|Classification and external resources|
Baby colic (also known as infantile colic) is a condition in which an otherwise healthy baby cries or displays symptoms of distress (cramping, moaning, etc.) frequently and for extended periods, without any discernible reason. The condition typically appears within the first month of life and often disappears rather suddenly, before the baby is three to four months old, but can last up to one year. The causes of colic are not settled science. One study found that children diagnosed with migraines were nearly three times as likely to have experienced colic as babies, suggesting colic may be an early response to migraine headaches. Another study concluded that babies who are not breastfed are almost twice as likely to have colic. Epidemiology suggests that chocolate, brassica, onions, and cow's milk are among the foods that a lactating mother may need to avoid.
The crying often increases during a specific period of the day, particularly the early evening. Symptoms may worsen soon after feeding, especially in babies that do not belch easily.
The strict medical definition of colic is a condition of a healthy baby in which it shows periods of intense, unexplained fussing/crying lasting more than 3 hours a day, more than 3 days a week for more than 3 weeks. However, many[who?] doctors consider that definition, first described by Morris Wessel, to be overly narrow and would consider babies with sudden, severe, unexplained crying lasting less than 3 hours/day as having "colic" (so-called "non-Wessel's" colic). In reality, this extreme version of colic is more likely to be the final stage of a condition that has worsened for a few weeks.
Persistent infant crying is much more than a parenting nuisance. Crying and the exhaustion associated with it can trigger serious problems, such as relationship stress, breastfeeding failure, shaken baby syndrome (also known as abusive head trauma—the leading cause of child abuse fatalities), postpartum depression (affecting 10–15% of new mothers and many new dads), excess visits to the doctor/emergency room (1 in 6 children are brought to the doctor/emergency rooms for evaluation of persistent crying), unnecessary treatment for acid reflux and maternal smoking. Crying and exhaustion may also contribute to Sudden Infant Death Syndrome (SIDS) and suffocation (from agitated babies flipping onto their stomachs, concerned parents placing fussy babies on the stomach to sleep, tired parents falling asleep with their baby in unsafe places, like couches or beds with bulky covers), infant obesity, maternal obesity and even automobile accidents.
For many years, the number one belief of worried parents, grandparents and doctors has been that colicky crying was a sign of abdominal pain (e.g. intestinal spasm, overfeeding, trapped gas). In fact, even the word "colic" is derived from the ancient Greek word for intestine (sharing the same root as the word "colon"). Today, it is fairly well established that there are a variety of causes of colic symptoms, the most common of which include: stomach gas (possibly due to poor burping or milk flow issues), intestinal gas (pocketed in the intestinal tract), neurological overload (the overwhelmed and overstimulated baby that becomes exhausted) and even a muscular type of colic (perhaps due to muscle spasm and birth trauma). A gastrointestinal (GI) theory of colic seems logical because fussy babies often: grunt/pass gas/double-up/cry after eating; have borborygmi; improve with stomach pressure, warmth or massage; may improve with pain medication (e.g. paregoric) or sips of herbal teas used for stomach upset (e.g. mint, fennel). However, 85–90% of colicky babies have no evidence of serious GI abnormality.
Research at Guy's Hospital in 1999 linked one of the causes of colic to lactose intolerance. Transient lactase deficiency, a temporary lactose intolerance in young infants, has been shown to be a cause of colic in 40% of infants with the condition. Colicky babies fed milk pre-incubated with lactase enzyme showed a 45% reduction in colic symptoms.
Some have said that babies cry because they sense their mother's anxiety, but this is highly unlikely. They simply do not have the ability to distinguish a mother's anxiety from depression, frustration, etc. In fact, even though parental anxiety is markedly reduced with successive children, it has been shown that a couple's later children are as likely to be colicky as their first. It is plausible, however, that anxiety may have some relationship to crying through a more circuitous route. Anxious parents are often so unsure of themselves that they jump from one calming intervention to another without doing any technique long enough for it to be effective.
