Continuity Clinic

COLICEvery Parent’s Nightmare

Michael Martin, MD

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Objectives

• Be able to define colic AND know it when you see it

• Be familiar with the other diagnoses that might resemble colic

• Know both medical and behavioral treatments that are available

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Is this Colic?

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Why Cry?

• Crying– normal primitive protective reflex– serves as an alarm to alert parents to problem

and get their attention Crying tends to assure “parental investment” in the infant

– “attachment behavior”

• Other potential reasons:– Ward off predators– Nutrition (frequent feeding)

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Why Cry?

• Colic – when cry is excessive without an identifiable need

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Background

• Other Animals– Infant chimpanzees

• Crying peaks in 2nd month of life • only manifest in nonhuman infants if separated from parent

• Other Cultures– !Kung San hunter gatherers of Botswana– Constant skin-to-skin contact, frequent moving with the infant in

a sling (or kaross), “continuous” feeding (every 15 min for 1 to 2 min per feed), upright posture, and caregiver responds to every fret and whimper within 10 seconds

– Frequency of crying is the same as in Western infants, but the duration is reduced about 50%

– 90% of the time, !Kung parents can calm their crying baby within 30 seconds

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Working Definition

• Infant cries more than 3 hours per day, and more than 3 days per week, and for more than 3 weeks (Wessel Criteria)– Also known as the rule of 3’s

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Why should you care?Associated Risks

• Increased risks of breastfeeding failure

• Postpartum Depression

• Martial Conflict

• Higher rates of child abuse

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Background

• Between 16% and 26% of all infants experience colic

• No predilection for race, ethnic groups, sex, socioeconomic grouping

• Temporal Pattern:– Excessive crying begins at 2 weeks of age– Peaks at 6 weeks– Decreases by 8 weeks– Resolves completely by 16 weeks

• Premature infants experience colic 2 weeks past due date

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Presentation

• Episodic crying spells UNRELATED to feeding• Pattern is diurnal, with increased crying in the

evening and night– Note: All infants experience crying episodes in the

evening that peaks at 6 weeks of age

• Physical signs (usually described by parents)– Infants draw up their legs while they cry– Tense abdomens– Arch their backs (parents describe them as “gassy”)

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EtiologyTheories Anyone?

• Maternal Anxiety

• Difficult infant temperament

• Brain Immaturity

• GI disorders– Gas and cramps– Aerophagia– Food intolerance– GERD

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Diagnosis

• Physical Examination – NORMAL!– Must rely on history taking

• Gastroesophageal reflux (GER), which can present with increased crying, often is suggested as causing colic– only 2% to 4% of infants who have symptoms of colic have been

shown to have GER

• Formula intolerance such as cow milk allergy often implicated but is associated with additional symptoms:– emesis, diarrhea,blood in the stool, severe eczema, or urticaria

• THIS IS A DIAGNOSIS OF EXCLUSION!

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Management

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Management

• Common books for parents that admit that for really fussy babies they have little to offer:– “Very often, you may not be able to quiet the

screaming.” What to Expect the First Year– “It’s completely all right to set the baby in the

bassinet while trying to drown out the noise with the running water of a hot shower.” The Girlfriend’s Guide to Surviving the First Year of Motherhood

– “The whole episode goes on at least an hour and perhaps for three or four hours.” Your Baby and Child

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Management-Traditional Medical Approaches-

• Simethicone (Mylicon) – RCT does not show superiority to placebo

• Dicyclomine (Bentyl) and Hyoscyamine (Levsin) – Anticholinergic (antispasmodic)– Has demonstrated reduced time of crying– AE: Sedation, apnea, seizures, and coma

(contraindicated in those under 6 months old)

• Dietary changes for a breastfeeding mother or multiple formula changes have not been shown to have benefit

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Management

• Behavioral: Tight swaddling, rapid swinging or jiggling motion, nonnutritive sucking, and steady loud white noise such as “hushing.” – Combining these techniques may calm both

caregiver and infant– Holding the infant for more than 3 hours daily

has been shown to decrease the intensity of the cry but not the duration

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Management

• Behavioral: The Happiest Baby on the Block– Swaddling– Side/Stomach– Shushing (white noise)– Swinging– Sucking

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Management-Complementary Medicine

• Herbal tea mixture: chamomile, vervain, licorice, fennel, and balm mint in a dose of 120 mL given TID

– improved colic in one RCT– Risks: large volume of tea potentially could cause poor caloric intake and

hyponatremia• Fennel Seed Oil

– 1 RCT study (125 infants) showed benefit– may cause allergic reactions of the skin (rashes) and respiratory tract (asthma

and breathing difficulties), seizures• Probiotics

– trial of Lactobacillus reuteri compared with simethicone in the treatment of infantile colic

– 95% of the probiotic treatment group were considered “responders” (ie, no longer met Wessel criteria) compared with only 7% of the simethicone group

– Bacteremia/septicemia, pneumonia, and meningitis have been documented in immunocompromised and severely debilitated patients in other studies

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Time heals all……..