Colic

For most parents, a human baby's crying is a particularly evocative signal, which compels them to seek and resolve the cause. Some babies, though, cry for prolonged amounts of time without apparent reason in the first three months after they are born, worrying their parents and leading many to seek expert help. In Western societies, this puzzling phenomenon has come to be known as colic. From a scientific viewpoint, both this word and the nature of the phenomenon that underlies it remain a source of controversy.

Defining and Measuring Colic

Part of the confusion in this area arises because the word colic has historical and etymological connotations. It comes from the Greek word kolikos, the adjectival form of kolon (the intestine), so that it is often used not just to refer to the behavior— crying—but to infer the presumed cause: gastrointestinal disturbance and pain. The eminent English pediatrician Ronald Illingworth, for instance, referred in 1985 to "pain that is obviously of intestinal origin" (p. 981). In fact, whether or not most babies who cry in this way have indigestion, and whether they are in pain, are both uncertain.

The second source of confusion is that, for obvious reasons, the clinical phenomenon is parental complaint about infant crying, rather than infant crying itself. Not surprisingly, factors such as parental inexperience have been found to increase the likelihood of clinical referral, throwing the spotlight onto parental, rather than infant, characteristics. This has raised issues about individual parents' vulnerability and tolerance, and about the extent to which colic as a distinct condition might be a Western, socially constructed, phenomenon.

One way to resolve this confusion is to define colic strictly in terms of a specific amount of infant crying. Morris Wessel and colleagues' (1954) Rule of Threes ("Fussing or crying lasting for a total of more than three hours per day and occurring on more than three days in any one week," p. 425) has been used in this way. From a research point of view, the advantage is that infants can be identified for study in a standard way. The disadvantage is that the definition is arbitrary; it is unlikely to help parents to be told that their baby does not have colic because he or she fails to meet this research criterion. Moreover, it implies the need to measure crying for a week without intervening, which many parents are reluctant to do.

Rather than employing a single definition, a workable alternative is to define colic broadly as prolonged, unexplained crying in a healthy one- to three-month-old baby, and the impact of this on parents. Information about the infant and parental parts of this phenomenon, within and between cultures, can then be sought in a systematic way. The alternative—of abandoning and replacing the word colic—has also been proposed, but it is so ingrained that this seems unlikely to work in practice.

Infant Crying and Its Impact in Western Cultures

Ronald Barr, Ian St. James-Roberts, and Maureen Keefe (2001) brought together our knowledge of infant crying and its impact on Western parents and clinical services. The principal findings can be summarized as follows:

1. In general, Western infants cry about twice as much in the first three months as they do at later ages, with the amount of crying peaking at around five weeks of age (the infant crying peak). Around two hours of fussing and crying in twenty-four hours has been reported in U.S., Canadian, and English samples. Rather less has been reported in other European countries, but the reason for this is not yet clear. Infant crying at this age also clusters in the evening (the evening crying peak);
2. As well as its greater amount, infant crying in the first three months has distinct qualitative features, which help to explain its impact on parents. These include the existence of bouts which occur unexpectedly and are prolonged, relatively intense to listen to, and difficult to soothe effectively;
3. Parental complaints to clinicians about infant crying problems also peak during the first three months, while infants identified in this way share the same features as other infants, but often to a more extreme degree. This has led to the view that many infants identified as problem criers—and hence labelled as colic cases—are at the extreme end of the normal distribution of crying at this age, rather than having a clinical condition;
4. Crying in the early months is a graded signal, which signals the degree of an infant's distress, but not precisely what is causing the crying (Gustafson, Wood, and Green 2000). It was previously believed that babies had different cry "types" (e.g., hunger, anger, pain) that allowed a sensitive parent to detect the causes of crying and to intervene to stop it. The unfortunate implication was that a baby who cried a lot had incompetent parents. Instead, it has become clear that "reading" the cause of crying from its sound is at best difficult and, in everyday circumstances, often impossible during the first three months. At this age, babies may cry intensely but the cry itself does not tell you what the problem is;
5. Most babies grow out of their crying as they get older. Providing their parents can cope, follow-up studies have found that the infants are normal in their cognitive, social and emotional development, and sleep. However, a small minority do have long-term problems (Papousek and von Hofacker 1998). It is not yet clear whether these infants are different in what causes their crying, or in how their parents respond to and care for their babies over the long term.
6. Women who are prone to depression can have their depression triggered by an objectively irritable newborn (Murray et al. 1996). This emphasizes the need to consider infant crying and colic in terms of parental and family vulnerability, rather than solely as an infant phenomenon.

