This is a 20 day old newborn that is brought to the emergency department at 10 pm with a chief complaint of extreme fussiness. His parents think he has abdominal pain as he is "gassy" and pulls his legs up as if he is trying to stool. He passes a lot of gas from his rectum and his parents can hear his stomach gurgling a lot. Tonight's episode has lasted for 4 hours with intractable crying, and his parents are very distraught. They have tried feeding, a pacifier, rocking, burping, changing the diaper, and inserting a rectal suppository but nothing has relieved the crying. He is currently feeding a standard cow's milk formula with iron without vomiting or diarrhea. Further questioning reveals this is the fourth day in a row that this has happened on a daily basis, usually in the evening, but the baby usually cries for about 2 to 3 hours.
He was born at term with no prenatal problems or infection at time of birth. No maternal use of illegal drugs. He has been feeding well with good weight gain and no fussiness until 4 days ago (age 16 days of age). No apnea, no vomiting, no fever, no constipation, no seizure activity, no trauma or history of shaking or abuse. He has been acting normally between daily episodes of fussiness.
Exam: VS T 37.0, P 130, RR 32, BP 80/55, oxygen saturation 100% in room air. Height, weight and head circumference are at the 50th percentile. He is a healthy appearing infant who is not crying at this time. He is alert and active. HEENT: Soft fontanelle, good eye contact. No evidence of corneal abrasion or watery eyes. Vigorously feeding during exam. No signs of closed head injury. Neck, heart and lung exams are normal. His abdomen is soft and non-distended. There is no definite tenderness. Bowel sounds are active. He has no inguinal hernias. His testes are normal. No tourniquets are noted over his penis and digits. He is moving all extremities well and his muscle tone is normal. He has no pain on movement. Color and perfusion good. No pallor or mottling of his skin is present.
Diagnostic impression by the physician: Unexplained recurrent crying with normal physical examination. Unclear etiology.
Colic is one of the most commonly made diagnoses during the first 4 months of life with a reported incidence of 10% to 35% of all infants. The word "colic" is derived from the Greek word "kolikos", which refers to the large intestine. Colic has also been called the three month colic, infant colic syndrome, or paroxysmal fussing in infants. The classic definition of infantile colic was described by Wessel (1) in 1954 as, crying lasting more than 3 hours per day, 3 days per week, and continuing more than 3 weeks in infants less than 3 months of age. During these paroxysms, the legs are often flexed, the infant may be described as gassy, and parents often think the infant has abdominal pain. In addition, crying is not relieved by normal parental interventions (feeding, burping, changing diapers, etc.).
How much crying is normal? In 1962, Brazelton (2) published characteristics of the median daily crying at various ages: At 2 weeks of age: 1 hour and 45 minutes. At 6 weeks of age: 2 hours and 45 minutes. At 12 weeks of age: less than 1 hour. The peak time for crying is 3:00 pm through 11:00 pm ("prime time"). Infants whose crying significantly exceeds these median values could be labeled as having "colic"; however, this is also dependent on the parents' ability to cope with crying and as to whether they label their infant's behavior as "normal crying" or "abnormal crying" (i.e., colic) (2).
The four clinical signs of colic are: 1) paroxysmal onset, 2) distinctive high-pitched pain cry, 3) physical signs of hypertonia and 4) inconsolability (3). Colic presents as intermittent and unexplained crying during the first three months of life by babies that are otherwise healthy. The "infant colic syndrome" (paroxysmal fussing) basically involves cyclic discrete periods of intractable crying, usually on a daily basis, with onset at 1-4 weeks of age (may be as early as the first week of age) and dramatic spontaneous improvement by 3-4 months of age. In addition to infant irritability, colic is characterized by recurrent episodes, excessive restlessness or activity, or diminished consolability. Colic is distinguished in that the crying is paroxysmal, intense and different in type from normal fussing and crying.
