by Wessel in 1954 as rule of 3’s (crying for 3 hours or more per day on at least 3 days per week for >=3 weeks). The Rome group updated this definition (as these time markers are somewhat arbitrary) in the Rome IV criteria for functional gastrointestinal disorders as “recurrent crying or ‘fussiness’ in a thriving, afebrile, well infant less than 5 months of age, without apparent cause, that cannot be resolved by the caregiver.” It occurs in 5-20% of otherwise healthy babies (and is seen globally), and is most often benign and self-limited. Some have theorized babies who cried more had an evolutionary advantage for survival as it meant more holding and soothing. In clinic, I often say a baby has a “good survival instinct” when I am talking to families to normalize crying behaviors or other contact-seeking behaviors that get babies the help they need.
  2. What is the differential for excessive crying and what is the work-up? Less than 5% of cases have an identified cause. We need to think about cow’s milk protein intolerance, GERD, abuse, infantile migraines, isolated fructose intolerance, maternal medications in breast milk (like fluoxetine), hair tourniquet, occult infection (especially UTI), and corneal abrasion. Mothers of infants with colic are more likely to have depression, so this should be assessed and referrals made, as needed. If there is no sign of other illness or injury on exam (including red flags of distended abdomen, fever, or lethargy), then no routine work-up is needed.
  3. What is the natural history for colic? Colic begins at 2-4 weeks and worsens until 6-8 weeks then improves and usually resolves by 4 months of age. The increased crying behavior occurs in the afternoons and evenings, the same times of day as in non-colicky infants, often referred to as the “evening fussies.” Colic can be considered a more extreme end of the spectrum of normal emotional development. Often there is a connection to difficult feeding behaviors and sleep, so these should be assessed.
  4. What are the long-term outcomes among infants with colic? At 4 months, those who had colic may have more sleeping difficulties. There may be some differences in temperament and family functioning. But, there have been no long term differences found in cognitive development.
  5. What are the treatment options for colic? There are very few evidence-based treatments, including a lack of evidence from Cochrane reviews for various pain-relieving agents or for manipulative therapies. There is some evidence that babies with colic have different fecal microflora (including higher rates of Helicobacter pylori stool antigen positivity) and some signs of colonic irritation. Studies of probiotics as a treatment for colic have been somewhat mixed, but there is data from a recent meta-analysis to suggest Lactobacillus reuteri may be effective in reducing crying time in exclusively breast fed infants. Infant crying can lead to parents feeling anger, frustration, and inadequacy. Asking about and addressing these emotions are important parts of caring for the parents. Give parents permission to put their baby in a safe place and leave for 5-10 minutes to take a break.

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