Infant Crying and Its Impact in Non-Western Cultures

In his 1985 review, Illingworth identified a Punjabi word for infant colic, noting that it was recognized in India, where it was considered to be due to the evening gods. In contrast, many anecdotal accounts have suggested that babies in non-Western cultures hardly cry at all, and attribute this to the almost continuous holding, frequent breast-feeding, and rapid response to babies' cries in such cultures (referred to as proximal care). Overall, the empirical evidence from non-Western cultures is not adequate to resolve this issue. There is clear evidence of a difference in amounts infants cry inbetween African cultures which employ proximal, compared to more distal care (Hewlett et al. 2000). However, the study involved infants over three months of age, by which age colic is usually over, and crying has reduced, in Western infants. Other studies have certainly indicated that non-Western infants cry less in the first three months (Barr et al. 1991; Lee 2000), but this finding requires clarification and it is uncertain whether it reflects care differences or other factors. Attempts to introduce aspects of proximal care, such as supplementary carrying, into Western families have not produced reliable benefits (St. James-Roberts et al. 1995).

Since infants often do stop crying when responded to, it is reasonable to suppose that proximal care is associated with somewhat reduced crying, but whether or not it prevents the bouts of prolonged, unexplained, and "unsoothable" crying in one- to three-month-old infants that trouble Western parents is not yet known.

The Causes of Colic

Although most babies identified as colic cases probably have nothing wrong with them, organic disorders, including food intolerances, can give rise to crying in occasional cases. The best evidence-based estimate is that organic diseases as a whole are responsible for no more than 10 percent of cases where unexplained crying in one- to three-month-old infants is the presenting complaint (Gormally 2001).

There is growing evidence that intolerance of certain foods, especially cow's milk protein, can cause crying in some young babies. The mechanism is not certain, but it appears to be possible for the proteins to be passed via breast-feeding as well as bottle-fed milk or formula. However, reviews by a research pediatrician (Gormally 2001) and pediatric gastroenterologist (Treem 2001) have both concluded that food intolerance of this sort is rare. William Treem estimates that about 2 percent of infants overall are allergic to cow's milk protein, while only 1 in 10 infants taken to clinicians with problem crying have food intolerance. Only around 5 percent of infants diagnosed as having colic have gastroesophageal reflux (gastric acid refluxed into the esophagus). Treem also emphasizes that infants with feed-intolerance or gastrointestinal disorders can often be easily identified, by symptoms such as vomiting and diarrhea, blood in their stools, or a strong family history of atopy, asthma, or eczema.

A second possible cause of colic sometimes proposed is inadequate parenting. As noted above, it remains possible that Western approaches to baby-care as a whole may contribute to infant crying, although there is insufficient evidence to establish if this is the case. In principle, too, parental neglect can cause a baby to cry. However, recent evidence has made clear that many—probably most—Western babies who cry a lot do so in spite of highly sensitive and responsive parental care. Indeed, their parents have usually made extraordinary efforts to resolve the crying. The implication is that there is something about these babies that makes them cry despite care that does not cause crying in most babies.

The search for what this might be has focused on the so-called neurobehavioral shift believed to occur at around two months of age, whereby control over behavior moves from subcortical brain systems to the cerebral cortex. Evidence of this shift can be seen in the disappearance of newborn infant reflexes, such as the grasping reflex, and in the emergence of social smiling and more sophisticated perceptual and cognitive abilities. During this transition period, neurological regulation of behavior is believed to be poor, leading infants to be more or less overreactive, or poor at damping-down their crying once they have started (that is, at self-soothing). Several studies have found evidence that infants who cry a lot are highly reactive when undressed and challenged by handling and standard tests (e.g., White et al. 2000). The goal now is to understand the neurological and developmental processes involved, so that the reasons for the differences in reactivity between babies becomes clear. By understanding the types of stimulation which most provoke reactive behavior, it may also be possible to assist parents in how to minimize it.