The defining elements of colic, according to Carey (4) are: full force crying for at least 3 hours per day, for 4 or more days per week, in infants who are less than 4 months old and are otherwise healthy. The infant begins a colic episode with a paroxysmal or sudden onset of crying. The cry reaches a screaming level, is often high pitched and coupled with facial grimacing indicating that the infant is in severe pain. There is increased motor activity, which may include flexion of the elbows, clenched fists, and generalized hypertonicity of the musculature, with the knees drawn up or legs stiff and extended. Milder cases of "colic" may exist, but defining this would be difficult.
There is no clear understanding of the etiology, pathophysiology and treatment of colic; however, proposed models for the etiology of colic fall into 3 broad categories: intrinsic or biological factors in the infant, extrinsic factors in the psychosocial environment and an interaction or systems approach.
The most important thing to remember about infants who present with intractable crying is this: ALL THAT CRIES IS NOT COLIC! Crying is a non-specific response in an infant, which may be a major symptom of an underlying pathologic process. The etiologies of intractable crying in infancy range from a benign phase of psychomotor development to a life threatening illness. The etiology is initially obscure and an accurate diagnosis is dependent on a knowledgeable and organized approach. A careful history and physical exam with selected laboratory studies usually establishes a diagnosis.
Since most of these patients initially present to the emergency department, the emphasis is on the evaluation of the infant or young child with intractable crying, and one must exclude serious underlying illness. In Poole's 1991 study (5) in afebrile infants, those who ceased crying before or during the initial assessment were unlikely to have a serious underlying illness, whereas the persistence of excessive crying after the initial examination was predictive of a serious underlying process. Therefore, do NOT discharge an infant or young child with persistent, excessive crying. Look for "red flags" in the history and physical, which suggest the possibility of significant underlying pathology (see Tables 1 and 2). The presence of any of these "red flags" should prompt a more extensive evaluation and aggressive management, often including specialty consultation and hospitalization (e.g., meningitis or sepsis).
Robert Bolte (6) has described "Red Flags" of non-colic causes of extreme fussiness, which may be signs or symptoms of life threatening illness, obtained by further history or physical examination. ANY OF THESE RED FLAGS SUGGEST NON-COLIC ETIOLOGIES OF FUSSINESS and must lead to extensive evaluation and aggressive management (Tables 1 and 2) (6). Do not make a diagnosis of colic on patients with any of these historical or physical examination "red flags" until other causes listed under "differential diagnosis" (Table 3) are ruled out.
Table 1 - Historical "Red Flags" Associated with Intractable Crying in Infancy (6)
. . . . . 1. Fever (>38 degrees C, 100.4 degrees F, rectal) in an infant less than twelve weeks of age.
. . . . . 2. Paradoxical irritability (infant doesn't want to be held).
. . . . . 3. Premature rupture of membranes (>24 hours), perinatal maternal fever/infection, neonatal jaundice.
. . . . . 4. Maternal drug use.
. . . . . 5. Poor feeding, poor weight gain.
. . . . . 6. Significant decrease in level of activity, cyanotic/apneic "spell", or seizure-like episode.
. . . . . 7. Bilious or projectile vomiting.
. . . . . 8. History not suggestive of classical "infant colic syndrome".
. . . . . 9. History suggestive of physical abuse (injury not consistent with reported history, inappropriate delay, non-maternal caretaker).
. . . . . 10. Antibiotic pre-treatment ("partially treated" sepsis/meningitis), particularly in the young infant.
. . . . . 11. History of recent head trauma.
Table 2 - Physical Examination "Red Flags" Associated with Intractable Crying in Infancy (6)
. . . . . 1. Fever (>38 degrees C, 100.4 degrees F, rectal) in the infant less than twelve weeks of age.
. . . . . 2. Hypothermia.
. . . . . 3. Heart rate >230.
. . . . . 4. Lethargy, poor eye contact.
. . . . . 5. Paradoxical irritability.