What is clear is that there are various causes of colicky babies other than the obvious gassy causes:
- Fussiness peaks at about 6 weeks and reliably ends by 3–4 months, yet infants continue to experience plenty of burps, flatus, bowel movements, etc. well beyond 4 months of age
- Premature babies—with very immature intestines—have no more colic than full term-ers (despite the fact that their intestines are much more immature). And, when they do get colic it doesn't start until they reach their due date. (In other words, a baby born three months early has the same 10–15% chance of developing colic as a full term baby.) Despite eating, defecation, burping and flatulating every day, he/she will have almost no fussing during the first three months.
- Contrary to the belief that babies cry from swallowed air, X-ray studies reveal that when babies start wailing, they have much less air trapped in their stomachs than they do after the colic is over and they are calm and relaxed. (Babies gulp air while crying. So they have more air in the stomach after crying, but it is totally innocuous.)
- "Burp" drops (simethicone) are no better at reducing crying than drops of distilled water.
- Car rides and vacuum cleaner sounds may calm fussing, yet have no power to lessen GI pain.
- In 90% of cases, colic is unrelated to a baby's diet. However, in 10% of cases colic is triggered by stomach discomfort from food allergy and requires altering the diet of a breastfeeding mom or switching a baby to a hypoallergenic formula (e.g. Pregestimil). The most problematic foods for fussy babies seem to be cow's milk based formula and, for breastfeeding babies, dairy products in the mother's diet. Other, less common allergens are wheat, soy and nuts. Breastfed babies may also become fussy from stimulants in the mother's diet (see section on treatment). Parents and doctors commonly switch fussy babies to a soy formula; however, it is not clear that soy reduces colic.
Also, unlike older children and adults who have GI discomfort from lactose intolerance, there is little evidence that this causes crying among infants. However later research, initially by Professor Kearney at Cork University Hospital (published 1995) and then by Dr Dipak Kanabar at Guy's Hospital in London clearly demonstrated that infant colic was linked to transient lactose intolerance and could be controlled by pre-incubating the baby's feed with lactase enzyme. This is now the preferred method of treating colic in UK and Ireland using commercial lactase enzyme drops sold over-the-counter or on NHS prescription.
Some reports have associated colic to changes in the bacterial balance in a baby's intestine. They suggest treating the crying with daily doses of probiotics, or "good bacteria" (such as Lactobacillus acidophilus or Lactobacillus reuteri). In a 2007 study, 83 colicky babies given the probiotic Lactobacillus reuteri had reduced crying time. After one week, treated babies had 10% less crying time (159 min/day vs. 177 min/day). By 4 weeks, treated babies had 65% less crying (51 min/day vs. 145 min/day). In a 2010 study conducted with the same probiotic strain, similar benefits were seen in colicky infants. However, another study found no reduced colic in over 1000 babies who were given a mixture of four other probiotic strains from birth.
In 2009, a U.S. study observed that colicky babies had a higher incidence of mild intestinal inflammation and a specific intestinal bacteria, Klebsiella. But, a commentary in the same journal, noted that the inflammation and bacteria were most likely just an exaggerated variation of normal.
One study demonstrated higher incidence of colic among breast fed infants, bringing a possibility that stress hormones excreted into the breast milk were causing intestinal cramps. Child birth and breastfeeding can be very stressful and association with stress and intestinal discomfort are well known. Infants with colic have elevated level of cortisol indicating higher level of stress.
A study of prenatal maternal cortisol levels has validated the hypothesis of maternal stress as a potential cause of colic. The researchers found that infants whose mothers had high prenatal cortisol levels displayed more crying, fussing, and negative facial expressions during a series of videotaped bath sessions done between one and twenty weeks of age.
Another study found correlations between maternal depressive symptoms during pregnancy and infant crying. Mothers who had been more depressed had infants who cried more. Similar correlations were found between maternal anxiety levels during pregnancy and amount of crying in the infants at five weeks of age. The mothers with higher prenatal anxiety levels were more likely to have infants with colic. General psychosocial distress during pregnancy has also been found to correlate with infantile colic.