Managing Crying in Oneto Three-Month-Old Infants

Many parents are accurate in their judgments of crying, but some may be influenced by their anxiety or expectations. Because the presenting complaint is usually parental concern about infant crying, accurate assessment of the crying is the first goal. Behavior diaries kept prospectively by parents are the method of choice, with detailed questionnaires and interviews being used where diaries are impossible. The resulting information can assist diagnosis and may provide parents with reassurance and insight.

Many parents link their baby's crying to digestive disturbances and are likely to want to change their method of infant feeding. As noted earlier, such disturbances are rare—evidence suggests no more than 2 percent of infants overall, and 10 percent of infants who are presented with crying problems, have gastrointestinal disorders, and these cases can usually be identified by their symptoms. Siobhán Gormally (2001) adds other symptoms of organic disorders for parents and physician to look out for, including a high pitched cry, lack of a time-of-day peak, failure to thrive or weight loss, a positive family history of migraine, maternal drug ingestion, and persistence of symptoms past four months of age. She stresses the importance of infant skin, eye, skeletal, neurological, gastrointestinal, and cardiovascular assessments, highlighting the need for parents to involve physicians in the decision process.

Where infants lack these symptoms, and are otherwise healthy and putting on weight normally, there is no evidence-based reason for assuming that their crying has a gastrointestinal cause, or for treating it with a change of feeding method or diet. In practice, clinicians differ in how readily they recommend a dietary change as a treatment for persistent crying. Where this is contemplated, the disadvantages need to be balanced against the possible gains. One is that breast-feeding is beneficial for young babies, whereas excluding cow's milk protein from a lactating mother's diet is likely to be trying for her and her family. A second is that research trials using dietary change to treat crying have seldom produced clear-cut advantages. Typically, some infants have improved somewhat, but continue to cry above normal levels, whereas other infants have not benefited at all. Other pitfalls include a high placebo rate–where babies seem to improve initially following any change—and the danger that an infant will be considered generally allergic or fragile by parents.

The alternative to dietary change is to use behavior management strategies to support parents and to help them to minimize the crying until it resolves. This approach follows from the evidence, cited earlier, that some parents are especially vulnerable to persistent infant crying, highlighting the need to consider this as a family, rather than infant, problem. Elements of this approach can include:

• Viewing the first three months of infancy as a developmental transition, which all babies go through more or less smoothly.
• Reassuring parents that it is normal to find crying aversive and discussing the dangers of abuse and shaken baby syndrome.
• Examining the notion that crying means that there is something wrong with a baby of this age and introducing alternatives—such as the possibility that it signals a reactive or vigorous baby.
• Discussing ways of containing and minimizing the crying, and highlighting positive features of the baby.
• Considering the availability of supports and the development of strategies which allow parents to cope, take time out and "recharge their batteries."
• Empowering parents and reframing the first three months as a challenge to be overcome, with positive consequences for themselves and their relationships with their babies.

Also implicit in this approach is the need for health services to find means of identifying and supporting the most vulnerable families, and to continue to monitor the infant, at least until the crying problems have resolved.

See also:Childcare; Childhood, Stages of: Infancy

Bibliography

barr, r. g.; konner, m.; baseman, r.; and adamson, l.(1991) "crying in kung san infants: a test of the cultural specificity hypothesis." developmental medicine and child neurology 33:601–610.

barr, r. g.; st. james-roberts, i.; and keefe, m. r., eds.(2001). new evidence on early infant crying: its origins, nature and management. skillman, nj: johnson and johnson pediatric institute round table series.

gormally, s. (2001) "clinical clues to organic etiologies ininfants with colic." in new evidence on early infant crying: its origins, nature and management, edited by r. g. barr, i. st. james-roberts, and m. r. keefe. skillman, nj: johnson and johnson pediatric institute round table series.

gustafson, g. e.; wood, r. m.; and green j. a. (2000)."can we hear the causes of infant crying?" in crying as a sign, a symptom, and a signal, ed. r. g. barr, b. hopkins, and j. a. green. london: mackeith press.

hewlett, b. s.; lamb, m.; leyendecker b.; andscholmerich, a. (2000). "internal working models, trust, and sharing among foragers." current anthropology 41:287–297.

illingworth, r. s. (1985). "infantile colic revisited."archives of disease in childhood 60:981–985.

lee, k. (2000). "crying patterns of korean infants in institutions." child: care, health and development 26:217–228.

murray, l.; stanley, c.; hooper, r.; king, f.; and fiori-cowley, a. (1996). "the role of infant factors in postnatal depression and mother-infant interaction." developmental medicine and child neurology 38:109–119.

