Infantile Colic

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 colic^{1, 2}.

By Evan-Amos, via Wikimedia Commons (public domain)

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.

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

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.