Infantile Colic

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Original Author(s): Ranveer Sanghera and Raeesa Shah
Last updated: 1st June 2024
Revisions: 10

Original Author(s): Ranveer Sanghera and Raeesa Shah
Last updated: 1st June 2024
Revisions: 10

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Introduction

Infantile colic is defined as excessive crying in the first few months of life. It is very common, with 1 in 6 families seeking advice from healthcare professionals about symptoms related to colic1, 2.

A baby crying within the first few days of life

Fig 1. A baby crying within the first few days of life

Epidemiology

The average prevalence of infantile colic is 20% in infants under 12 months of age3. The prevalence is highest in infants under 6 weeks (17-25%) and decreases significantly by 10-12 weeks (0.6%)4. It occurs equally in both sexes, and in breastfed and bottle-fed infants. There is no correlation with gestational age or socioeconomic status5.

Infantile colic is self-limiting and usually resolves by 5 months of age6.

Pathophysiology

The underlying cause is unknown however there are a few factors that may contribute, and it is thought that infantile colic is caused by a combination of these:

  • Increased gas production in the gut (due to decreased lactobacilli and increased coliform bacteria)
  • Abnormal gastrointestinal motility and pain signalling from the gut viscera
  • Gut inflammation6

Deregulation of the central nervous system7 (responding to external stimuli in a way that doesn’t match reality8) and differences in sensory processing may also cause frequent, unresolving episodes of crying.

Risk factors

  • Family tension
  • Parental anxiety or depression
  • Inadequate parent-infant interaction6
  • Misinterpretation of crying

Clinical features

Infantile colic is a diagnosis of exclusion and should only be made after a history and examination of both the infant and parents and carers.

Rome IV diagnostic criteria7:

  • Infant is <5 months of age when symptoms start AND stop.
  • Recurrent and prolonged periods of infant crying, fussing or irritability with non-obvious causes and cannot be prevented or resolved by caregivers.

Additional clinical signs:

  • Crying usually in the late afternoon or evening
  • Fist clenching
  • Drawing knees up to abdomen
  • Arching back when crying1

Red flag features

These features must be excluded as they may indicate an illness that is potentially more serious:

  • Weak cry that is continuous
  • Abnormally high-pitched cry
  • Apnoea
  • Irregular breathing pattern
  • Increased work of breathing or grunting
  • Central or peripheral cyanosis
  • Fever
  • Vomiting (bilious or projectile)
  • Blood in stool1
  • Weight loss or faltering growth

Examination

Examination is important in infantile colic to rule out differential diagnoses. Signs of an underlying cause can be elicited by:

  • Routine observations
  • Weight plotting and comparison to previous measurements
  • Complete physical examination: full exposure to assess trauma or evidence of non-accidental injury*
  • Observe the parent/carer interaction with the infant
  • Maternal breast examination if there are concerns about breastfeeding9

*If non-accidental injury then the local child safeguarding lead/community paediatrician should be contacted immediately

Differential diagnosis1

Differentials for infantile colic will differ depending on whether symptoms are acute or chronic.

Acute Chronic
Intussusception or volvulus intestinal obstruction Hunger or dehydration
Pyloric stenosis Inadequate winding technique
Incarcerated or strangulated hernia Constipation
Trauma or non-accidental injury Gastro-oesophageal reflux disease
Sepsis Non-IgE mediated food allergy
Hydrocephalus  

 

Investigations

If history and examination reveal no abnormalities besides inconsolable crying then biochemical and radiological investigations are not indicated.

Management

Reassure parents and carers that it is a common problem that usually resolves by 5 months of age.

If the mother is breastfeeding, encourage continuation of this whenever possible.

Support for parents/carers is available from the following sources:

  • NHS information leaflet on colic
  • Self help group cry-sis cry-sis.org.uk
  • Health visitor or nursery nurse
Strategies to manage colic episodes Advice for parents/carers
Holding baby through episode of crying Rest when baby is asleep
Gentle motion (pushing pram, rocking crib) Reassure that they can put their baby in a safe place e.g. cot for a few minutes if they are unable to cope with the crying
‘White noise’ e.g. a fan or vacuum
Giving the infant a warm bath
Optimise winding technique Ask family and friends for support if possible1

Referral

Consider a paediatric referral for any of the following:

  • Parents/carers unable to cope despite reassurance and advice in primary care
  • Suspected faltering growth
  • Symptoms persist beyond 5 months of age
  • Suspected underlying cause for symptoms which cannot be managed in primary care1

Complications

If appropriate support is not available the child and family may become at risk of:

  • Child maltreatment1
  • Early breastfeeding cessation2
  • Family/relationship difficulties
  • Parental/carer sleep deprivation, fatigue, stress, anxiety, depression, loss of parental confidence

References

(1) https://cks.nice.org.uk/topics/colic-infantile/.

(2) Ellwood, J., Draper-Rodi, J. and Carnes, D. (2020) Comparison of common interventions for the treatment of infantile colic: a systematic review of reviews and guidelines. BMJ Open 10(2).

(3) Vandenplas, Y., Abkari, A., Bellaiche, M., et al. (2015b) Prevalence and health outcomes of functional gastrointestinal symptoms in infants from birth to 12 months of age. Journal of Pediatric Gastroenterology and Nutrition 61(5), 531-537.

(4) Wolke, D., Bilgin, A. and Samara, M. (2017) Systematic review and meta-analysis: fussing and crying durations and prevalence of colic in infants. Journal of Pediatrics 185, 55-61.

(5) Johnson, J.D., Cocker, K. and Chang, E. (2015) Infantile colic: recognition and treatment. American Family Physician 92(7), 577-582.

(6) Mai, T., Fatheree, N.Y., Gleason, W., Liu, Y. et al. (2018) Infantile colic: new insights into an old problem. Gastroenterology clinics of North America 47(4), 829-844.

(7) Zeevenhooven, J., Koppen, I.J.N. and Benninga, M.A. (2017) The new Rome IV criteria for functional gastrointestinal disorders in infants and toddlers. Pediatric Gastroenterology, Hepatology and Nutrition 20(1), 1-13.

(8) https://theprivatetherapyclinic.co.uk/blog/what-is-nervous-system-dysregulation/#:~:text=Experiencing%20chronic%20nervous%20system%20deregulation,mental%20and%20emotional%20health%20issues.

(9) Drugs and Therapeutics Bulletin (2013) Management of infantile colic. British Medical Journal 347, 1-5.