papousek, m., and von hofacker, n. (1998). "persistentcrying in early infancy: a non-trivial condition of risk for the developing mother-infant relationship." child: care, health and development 24:395–424.

st. james-roberts, i.; hurry, j.; bowyer, j.; and barr, r. g.(1995). "supplementary carrying compared with advice to increase responsive parenting as interventions to prevent persistent infant crying." pediatrics 95:381–388.

treem,w. r. (2001). "assessing crying complaints: the interaction with gastroesophageal reflex and cow's milk protein intolerance." in new evidence on early infant crying: its origins, nature and management, edited by r. g. barr, i. st. james-roberts, and m. r. keefe. skillman, nj: johnson and johnson pediatric institute round table series.

wessel, m. a.; cobb, j. c.; jackson, e. b.; harris, g. s.; and detwiler, a. c. (1954). "paroxysmal fussing in infancy, sometimes called 'colic.'" pediatrics 14:421–433.

white, b. p.; gunnar, m. r.; larson, m. c.; donzella, b.; and barr, r. g. (2000). "behavioral and physiological responsivity, sleep, and patterns of daily cortisol production in infants with and without colic." child development 71:862–877.

ian st. james-roberts

Colic

Definition

Colic is persistent, unexplained crying and discomfort in an otherwise healthy baby between the ages of two weeks and about five months.

Description

Colic affects 10-20% of all infants. It is more common in boys than in girls and most common in a family's first child. Symptoms of colic usually appear when a baby is 14-21 days old, reach a peak at the age of three months, and disappear within the next eight weeks.

Causes & symptoms

Some babies who have colic are simply fussy. Others cry so hard that their faces turn red, then pale. Episodes may occur frequently but intermittently, usually beginning with prolonged periods of crying in the late afternoon or evening. Crying may intensify, taper off, and then get even louder. It can last for just a few minutes or continue for several hours. During a colicky episode, babies' bellies often look swollen, feel hard, and make a rumbling sound. Many babies grow rigid, clench their fists, curl their toes, and draw their legs toward their body. A burp or a bowel movement can end an attack. Most babies who have colic do not seem to be in pain between attacks.

One cause of colic may be the swallowing of large amounts of air, especially during feeding time. Air may then become trapped in the digestive tract and cause discomfort. Other possible causes include:

• immaturity of the digestive system
• food intolerances
• too little or too much food
• lack of sleep
• loneliness
• overheated formula
• overstimulation resulting from too much noise, light, or activity
• stress and tension on the part of the mother and other caregivers
• foods the mother eats, if breast-feeding, which are allergens or irritants for the baby

Diagnosis

Colic is suspected in an infant who:

• has cried loudly for at least three hours a day at least three times a week for three weeks or longer
• is not hungry but cries for several hours between dinnertime and midnight
• demonstrates the clenched fists, rigidity, and other physical traits associated with colic

The baby's medical history and a parent's description of eating, sleeping, and crying patterns are used to confirm the diagnosis of colic. Physical examination and laboratory tests are used to rule out infection, intestinal blockage, and other conditions that can cause abdominal pain and other colic symptoms.

Treatment

Parents should consult their healthcare practitioner before giving any herbal or allopathic medications to very young children. Teas made with chamomile (Matricaria recutita ), lemon balm (Melissa officinalis ), peppermint (Mentha piperita ), catnip (Nepeta cataria ), or dill (Anethum graveolens ) can lessen bowel inflammation and reduce gas . Slippery elm powder (Ulmus fulva ) is soothing and healing for the digestive system. Homeopathic remedies that may be effective for colic include Bryonia 30c every five minutes as needed, and Chamomilla 6c every five minutes for up to an hour. A homeopath can be further consulted for remedies to help strengthen the child's entire constitution. In addition, it is helpful to give the Bach flower essence called Rescue Remedy to the infant and to the caregivers. This will help to calm the situation.

Hands-on treatments are often helpful in treating colic. Squeezing the acupressure point at the webbing between the thumb and index finger of either hand can calm a crying child. Gently massaging the abdomen with a circular motion can also be used. Applying warm compresses over the child's abdomen can also relieve cramping.