. . . . . 6. Pallor, mottling, poor perfusion, weak pulse.
. . . . . 7. Hypotonia, jitteriness, poor feeding.
. . . . . 8. Petechiae, ecchymoses.
. . . . . 9. Meningismus, full fontanel, head circumference >95%.
. . . . . 10. Retinal hemorrhages, signs of basilar fracture/closed head injury.
. . . . . 11. Tachypnea, retractions, nasal flaring, cyanosis.
. . . . . 12. Abnormal extremity movement (hip, etc.).
. . . . . 13. Abdominal tenderness/mass.
. . . . . 14. Bloody stool (not just external streaks).
. . . . . 15. Bilious or projectile vomiting.
. . . . . 16. Weight less than the fifth percentile for age.
Table 3 - Differential diagnosis of Infant Colic Syndrome(6):
. . . . . 1) otitis media
. . . . . 2) meningitis/sepsis
. . . . . 3) encephalitis
. . . . . 4) urinary tract infection
. . . . . 5) osteomyelitis, septic arthritis
. . . . . 6) pneumonia
. . . . . 7) gingivostomatitis, pharyngitis
. . . . . 8) gastroenteritis
. . . . . 9) Kawasaki Disease
. . . . . 1) child abuse - shaken baby
. . . . . 2) corneal abrasion or foreign body in eye
. . . . . 3) accidental fracture/musculoskeletal injury
. . . . . 1) intussusception
. . . . . 2) reflux esophagitis (GERD)
. . . . . 3) constipation/anal fissure
. . . . . 4) midgut volvulus
. . . . . 5) incarcerated inguinal hernia
. . . . . 6) appendicitis
. . . . . 7) milk protein intolerance
. . . . . 8) testicular torsion
. . . . . 9) penile tourniquet (from hair)
. . . . . 1) underfeeding
. . . . . 1) hypoxemia/hypercapnia
. . . . . 1) hyponatremia, hypernatremia
. . . . . 2) metabolic acidosis
. . . . . 3) hypocalcemia/hypercalcemia, hypoglycemia, hyperglycemia
. . . . . 4) inborn errors of metabolism
. . . . . 1) diaper dermatitis
. . . . . 2) atopic eczema
. . . . . 3) burns (accidental and non-accidental)
. . . . . 4) foreign body (pin)
. . . . . 5) hair encirclement (strangulation of digit, penis, clitoris, uvula) diagnosed by a thorough physical exam
. . . . . 6) bites and stings
VIII. Drugs and Toxins
. . . . . 1) neonatal narcotic withdrawal
. . . . . 2) neonatal barbiturate, ethanol, hydantoin withdrawal
. . . . . 3) irritability related to smoking mothers who breastfeed
. . . . . 4) reaction to pertussis immunization
. . . . . 5) theophylline, antihistamine, decongestant, cyclic antidepressant, amphetamine, cocaine toxicity
A thorough history and a meticulous physical exam are the cornerstones of accurate diagnosis. Poole (5) described 56 afebrile infants who presented with unexplained excessive crying to the emergency department. The history provided clues to the final diagnosis in 20% of the cases, while the physical exam revealed the final diagnosis in 41% of the cases and provided clues to the final diagnosis in another 11%. Physical examination must start with a 2 or 3 minute period of observation from a distance with the child undressed, on the parent's lap. Assess the patient's appearance, distractibility, alertness, eye contact, ability to be comforted, respiratory rate and pattern, spontaneous extremity movement, etc. The extent of your work-up is usually determined from this observation period. Special emphasis should be given to the examination of the skin, palpation of the abdomen, eye examination (with funduscopic and eversion of the eyelids), evaluation of anterior fontanelle fullness, inspection of the tympanic membranes, oropharynx, and gums, palpation of extremities and clavicles, and performance of an anal rectal exam which may be done with a cotton tip swab.
