Patient education: Colic (excessive crying) in infants (Beyond the Basics)

COLIC OVERVIEW — Colic is the term used to describe infants who cry excessively for no apparent reason during the first three months of life. Colic is one of the most distressing problems of infancy. It is distressing for the infant, the parents, and for the health care provider. The cause of colic is not well understood, but it resolves in most infants by three to four months of age. Even though it usually goes away on its own, it can be helpful to learn more about colic to gain a better understanding of this difficult stage of your baby's life.

COLIC DEFINITIONS — Colic is defined as "excessive crying." An infant with colic usually cries for more than three hours per day on more than three days per week.

Colic is extremely common and occurs in up to 40 percent of all infants. It usually starts sometime between the third and sixth week after birth and ends when a baby is three to four months of age. Colic occurs with equal frequency in the following groups:

●Males and females

●Breast- and bottle-fed infants

●Full-term and preterm infants

●The first and second child (and other siblings as well)

Normal crying patterns — All infants cry more during the first three months of life than during any other time. There is no standard definition for "excessive" crying, although it is normal for infants to cry for up to two hours per day. Infants without colic cry, although generally less frequently and for a shorter time than infants with colic.

Colic — Colic is more than excessive "normal" crying, at least in some infants. Colic differs from "normal" in the following ways:

●The crying episodes generally last a total of more than three hours per day.

●Each episode of colic has a clear beginning and end, and the onset is unrelated to what was happening before the episode started; the infant may have been happy, fussy, feeding, or even sleeping. The crying episode begins suddenly and often occurs in the evening hours.

●Colic episodes are more intense, louder, and higher pitched than "normal" crying. Infants with colic may sound as if they are in pain or are screaming.

●Infants with colic may have physical symptoms (table 1).

●Infants with colic are difficult or impossible to soothe, no matter what the parents do. There may be periods of quiet, but infants often remain fussy. Crying may end after the infant passes gas or a bowel movement.

For all infants, colic is a temporary problem. It resolves by three months of age in 60 percent of infants and by four months in 90 percent of infants.

OTHER CAUSES OF EXCESSIVE CRYING — There are a number of reasons, other than colic, that an infant may cry excessively; these can range from simple problems such as hunger to more serious problems such as infection.

A parent should first check for manageable causes of crying:

●Hunger – Try feeding the baby to see whether hunger is the problem. Although most young infants (younger than three months) feed every two to four hours, all babies go through periods when they will want to feed more frequently (usually during growth spurts).

●Pain – Check to see if the baby is uncomfortable because of illness or physical injury. Feel the skin to determine if the baby is overheated or too cold. Check to see if the clothing or diaper is too tight or if a hair is wrapped around a finger, toe, or the penis (called a hair tourniquet).

●Fatigue or overstimulation – Babies often cry when they become tired or overstimulated from playing or being handled. Swaddling the baby loosely, leaving room for the legs to move (figure 1), offering a pacifier, or a change of scenery (such as a stroller or car ride) may help the baby to fall asleep.

●Food sensitivities – Infants can have an allergy or sensitivity to foods in their mother's diet or a component of their formula. Foods such as milk, eggs, nuts, and wheat in a mother's diet have a direct effect on the composition of her breast milk; these foods can occasionally cause food reactions and digestive problems such as abdominal pain, cramping, and diarrhea. Infants also can be allergic to a protein in cow's milk-based formulas or dairy products consumed by the mother (if the infant is breastfeeding); cow's milk protein allergy may cause fussiness and blood in the stools. Lactose (a type of sugar found in cow's milk) intolerance has little to no effect on the development of colic.

Food sensitivities may be suspected if an infant cries or spits up a large amount within an hour of feeding or if a baby has constipation or diarrhea. Symptoms of cow's milk allergy include eczema, wheezing, diarrhea, or vomiting. Symptoms of cow's milk protein allergy include fussiness and blood in the stool. (See "Patient education: Acid reflux (gastroesophageal reflux) in babies (Beyond the Basics)".)

If these causes have been eliminated and the baby continues to cry excessively, parents should speak with their health care provider. Most infants who cry excessively do not have a serious underlying medical problem; a health care provider can help to make this determination. (See 'When to seek help' below.)

COLIC DIAGNOSIS — The diagnosis of colic is often made after it has run its typical three- to four-month course. If you are concerned about your infant's crying, call your child's doctor or nurse to discuss your concerns and possible management strategies.

Home monitoring — You can monitor your infant's crying by keeping a written record of the following information. You can share this information with your child's doctor or nurse to help determine the cause of crying as well as the best ways to manage it.