Soothing movements may help to calm the baby. Colicky babies cry less when they are soothed by the motion of a swing, a car ride, or being carried in a parent's arms. Taking the infant for a walk may also help with soothing and encouraging sleep. Rocking the baby in a quiet, darkened room can be used to reduce over-stimulation, as well.

Giving small, frequent feedings rather than a few large feedings will be easier on digestion for a bottle-fed baby. For those who breastfeed, food allergens can be transmitted through the milk of the mother. Therefore, foods that cause problems in the infant should be removed from the mother's diet. These are most often likely to be coffee, tea, chocolate, citrus fruit, peanuts, wheat, and vegetables belonging to the cabbage family, including broccoli.

Allopathic treatment

Medications do not cure colic. Doctors sometimes recommend simethicone (Mylicon drops) to relieve gas pain. Generally, parents are advised to take a practical approach, using home remedies. However, a doctor should be notified if a baby with colic:

• develops a rectal fever higher than 101°F (38.3°C)
• cries for more than four hours without relief
• vomits
• has diarrhea or stools that are black or bloody
• continually loses weight
• continually eats less than normal

Expected results

Colic is distressing, but it is not dangerous. Symptoms almost always disappear before a child is six months old.

Prevention

To help prevent air from being swallowed during feedings, the infant's back can be gently massaged to release trapped gas bubbles. Keeping the infant in a sitting position while feeding is also helpful. Bottle-fed babies can swallow air if the nipple holes in the bottle are either too large or too small. This can be checked by filling the bottle with formula, turning it upside down, and counting the number of drops released as the bottle is being shaken or squeezed. The hole should allow the release of formula at the rate of one drop per second. In addition, sometimes a different style of nipple may improve nursing. A pharmacy should be consulted for additional guidance.

Cow's milk can often be disruptive to an infant's digestion. When cow's milk is the source of the symptoms, bottle-fed babies should be switched to a soy protein formula. (Regular soymilk should not be used, as it is not formulated for the nutritional needs of a nursing infant.) Goat's milk is easier to digest than cow's milk, and is also an acceptable substitute. Alternately, a tablespoon of acidophilus liquid or powder can be added to eight ounces of the infant's formula. A tablespoon of yogurt can also be used for this purpose. If an intolerance to cow's milk is suspected in a breastfed infant, the mother should eliminate dairy products from her diet, gradually reintroduce after seven days, and monitor the baby's symptoms. This should be done with any suspected allergen or irritating foods.

Resources

BOOKS

Editors of Time Life Books. The Medical Advisor: The Complete Guide to Alternative & Conventional Treatments. Alexandria, VA: Time-Life Books, 1996.

Taylor, Robert, ed. Family Medicine Principles and Practice. New York: Springer-Verlag, 1994.

Weed, Susun. Wise Woman Herbal for the Childbearing Year. New York: Ash Tree Publishing, 1986.

ORGANIZATIONS

American Academy of Family Physicians. 880 Ward Parkway, Kansas City, MO 64114. http://www.aafp.org.

Patience Paradox

Colic

Definition

Colic is persistent, unexplained crying in a healthy baby between two weeks and five months of age.

Description

Colic, which is not a disease, affects 10-20% of all infants. It is more common in boys than in girls and most common in a family's first child. Symptoms of colic usually appear when a baby is 14-21 days old, reach a crescendo at the age of three months, and disappear within the next eight weeks. Episodes occur frequently but intermittently and usually begin with prolonged periods of crying in the late afternoon or evening. They can last for just a few minutes or continue for several hours. Some babies who have colic are simply fussy. Others cry so hard that their faces turn red, then pale.

Causes and symptoms

No one knows what causes colic. The condition may be the result of swallowing large amounts of air, which becomes trapped in the digestive tract and causes bloating and severe abdominal pain.

Other possible causes of colic include:

• digestive tract immaturity
• food intolerances
• hunger or overfeeding
• lack of sleep
• loneliness
• overheated milk or formula
• overstimulation resulting from noise, light, or activity
• tension

During a colicky episode, babies' bellies often look swollen, feel hard, and make a rumbling sound. Crying intensifies, tapers off, then gets louder. Many babies grow rigid, clench their fists, curl their toes, and draw their legs toward their body. A burp or a bowel movement can end an attack. Most babies who have colic do not seem to be in pain between attacks.