If colic is determined to be the likely diagnosis, there have been a number of studies with varying results regarding treatment:
1. Taubman's (7,8) behavior-modification approach provides useful information for counseling parents (Table 4). His behavior-modification approach resulted in a 65-70% decrease of crying time (3.2 to 1.1 hours per day) in colicky infants in his 1984 and 1988 studies and a similar reduction in the crying time (3.8 to 1.1 hours per day) in a 1998 controlled study by Dihigo (9). This "good" approach assumes that colic results from inadvertent failure to respond to the infant's desires. The infant's crying is not a "cry of pain" but rather a way to communicate a need or desire. Taubman also described a "bad" approach (ignoring the baby) which assumes colic that results from over stimulation, therefore generally "ignoring" the baby (letting them cry) would be the logical treatment. The ignoring approach did not result in any decrease in the crying time in Taubman's 1984 study.
2. Simethicone (Mylicon, OTC) (10) (a non-toxic "defoaming" agent). The apparent effectiveness of simethicone (seen within 1-4 days in 54-67% of treated infants) probably represents a high-grade placebo effect. Simethicone converts gas foam into non-foam gas, but the gas remains in the bowel lumen.
3. Herbal tea (commercially available chamomile tea). Weizman, et al (11) showed that 57% of colicky babes improved (vs. 26% placebo), 5 oz. tea per dose with each colic episode not to exceed three times per day.
4. General counseling (6,7,12,13,14). Empathy and describing the natural history of colic to parents results in improvement by 3-4 months. Increased carrying time, automatic rocker swings, driving around the neighborhood (with baby in a car seat) and nap-time swaddling are benign measures that may be helpful.
Paregoric (tincture of opium), Bentyl (dicyclomine, possible association with SIDS) and Levsin (hyoscyamine sulfate, associated with anticholinergic toxicity) should NOT be used (6). Placing the infant in a car seat on the washing machine should NOT be used because of the possibility of falls and secondary head injury (6). Empiric formula changes are generally not useful, but this is a benign measure and it is often suggested. Mothers who are breast and bottle feeding should be encouraged to breast feed as much as possible and minimize formula feeding. Infants who are exclusively formula fed can be changed to a protein hydrolysate formula (Nutramigen, Pregestimil, Alimentum), as a trial to see if there is a beneficial response.
Table 4 - Good Colic Advice" for Parents: The underlying assumption of this advice is that continued crying in colicky infants results from the parents' inadvertent failure to respond to their infant's desires which the cries are signaling to the parents. The infant's crying is not a "cry of pain" but rather a way to communicate a need or desire.
1. Try to never let your baby cry.
2. In attempting to discover why your infant is crying consider these possibilities:
. . . . . a. The baby is hungry and wants to be fed.
. . . . . b. The baby wants to suck, although he/she is not hungry.
. . . . . c. The baby wants to be held.
. . . . . d. The baby is bored and wants stimulation.
. . . . . e. The baby is tired and wants to sleep.
. . . . . f. The baby needs his/her diaper changed.
3. If the crying continues for more than 5 minutes with one response, then try another.
4. Decide on your own in what order to explore the above possibilities.
5. Don't be too concerned about overfeeding your baby.
6. Don't be too concerned about spoiling your baby.
When infant crying continues despite all efforts to stop it, including feeding, do the following:
1. Put the baby in the crib and let him cry for up to one-half hour.
2. If still crying, pick the baby up for a minute or so to calm him/her then return him/her to the crib.
3. Repeat the above until the infant falls asleep or three hours have passed.
4. After three hours, feed the baby.
5. Do not shake the baby.
In summary, it is important to remember that crying is a non-specific response in an infant, which may be a major symptom of an underlying severe pathologic process and NOT necessarily just "colic." A careful history and examination combined with selected laboratory studies usually establishes a diagnosis. Crying may simply be a normal response to stress such as hunger, discomfort, or over or under-stimulation, or may represent the "infant colic syndrome" (paradoxical fussiness). Close follow-up is crucial if the etiology of the irritability and excessive crying is still somewhat obscure at discharge. Do not discharge an irritable infant if "extreme fussiness" has not resolved, particularly if a "red flag" is present.
