creation date: 2025-08-05 02:45
tags: Pathologies
Infantile Colic
Background
Definitions
Infantile colic is a benign condition characterized by persistent and inconsolable crying episodes in an otherwise healthy and well-fed infant.
This typically manifest in week 2-3 of life, symptomatically peak around 6 weeks, and resolve by the age of 12 weeks.
Etiology and Pathogenesis
The etiology of infantile colic is unknown. A number of factors have been theorized with unclear evidence to contribute to colic. Proposed etiologies includes:
- Gastrointestinal disturbances (faulty feeding, Cow’s milk intolerance, intestinal hypermotility, microflora changes)
- Tobacco smoke and nicotine exposure
- Early manifestation of migraine
- Hypersensitivity to environmental stimuli
It should be noted that infantile colic occurs in an otherwise healthy infant and thus underlying conditions that causes crying episode would not be classified as infantile colic.
Clinical Presentation
Signs & Symptoms
Features that differentiate colic from normal crying are:
- Paroxysmal - episodes have clear beginning and end, onset unrelated to what infant was doing prior to the episode, and often occur in evening hours
- Qualitative difference - colic is louder, higher and more variable in pitch, and more turbulent and dysphonic. Mothers describe cries are more distressing/urgent than mothers of noncolicky infants.
- Hypertonia - facial flushing, circumoral pallor, tense abdomen, drawing up legs, clenching of fingers, stiffening of arms, or arching of back may be present
- Difficulty consoling - crying my diminish but infant may still remain fussy
While these characteristics can occur with normal crying, it is typically at lower frequencies and shorter durations.
History & Physical Exam
Beyond confirming the features of colic, history and physical should be used to differentiate it from alternative diagnoses. Particularly important aspect of the history includes:
- Infant feeding, stooling, urination, and sleeping patterns
- Vomiting history, blood in stool, bilious/projectile vomit
- Prenatal and perinatal history
- Psychosocial history (including interaction with parents and extended family member, relevant to soothing techniques)
Important aspects of physical examination of the infant include:
- Assessment of temperament and responsiveness to stimuli
- Growth parameters
- Assessment of identifiable causes for crying (eg. foreign body, otitis media, abdominal tenderness)
Diagnosis
Criteria
A presumptive diagnosis is made using the Wessel criteria (rule of 3):
- Episodes lasting ≥3 hours per day
- Occurs ≥3 days per week
- Persists for ≥3 weeks
This is a presumptive diagnosis of exclusion, requiring other causes of crying to be excluded. The confirmation of the diagnosis is made in retrospect after it resolves.
Work-up
Laboratory of imaging studies are generally not necessary unless a particular alternative diagnosis is suspected.
Work-up consist of ruling out differential diagnoses using history and physical.
Differential
Potential causes of prolonged or excessive crying in a young infant:
General:
- Drug ingestion or overdose
- Hunger or inadequate feeding
- Neonatal abstinence syndrome (withdrawal from drugs exposed in the womb)
Skin: - Hair tourniquet of digit or penis
- Open diaper pin poking skin
- Diaper rash
Eyes: - Corneal abrasion or foreign body
- Glaucoma
ENT: - Otitis media
- Thrush
Cardiovascular: - Anomalous origin of left coronary artery
- Heart failure
- Supraventricular tachycardia
Gastrointestinal: - Anal fissures
- Constipation
- Gastroenteritis
- Gastroesophageal reflux
- Gastrointestinal obstruction
Genitourinary: - Meatal ulcer
- Ovarian torsion
- Testicular torsion
- Urinary tract infection
- Urinary tract obstruction
Skeletal: - Fracture
- Osteomyelitis or septic arthritis
Neurologic: - Abusive head trauma
- Meningitis
- Neuromuscular disease, DNS disorder, metabolic disease
Red Flags / Complications
Crying that is concerning:
- Grunting or holding breath
- Flinching
- Not moving
- Doesn’t interact with people or objects
- New angry appearance
Crying that suggests sickness:
- Weak, whimpering, not energetic
- Not a lot of energy to vocalize
- Limp and less responsive
Infantile colic itself is benign and self-limiting. However, challenges may occur between the parent and infant, particularly when it comes to the bond with the patient, familial stress, and maternal depression.
The most severe potential adverse outcome is shaken baby syndrome. Parents should be encouraged to seek support and rest, and reminded not to shake the baby which can cause microhemorrhages and permanent brain damage.
Management
Caregiver support and education
Important aspects of caregiver support includes:
- Education that colic is common and resolves spontaneously by 3-4 months of age
- Reassurance of benign nature of colic
- Reassurance that colic is not a fault of the caregiver and acknowledgement that caregiver is doing the best they can
- Acknowledgement that feelings of frustration, anger, exhaustion, guilt, and helplessness are normal
Interventions
A number of first-line interventions can be attempted to address potential etiologies of colic.
Feeding techniques can be modified if feeding problems are suspected.
- Bottle-feeding in a vertical position (with a curved bottle)
- Frequent burping to reduce swallowed air
- Using bottle with collapsible bag may reduced swallowed air
- Changes to breastfeeding technique (refer to lactation clinic)
Soothing techniques may be suggested for experimentation. Techniques should be tested for several days to week before moving on to other interventions.
- Using a pacifier
- Taking infant for ride in car or walk in stroller
- Holding infant or placing them in front carrier
- Rocking infant
- Changing the scenery
- Minimize visual stimuli
- Use infant swing
- Provide a warm bath
- Rubbing the infant’s abdomen
- Hip healthy swaddling (note, there are associated risks of SIDS)
- Heartbeat audiotapes or white noise
Other unproven interventions are not routinely suggested but parents may consider on a case-by-case basis.
- Dietary changes
- Probiotics (Lactobacillus reuteri drops)
Some interventions are not recommended due to potential risk and lack of evidence for benefits including simethicone, acupuncture, and manipulative therapies.