Diagnosis

Pediatricians and family physicians suspect colic in an infant who:

• has cried loudly for at least three hours a day at least three times a week for three weeks or longer
• is not hungry but cries for several hours between dinnertime and midnight
• demonstrates the clenched fists, rigidity, and other physical traits associated with colic

The baby's medical history and a parent's description of eating, sleeping, and crying patterns are used to confirm a diagnosis of colic. Physical examination and laboratory tests are used to rule out infection, intestinal blockage, and other conditions that can cause abdominal pain and other colic-like symptoms.

Treatment

Medications do not cure colic. Doctors sometimes recommend simethicone (Mylicon Drops) to relieve gas pain, but generally advise parents to take a practical approach to the problem.

Gently massaging the baby's back can release a trapped gas bubble, and holding the baby in a sitting position can help prevent air from being swallowed during feedings. Bottle-fed babies can swallow air if nipple holes are either too large or too small.

Nipple-hole size can be checked by filling a bottle with cold formula, turning it upside down, and counting the number of drops released when it is shaken or squeezed. A nipple hole that is the right size will release about one drop of formula every second.

Babies should not be fed every time they cry, but feeding and burping a baby more often may alleviate symptoms of colic. A bottle-fed baby should be burped after every ounce, and a baby who is breastfeeding should be burped every five minutes.

When cow's milk is the source of the symptoms, bottle-fed babies should be switched to a soy milk hydrolyzed protein formula. A woman whose baby is breastfeeding should eliminate dairy products from her diet for seven days, then gradually reintroduce them unless the baby's symptoms reappear.

Since intolerance to foods other than cow's milk may also lead to symptoms of colic, breastfeeding women may also relieve their babies' colic by eliminating from their diet:

• coffee
• tea
• cocoa
• citrus
• peanuts
• wheat
• broccoli and other vegetables belonging to the cabbage family

Rocking a baby in a quiet, darkened room can prevent overstimulation, and a baby usually calms down when cuddled in a warm, soft blanket.

Colicky babies cry less when they are soothed by the motion of a wind-up swing, a car ride, or being carried in a parent's arms. Pacifiers can soothe babies who are upset, but a pacifier should never be attached to a string.

A doctor should be notified if a baby who has been diagnosed with colic:

• develops a rectal fever higher than 101°F (38.3°C)
• cries for more than four hours
• vomits
• has diarrhea or stools that are black or bloody
• loses weight
• eats less than normal

Alternative treatment

Applying gentle pressure to the webbed area between the thumb and index finger of either hand can calm a crying child. So can gently massaging the area directly above the child's navel and the corresponding spot on the spine. Applying warm compresses or holding your hand firmly over the child's abdomen can relieve cramping.

Teas made with chamomile (Matricaria recutita ), lemon balm (Melissa officinalis ), peppermint (Mentha piperita ), or dill (Anethum graveolens ) can lessen bowel inflammation and reduce gas. A homeopathic combination called "colic" may be effective, and constitutional homeopathic treatment can help strengthen the child's entire constitution.

Prognosis

Colic is distressing, but it is not dangerous. Symptoms almost always disappear before a child is six months old.

Prevention

Many doctors believe that colic cannot be prevented. Some alternative practitioners, however, feel that colic can be prevented by an awareness of food intolerances and their impact.

Resources

ORGANIZATIONS

American Academy of Family Physicians. 8880 Ward Parkway, Kansas City, MO 64114. (816) 333-9700. 〈http://www.aafp.org〉.

American Academy of Pediatrics. 141 Northwest Point Boulevard, Elk Grove Village, IL 60007-1098. (847) 434-4000. 〈http://www.aap.org〉.

Colic

Definition

Colic is defined as when a baby cries for longer than three hours every day for more than three days a week. It is the extreme end of normal crying behavior. The condition is harmless, even though it is distressing for parents or caregivers.

Description

Almost all babies go through a fussy period, but when crying lasts longer than about three hours a day and is not caused by a specific medical problem, it is considered colic. Pediatricians will tell parents that babies do not exhibit colic symptoms until around three weeks of age, but there are many parents who would disagree. The physician may also tell the parents that it will be at its worst around six weeks of age and then usually stops around three or four months of age. Some parents might disagree with that, too. It can be acknowledged as a relatively short period of time in a baby's life, but it seems like an eternity to the parents. It frequently, but not always, starts at the same time of day, and for most babies that is in the evening. The inconsolable crying begins suddenly; the legs may be drawn up, and the belly distended. The hands may be clenched. It seems as if it goes on forever and winds down when the baby is exhausted or when gas or stool is passed. Some babies continue crying for longer than three hours.