●When does crying occur and how long does it last? Crying that occurs directly after feeding may be caused by gastroesophageal reflux (heartburn) or swallowed air. (See "Patient education: Acid reflux (gastroesophageal reflux) in babies (Beyond the Basics)".)

●Does the crying begin at the same time every day? Does the infant cry at other times of the day?

●What seems to trigger an episode of crying? What helps to stop crying?

●What do you do when the baby cries? You can hurt your child if you yell, shake, or hit.

●What does the cry sound like? Infants with colic often have a higher pitched, louder, and more intense sounding cry.

●How and what do you feed the baby? As mentioned above, overfeeding, underfeeding, and feeding inappropriate foods can cause colic.

●Is the crying getting better, worse, or is it about the same?

●How do you feel when the baby cries? Living with a colicky infant is hard; some parents feel overwhelmed and incapable of caring for their infant, while others blame the infant for being difficult.

●How has colic affected your family? Colic affects all members of a household, and it is important to consider input from everyone.

●Why do you think the baby cries? Discuss your thoughts and concerns about your infant with your child's doctor or nurse.

COLIC MYTHS AND FACTS — There are a number of myths about the causes and treatments of colic. Myths often develop to explain problems that are not well understood. You can learn to separate myths from facts through education and support from respected sources, including health care providers.

●Babies do not cry to manipulate you.

●It is not possible to spoil a baby by holding or comforting them.

●Rice cereal does not improve colic. Infants should be given only breast milk or formula until they are four to six months old, unless told otherwise by a health care provider. (See "Patient education: Starting solid foods with babies (Beyond the Basics)".)

●Studies show that simethicone (sample brand name: Mylicon) and lactase (the enzyme that helps to digest lactose, the sugar in milk) do not help with colic. Simethicone may also react with levothyroxine, a drug used to treat congenital hypothyroidism, resulting in inadequate treatment of the hypothyroidism [1].

COLIC MANAGEMENT — The goals of treatment for colic are to decrease the infant's crying, help your family cope, and prevent long-term difficulties in your family's relationships. Many doctors recommend trying several strategies at once (table 2).

Parental support — Parents of infants with colic often feel frustrated, angry, exhausted, guilty, and helpless because of their child's crying. These feelings are normal and do not indicate that you are incapable or unworthy of caring for your child.

Take a break — It is normal for you to need a break from a child who cries excessively. If you are alone and need a break, leave the infant in a safe place for a few minutes; the infant should be placed on their back in a crib or bassinet with side rails. Loose blankets, pillows, and toys that could suffocate the child should be removed.

Taking a break allows you to call a friend or relative for help, get away from the crying, and can prevent you from potentially harming your child. Shaking, smothering, or slapping will not stop an infant's crying but can seriously injure or even kill the child. In the United States, you can call 24 hours a day, seven days a week and speak with a professional counselor at 1-800-4-A-CHILD (422-4453).

Shaken baby syndrome is the term used to describe the injuries suffered by infants who are violently shaken, often by a parent or other adult who has become overwhelmed by excessive crying. Infants do not have sufficient strength in their neck to limit head movement, and shaking causes the head to move suddenly and uncontrollably. As the head moves backwards and forwards, the brain hits the inside of the skull, causing serious damage and even death. (See "Patient education: Head injury in children and adolescents (Beyond the Basics)".)

Dietary and feeding technique changes

Bottle-fed infants — A number of devices (nipples, bottles) have been designed to decrease the amount of air swallowed during feeding. You may try positioning your infant in a vertical (sitting up) position while feeding. You may also try a curved bottle or collapsible bag, in combination with frequent burping. These techniques can reduce the amount of air swallowed, which may reduce colic in some infants.

Your doctor may suggest a trial of a different formula for one week (for bottle-fed infants). The original formula should be restarted if there is no change; low allergy (hypoallergenic) formulas are more expensive than traditional formula and do not need to be continued if crying does not improve after a one-week trial of the new formula.

Breastfed infants — Mothers who breastfeed may try consuming a hypoallergenic diet to reduce their infant's colic. A hypoallergenic diet eliminates potentially aggravating food groups, including milk, eggs, nuts, and wheat.

To try a hypoallergenic diet, stop eating a single food group for a one-week trial period while you monitor the infant's crying. You can restart the food if you do not see improvement. This type of diet appears to be more effective for infants whose mothers have eczema, asthma, or allergic rhinitis, or if the infant has symptoms of cow's milk allergy (including eczema, wheezing, diarrhea, or vomiting).