Birth complications may have a direct impact on the infant. Researchers have found correlations between childbirth complications and amount of infant crying. More stressful deliveries were linked to more crying.
Insufficient physical contact after birth may be a contributing factor to infant colic. In a controlled experimental study, infants who were held/carried an extra two hours per day cried significantly less at six weeks of age than those who were offered two extra hours per day of visual stimulation. Another study found increased crying in infants whose mothers affirmed a perceived risk of spoiling young infants with too much physical contact.
T. Berry Brazelton has suggested that overstimulation may be a contributing factor to infant colic and that periods of active crying might serve the purpose of discharging overstimulation and helping the baby’s nervous system regain homeostasis.
Aletha Solter corroborates Brazelton’s theory that some crying represents a beneficial discharge process, and has proposed a more general stress release theory of infant crying. She has hypothesized six major contributing factors to infant colic: 1) Prenatal stress and birth trauma, 2) Unfilled needs (especially the need for physical contact), 3) Overstimulation, 4) Developmental frustrations, 5) Physical pain (including intestinal discomfort), and 6) Frightening events.
Over the past 15 years, many thousands of babies have been given medicine in the belief that their colic was caused by painful acid reflux, so-called gastro-esophageal reflux disease (GERD). From 1999–2004, the use of a popular class of liquid antacid (proton pump inhibitor, or PPI) in young children increased 16 fold. And, from 2000–2003 there was a 400% increase in the number of babies treated with anti-reflux medicines. By all accounts this rate of increase has continued—or accelerated—from 2003 to the present.
In truth, most babies have mild reflux, often referred to as "spitting up." Over the past 5 years, several studies have proven that GERD rarely causes infant crying. Even crying during feeding and crying accompanied by writhing and back arching is rarely related to acid reflux, unless the baby also has:
- 1) poor weight gain (less than 15 gram/day)
- 2) vomiting more than 5 times/day; or
- 3) other significant feeding problems.
A multicenter study, organized by researchers at Pittsburgh Children's Hospital, concluded that GERD medicine is no better than plain water at reducing infant crying. Surprisingly, 50% of fussy babies improved on medicine, but so did 50% of fussy babies given the placebo. In the meantime, research has shown that proton pump inhibitors can cause decreased bone density in adults. No research has been done on bone density or growth in children given PPIs and this use is not approved by the FDA and should be considered experimental.
"Red Flag" 
Babies who continue crying may simply be hungry, uncomfortable or ill. Parents who are unable to soothe their baby's crying must call their healthcare provider to make sure the baby is not sick. Fortunately, only 5% of colic cases are caused by illness (most commonly by intestinal allergy, described above).
Parents should be especially suspicious of illness or pain as the cause of their baby's fussing if the cry is accompanied by at least one of the following six "red flag" symptoms:
- Vomiting (vomit that is green or yellow, bloody or occurring more than 5/day)
- Change in stool (constipation or diarrhea, especially with blood or mucous)
- Abnormal temperature (a rectal temperature less than 97.0 °F (36.1 °C) or over 100.2 °F (37.9 °C)
- Irritability (crying all day with few calm periods in between)
- Lethargy (excess sleepiness, lack of smiles or interested gaze, weak sucking lasting over 6 hours)
- Poor weight gain (gaining less than 15 gram a day)
Babies with persistent crying or any "red flag" symptoms should be checked by a healthcare professional to rule out illness. The top ten medical problems to consider in irritable babies with "red flag" symptoms are:
- Infections (e.g. ear infection, urine infection, meningitis, appendicitis)
- Intestinal pain (e.g. food allergy, acid reflux, constipation, intestinal blockage)
- Trouble breathing (e.g. from a cold, excessive dust, congenital nasal blockage, oversized tongue)
- Increased brain pressure (e.g., hematoma, hydrocephalus)
- Skin pain (e.g. a loose diaper pin, irritated rash, a hair wrapped around a toe)
- Mouth pain (e.g. yeast infection)
- Kidney pain (e.g. blockage of the urinary system)
- Eye pain (e.g. scratched cornea, glaucoma)
- Overdose (e.g. excessive Vitamin D, excessive sodium)
- Others (e.g. migraine headache, heart failure, hyperthyroidism)
Effect on the family 
Infant crying can have a prominent effect on the stability of the family. Crying and the fatigue that typically accompanies it can inflict enormous emotional strain causing parents to feel they are providing inadequate care, triggering anxiety, stress, resentment and low self-esteem.