Demographics

Anywhere from 20 to 25 percent of babies cry enough to meet the definition of colic. There are approximately 4 million babies born every year in the United States, so that means almost a million babies have symptoms of colic.

Causes and symptoms

The baby with colic tends to be unusually sensitive to stimulation. Some babies experience greater discomfort from intestinal gas. Some cry from hunger. Some cry from overfeeding. Fear , frustration, or even excitement can lead to abdominal discomfort and colic. The situation may become a viscous cycle: the people caring for the baby become worried, anxious, or depressed, and the baby can sense their emotions and cries more. There are two theories regarding the cause of colic, and the first is that it is due to an immature nervous system. The majority of babies with colic can be classified with this condition to some degree. A small percentage of babies with colic may have milk allergies , reflux, and silent reflux. Formula changes or changes in diet for the breastfeeding mother can contribute to the problem. One recent study noted that the babies of mothers who smoke have a higher incidence of colic. The culprit is likely nicotine, which increases blood levels of a gut protein involved in digestion, according to Brown University epidemiologist Edmond Shenassa. This situation could result in painful cramping that makes babies cry.

When to call the doctor

Parents should call the pediatrician if they are concerned. A careful physical exam is prudent to insure the baby does not have a medical problem that needs attention. It is imperative not to misdiagnose a serious condition and call it colic. Should the behavior pattern of crying suddenly change and be associated with fever, vomiting, diarrhea , or other abnormal symptoms, parents should call the doctor immediately.

Diagnosis

Diagnosis occurs mostly by elimination. If the physical exam demonstrates nothing else is wrong, the pediatrician may diagnose colic by the parent's description of the crying.

Treatment

Parents should remember that colic is a benign condition, and the only treatment is through a matter of experimentation and observation. If a trigger for colic can be identified, that is a big start. Possible triggers include:

• Foods: Avoid stimulants such as caffeine and chocolate if breastfeeding.
• Formula: Switching formula works for some babies but is not at all helpful for others.
• Medicine: Medication that a breastfeeding mother takes may affect the baby.
• Feeding: If a bottle feeding takes less than 20 minutes, the hole in the nipple may be too large. Avoid overfeeding the infant or feeding too quickly.

Other strategies that can be tried include:

• movement and vibration
• using an infant swing
• rocking in a rocking chair
• going for a car ride
• holding the baby close in an upright position
• swaddling in a blanket

Nutritional concerns

The primary nutritional concerns are related to the breastfeeding mother's diet by avoiding the intake of stimulants. For those who are bottle feeding, a switch in the formula may be beneficial.

Prognosis

Colic is a benign condition. The infant outgrows it. Moreover, in spite of apparent abdominal pain , colicky infants eat well and gain weight normally.

Prevention

Very little can be done to prevent colic, other than trying to discover triggers that cause the baby to cry and to not smoke.

Parental concerns

It is natural for parents to be concerned when a baby cries, and their concern only heightens if it seems they can do nothing to stop the crying. Once a physical exam has been performed and medical causes have been ruled out, parents can accept the fact that the baby has colic and try to work with it the best way possible. They may want to take breaks from the baby by dividing childcare between them. A parent can be more loving to a baby when the parent has a chance to refresh.

See also Crying and fussing in an infant.

Resources

BOOKS

Seidel, Henry M., et al. Primary Care of the Newborn, 3rd ed. St. Louis, MO: Mosby, 2001.

WEB SITES

What Is Colic? Available online at <www.colichelp.com/> (accessed December 8, 2004).

"Your Colicky Baby." Kids Health for Parents. Available online at <http://kidshealth.org/parent/growth/growing/colic.html> (accessed December 8, 2004).

Linda K. Bennington, MSN, CNS

colic (kol-ik) n. severe abdominal pain, usually of fluctuating severity, with waves of pain seconds or a few minutes apart. infantile c. colic that is common among babies, due to wind in the intestine associated with feeding difficulties. intestinal c. colic due to partial or complete obstruction of the intestine or to constipation. Medical names: enteralgia, tormina. renal c. excruciating pain caused by dilatation and spasm of the ureter when stones are present in the kidney, renal pelvis, or ureter. See also biliary (colic).