There is no evidence that stopping breastfeeding and starting formula is of any benefit in babies who have colic. There are a number of benefits to breastfeeding and breast milk that are not available with formula. (See "Patient education: Deciding to breastfeed (Beyond the Basics)".)

Carrying — Some parents find that carrying their infant in their arms, a sling, or a front carrier can decrease the infant's and parents' anxiety. Although studies have not proven carrying to be effective for all infants, it is worth trying if your infant has not responded to other treatments. Using a sling or front carrier frees your hands and arms and allows you to move around while monitoring your infant.

Change in environment — There are many other techniques that may help to reduce crying: a pacifier, ride in the car, change of scenery, infant swing, and warm baths have been suggested and may help to soothe an infant with colic.

Swaddling (figure 1) may be soothing. Placing the infant near a white noise machine or clothes dryer may soothe an infant who is sensitive to noise.

Probiotics — Probiotics are microorganisms that have beneficial properties for the host (sometimes called "good bacteria"). Most commercially available probiotics are prepared from food sources like cultured milk (eg, Lactobacillus).

Some studies suggest that a particular probiotic, Lactobacillus reuteri, may be helpful in children with colic. However, additional studies are needed to confirm these results and to determine whether other probiotics may be more helpful.

Talk to your doctor or nurse before giving your infant any probiotic. Probiotics may not be appropriate and could be dangerous in some cases.

Herbal remedies — Herbs such as chamomile, fennel seed, and balm-mint are thought to have antispasmodic properties and have been used in infants with colic. Although a few studies have shown improvement in infants given a tea made with a specific mix of herbs, parents should be cautious about trying this type of treatment.

Gripe water is a mixture of herbs and water that has been promoted for its ability to cure colic. However, various types of gripe water have been found to contain dangerous ingredients, including glass particles and alcohol. A homeopathic remedy, colocynthis (found in Cocyntal and Hyland colic tablets) was also found to contain dangerous ingredients (including alcohol) [2].

Talk to your doctor or nurse before giving your infant any herbal remedy; herbal remedies may not be appropriate and could be dangerous in some cases.

Infant massage — Infant massage has been recommended to parents of infants with colic, although no studies have proven it to be of clear benefit.

WHEN TO SEEK HELP — Call your child's doctor or nurse during the day or night if any of the following occur:

●The baby has cried continuously for more than two hours.

●You are afraid that you or another caretaker may hurt the baby, or if someone has shaken the baby.

●If crying could be the result of an injury or fall.

●The baby has a fever of ≥100.4°F (38°C). Parents should call their infant's health care provider or go to an emergency department immediately. This table describes how to take a child's temperature (table 3). (See "Patient education: Fever in children (Beyond the Basics)".)

●The infant refuses to eat or drink anything for more than a few hours, vomits excessively, is not urinating well, has bloody stools, or has a change in behavior, including lethargy or decreased responsiveness.

A parent should call their child's health care provider's office during normal office hours if any of the following occur:

●You cannot soothe your baby's crying or you have questions or concerns about how to manage your crying baby

●Excessive crying continues after the infant is older than four months

●The infant fails to gain weight

LONG-TERM OUTCOMES OF COLIC — Colic can take a toll on families. Some researchers have suggested that colic interferes with child-parent interactions and can have a long-term effect on the family and child.

Long-term studies have examined the possible relationships between colic and later childhood, including temperament, sleep patterns, family functioning, asthma, and cognitive development. However, no significant relationship between colic and these features of later childhood have been proven.

WHERE TO GET MORE INFORMATION — Your child's health care provider is the best source of information for questions and concerns related to your child's medical problem.

This article will be updated as needed on our website. Related topics for patients and caregivers, as well as selected articles written for health care professionals, are also available. Some of the most relevant are listed below.

Patient-level information — UpToDate offers two types of patient education materials.

The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.

Patient education: Colic (The Basics)

Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.

Patient education: Acid reflux (gastroesophageal reflux) in babies (Beyond the Basics)
Patient education: Starting solid foods with babies (Beyond the Basics)
Patient education: Head injury in children and adolescents (Beyond the Basics)
Patient education: Deciding to breastfeed (Beyond the Basics)
Patient education: Fever in children (Beyond the Basics)

Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.

Infantile colic: Clinical features and diagnosis
Infantile colic: Management and outcome

The following organizations also provide reliable health information:

●National Library of Medicine

     (www.nlm.nih.gov/medlineplus/healthtopics.html)

●American Academy of Pediatrics

     (www.aap.org)

●American Academy of Family Physicians

     (www.familydoctor.org)

●The Nemours Foundation

(kidshealth.org/parent/growth/growing/colic.html)

●The Mayo Clinic

(www.mayoclinic.com)

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