1. Which of these are NOT a feature of the infant colic syndrome?
. . . . . a. distinctive high-pitched pain cry
. . . . . b. inconsolability
. . . . . c. paroxysmal onset
. . . . . d. vomiting
2. Which of these is correct?
. . . . . a. colic usually occurs in infants greater than 3 months of age
. . . . . b. fever often accompanies colic
. . . . . c. colic is very rarely seen
. . . . . d. none of the above are correct
3. All of the following are correct regarding historical red flags, except:
. . . . . a. Red flags suggest that this intractable crying infant may not be due to the classic "infantile colic syndrome".
. . . . . b. Red flags include head trauma.
. . . . . c. Red flags exclude maternal illicit drug use.
. . . . . d. Red flags include paradoxical irritability.
4. Physical red flags include which of the following (check all that apply):
. . . . . a. fever
. . . . . b. lethargy
. . . . . c. poor feeding
. . . . . d. abdominal tenderness
5. True/False: Good advice for parents assumes their infant is trying to communicate a need or desire resulting from the parents inadvertent failure to respond to their infant's desires.
6. An acceptable approach(es) to infant colic include(s):
. . . . . a. Let the baby cry and ignore the baby.
. . . . . b. Put the baby in a car seat on the washing machine.
. . . . . c. Shake the baby to sleep.
. . . . . d. Try to discover why your infant is crying.
1. Wessel M.A, Cobb JC, Jackson EB, et al. Paroxysmal Fussing In Infancy, Sometimes called Colic. Pediatrics 1954;14:421-424.
2. Brazelton TB. Crying In Infancy. Pediatrics 1962;29:579-588.
3. Lester BM, Boukydis CFZ, Garcia-Coll CT, Hole WT. Colic For Developmentalists. Infant Mental Health J 1990;11(4):321-333.
4. Carey WB. "Colic"-Primary Excessive Crying as Infant-Environment Interaction. Pediatr Clin North Am 1984;31(5):993-1005.
5. Poole SR. The Infant With Acute, Unexplained, Excessive Crying. Pediatrics 1991;88:450-455.
6. Bolte RG. Intractable Crying. In: May HL, et al (eds). Emergency Medicine. 1992, Boston: Little, Brown, and Company, 1810-1817.
7. Taubman B. Clinical Trial of the Treatment of Colic by Modification of Parent-Infant Interaction. Pediatrics 1984;74:998-1003.
8. Taubman, B. Parental Counseling Compared With Elimination of Cow's Milk or Soy Milk Protein for the Treatment of Infant Colic Syndrome: A Randomized Trial. Pediatrics 1988;81:756-761.
9. Dihigo SK. New Strategies for the Treatment of Colic: Modifying the Parent/Infant Interaction. J Pediatr Health Care 1998;12:256-262.
10. Danielsson B, Hwang CP. Treatment of Infantile Colic with Surface Active Substance (simethicone). Acta Paediatr Scand 1985;74:446-450.
11. Weizman Z, Alkrinawi S, Goldfarb D, et al. Efficacy of Herbal Tea Preparation in Infantile Colic. J Pediatr 1993;122(4):650-652.
12. Fleisher DR. Coping with Colic. Contemp Peds 1998;15:144-156.
13. Carey WB. The Effectiveness of Parent Counseling in Managing Colic. Pediatrics 1994;94:333-334.
14. Wolke D, Gray P, Meyer R. Excessive Infant Crying: A Controlled Study of Mothers Helping Mothers. Pediatrics 1994;94:322-332.
Answers to questions
1.d, 2.d, 3.c, 4.abcd, 5.true, 6.d