Overview
Definition:
Infant colic is defined as recurrent episodes of excessive crying in an otherwise healthy infant, typically lasting more than 3 hours a day, for more than 3 days a week, for more than 3 weeks, with no identifiable medical cause.
Epidemiology:
It affects an estimated 10-40% of healthy term infants, usually beginning within the first few weeks of life and peaking around 6 weeks, with resolution typically by 3-4 months of age
There is no clear predilection for gender or socioeconomic status.
Clinical Significance:
While generally a benign and self-limiting condition, infant colic can cause significant parental distress, anxiety, and sleep deprivation, leading to concerns about infant health, potential for adverse parenting outcomes (e.g., shaken baby syndrome), and increased healthcare utilization for reassurance and investigations.
Clinical Presentation
Symptoms:
Intense, inconsolable crying episodes
Crying often occurs in the late afternoon or evening
Infant may appear uncomfortable, drawing legs up towards the abdomen
May have periods of fussiness interspersed with crying
Some infants may appear to strain and pass gas during crying episodes.
Signs:
During crying spells, infant may appear red-faced, tense, and flushed
Abdomen may be distended or firm to palpation
Vital signs are usually normal between crying episodes
No fever, vomiting, diarrhea, or poor feeding is typically present.
Diagnostic Criteria:
The Wessel criteria (also known as the "rule of threes") are commonly used: crying for >3 hours/day, >3 days/week, >3 weeks duration in an infant <3 months old, with normal growth and development.
Diagnostic Approach
History Taking:
Detailed history of crying pattern (timing, duration, intensity)
Feeding history (breastfeeding, formula, amount, frequency)
Bowel habits (frequency, consistency, presence of blood or mucus)
Vomiting (frequency, volume, character)
Growth pattern
Parental stress levels and coping mechanisms
Red flags: fever, vomiting, diarrhea, poor weight gain, lethargy, irritability with feeding, any concerning abdominal distension or tenderness.
Physical Examination:
Thorough general examination focusing on the infant's overall well-being
Assess growth parameters (weight, length, head circumference)
Examine abdomen for distension, tenderness, masses, or umbilical hernia
Rectal examination to rule out anal fissure or obstruction
Assess for signs of infection or dehydration.
Investigations:
Generally, no investigations are required for typical infant colic
If red flags are present, consider: Complete blood count (CBC) to rule out infection
Stool examination for occult blood or leukocytes if diarrhea or blood is suspected
Abdominal X-ray if obstruction or severe distension is present
Urine analysis to rule out urinary tract infection.
Differential Diagnosis:
Gastroesophageal reflux disease (GERD)
Cow's milk protein allergy (CMPA) or other food intolerances
Gastroenteritis
Urinary tract infection (UTI)
Rectal fissure or constipation
Incarcerated umbilical hernia
Overtiredness
Neurological conditions (rare)
Kernicterus (rare).
Management
Initial Management:
Reassurance of parents that the condition is benign and self-limiting
Education on normal infant crying patterns and colic diagnosis
Advise on keeping a crying diary to track patterns and potential triggers.
Parental Support:
Emphasize importance of parental self-care and seeking help
Suggest strategies for coping with crying: taking breaks, seeking support from partner or family, swaddling, carrying, white noise, reducing stimulation
Recommend support groups for parents experiencing colic
Advise against parental blame or guilt.
Feeding Modifications:
For breastfed infants, consider maternal dietary elimination of common allergens (e.g., dairy, soy, eggs) for 2 weeks
For formula-fed infants, trial of a hydrolyzed protein formula or soy-based formula may be considered, although evidence is mixed
Avoid frequent switching of formulas
Ensure proper latch and feeding technique to reduce air swallowing.
Pharmacological Management:
Simethicone drops may provide modest relief for some infants by breaking up gas bubbles, though evidence is weak
Probiotics (e.g., Lactobacillus reuteri) have shown some benefit in a subset of infants, particularly those who are exclusively breastfed
Avoid over-the-counter medications not specifically indicated for infants or without medical guidance.
Other Therapies:
Gentle massage
Bicycle legs
Warm baths
Reducing environmental stimulation
Music or white noise
Gentle rocking or motion
Ensure infant is not overtired.
Complications
Early Complications:
Parental exhaustion and increased stress
Maternal postpartum depression
Shaken baby syndrome (in severe, untreated parental distress)
Increased healthcare visits and investigations for parental reassurance.
Late Complications:
Generally, no long-term sequelae in the infant if colic is indeed benign
However, if colic was a symptom of an underlying condition, the complications of that condition will persist.
Prevention Strategies:
Early parental education and reassurance
Providing practical coping strategies for parents
Identifying and managing underlying conditions if present
Promoting a supportive environment for parents.
Prognosis
Factors Affecting Prognosis:
The prognosis for infant colic itself is excellent, with spontaneous resolution in most cases by 3-4 months of age
Prognosis is poorer if colic is a symptom of a serious underlying medical condition.
Outcomes:
Infants with benign colic typically develop normally without any long-term health issues
Parental stress and anxiety are the primary outcomes that require management.
Follow Up:
Follow-up is primarily for parental reassurance and to monitor growth and development
Re-evaluate if symptoms persist beyond 4-5 months or if new concerning symptoms arise
Advise parents to seek immediate medical attention if any red flags appear.
Key Points
Exam Focus:
Remember the Wessel criteria for diagnosis (>3, >3, >3)
Differentiate benign colic from organic causes by looking for red flag symptoms
Parental support is paramount.
Clinical Pearls:
Always start with reassurance and education
Rule out red flags thoroughly before diagnosing benign colic
Empower parents with coping strategies and emphasize self-care
Consider probiotics for select cases.
Common Mistakes:
Over-investigating a typical colicky infant
Inappropriately blaming feeding practices without thorough assessment
Insufficient emphasis on parental support and education
Diagnosing colic without a proper history and examination to rule out organic causes.