Colic
The 5 S's

• a common problem that occurs
• there is a lack of a uniform definition for infantile colic
• definition: unexplained paroxysms of irritability, fussiness, or crying in an infant
• Rule of 3's: usually lasts longer than 3 hours per day, episodes occur more than 3 times per week, usually have been present for 3 weeks before presenting to physician, starts between day 3 and 3 weeks of age, (peaking at 6 weeks of age)     and usually subsides by 3-4 months of age
• Paroxysms generally occur in the evenings and usually start in the first month (between 3 and 21 days of age) and subside by 3 to 4 months of age. Patient appear normal between episodes.
• In an infant with colic, no underlying disease is responsible for the crying
• normal crying gradually increases from birth until 2 months of age, when the child may cry for a total of 2.5 hours per day. The distinction between normal crying and colic is not clear. Colic may simply represent a point further along an a continuum of infant behavior
• In a patient with a normal PE, is consolable, and has a hx c/w infantile colic, laboratory tests are usually not required.
• On crying...The newborn cry can emit a 80 to 100 dB sound for prolonged periods. Crying in early infancy is an excellent signal of need, but a poor signal of what is needed

Etiology

• unclear
• theories: dietary antigens (milk proteins), abnormal peristalsis, excessive gas production, infant temperment, "fourth trimester"
• Dietary antigens: may play a role in a subset of infants: cow's milk whey or casein; or soy milk protein; or maternal consumption of cow's milk have all been associated, but are not consistent findings. Parental consoling of the infant may be more effective than formula changes. Consoling may include: feeding, holding, giving a pacifier, stimulating or putting infant to bed. Re-exposure of a diet-treated group to cow or cow's milk antigen may not result in an increase in cyring time.
• Abnormal peristalsis or excessive gas: episodes may appear to be associated with pain that is relived after the passage of flatus; However, swallowed air is an unconvincing explanation for colic. Radiographs of fussy babies show they have more air in the GI tract when they finished crying than when they began.¹⁵ And two double-blind, controlled studies have proved that simethicone drops are no more effective at calming crying than is placebo.^16,17
• Dicyclomine hydrochloride, an anticholinergic, may result in decreased crying, but it has severe side effects (hypersensitivity reactions, apnea), so it is NOT APPROVED for children under 6 m/o. Drugs that have been shown to work include: simethicone, dimethicone, phenobarbitol and alcohol.
• Lactose malabsorption may present with gas, watery diarrhea and cramps. A lactose feeding with a hydrogen breath test may confirm this diagnosis. us a non-lactose containing formula (ie, soy-based, Nutramigen).
• GERD: Best current estimates are that, at most, only 2% to 4% of colic is secondary to GERD.
• The theory of the missing fourth trimester (Harvey Karp) is compatible with all known characteristics of colic :
  • Delayed onset in premature babies. The paucity of alert time in these babies may simulate life in the womb. It is not until two weeks post-term that babies enter a period of increased attention to the world.
  • Symptoms suggestive of intestinal pain. These are probably an overreaction of an immature neurologic system to normal intestinal sensations (e.g., the gastrocolic reflex).
  • Evening predominance of crying. This may be caused by a gradual accumulation of stress throughout the day in the absence of calming rhythmic stimulation.
  • Calming effect of relaxing and shushing. These two things directly mimic the womb.
  • Absence of colic in certain cultures. The parents in these cultures imitate the womb for the baby all day long with constant holding and rocking and frequent nursing.
  • Cessation of colic after approximately three months. This fits perfectly with the theory of the missing fourth trimester. Recreating the sensory milieu of the womb calms newborns not because they're nostalgic for the "good life" they had in the womb but because it triggers a profound soothing response—what I call the calming reflex—that halts crying and promotes relaxation.

Treatment

• The 5 S's
• Do not say colic is a developmental phenomenon that the child will soon outgrow. Empathize with the intense level of frustration and anger for the entire family. Colic may be associated with parental: exhaustion, breastfeeding failure, marital stress, postpartum depression, and child abuse.
• Reassure that no specific problem exists. Acknowledge that the infant is crying more than average and that it can be stressful for the family.
• Although controversial, changing the formula will probably not affect the course. A switch from lactose based to soy based formulas may backfire, as soy protein may be as antigenic as cow's milk. If an allergic cause is suspected, a formula change to a hydrolyzed casein formula (Nutramigen) may be considered.
• Consoling may include: feeding, holding, giving a pacifier, stimulating or putting infant to bed.
• Background noise or vibration may help.
• Overstimulation may be a cause. If inconsolable after 20-30 minutes of active intervention, decrease stimulation by putting infant to bed in a quiet environment
• Medication is controversial. No specific drug therapy can be recommended for the treatment of colic. Historical note: paregoric (a mixture of opium and ethanol) was used in the past!
• Close followup for anxious parents

Reference:

Kliegman. Practical Strategies in Pediatric Diagnosis and Therapy

Harvey Karp. A framework and strategy for understanding and resolving colic. Feb 1, 2004. Contemporary Pediatrics