Persistent infant crying has been associated with severe marital discord, postpartum depression, Shaken Baby Syndrome, SIDS/suffocation, early termination of breastfeeding, frequent visits to doctors, maternal smoking and over a quadrupling of excessive laboratory tests and prescription of medication for acid reflux.
Parents are at especially high risk of experiencing a serious reaction to their infant's crying; at-risk parents include teens, drug addicts, foster parents, parents of premies and parents of multiples. Families living in apartment buildings may also suffer strained relationships with neighbors and landlords if their babies cry loudly for extended periods of time each day.
Currently, the first approach most commonly recommended in healthy babies (without any "red flag" symptoms) is to use non-medicinal, noninvasive treatments like burping, stomach massage and gas release techniques as well as symptomatic and emotional support.
Some reports have associated colic to changes in the bacterial balance in a baby's intestine. These reports suggest treating the crying baby with daily doses of probiotics, or "good bacteria" (such as Lactobacillus acidophilus or Lactobacillus reuteri). In one study, 83 colicky babies given Lactobacillus reuteri had reduced crying time. After one week, treated babies had close to 20% less crying time (159 min/day vs. 197 min/day). By 4 weeks, treated babies had 74% less crying (51 min/day vs. 197 min/day). Overall, there was a 95% positive response to the Lactobacillus reuteri probiotic drops in colicky infants. However this study was not blinded so further studies are needed.
It has been an age-old practice to drug crying infants. During the second century BC, the Greek physician, Galen, prescribed opium to calm fussy babies, and during the Middle Ages in Europe, mothers and wet nurses smeared their nipples with opium lotions before each feeding. Alcohol was also commonly given to infants.
In past decades, doctors recommended treating colicky babies with sedative medications (e.g. phenobarbital, Valium, ethanol), analgesics (e.g. opium) or anti-spasm drugs (e.g. scopolamine, Donnatal, dicyclomine), but all of these have been stopped because of potential serious side-effects, including death.
Another age-old practice recommended by doctors is the "cry-it-out" approach (also known as "controlled crying.") The "cry-it-out" approach refers to the practice of leaving crying babies in their cribs and letting them cry themselves to sleep. First recommended in the U.S. by Luther Emmett Holt, it was later also recommended by Benjamin Spock in his best-selling book, Baby and Child Care. More recently, Richard Ferber has recommended a modified version of this approach.
Several pediatricians and psychologists have claimed that the "cry-it-out" approach is harmful to infants because it can interfere with the development of trust and secure attachment. In a 1972 study (of non-colicky subjects) that suggested some correlation between maternal responsiveness to infant crying and a net reduction in crying episodes over the first year of a baby's life, Bell and Ainsworth suggest that this behavior derives from an evolutionary need (described generally by Attachment theory:
the biological function of infant-mother attachment, and of both infant attachment behaviors and reciprocal maternal behaviors, is protection from danger; and in the original environment of evolutionary adaptedness it was likely that predators were the most conspicuous danger. Attachment behaviors protect an infant by bringing him close to his mother, who can defend him from danger or help him escape from it. In a species in which an infant is as helpless as the human, attachment behavior could not effectively perform its protective function were it not dovetailed with reciprocal maternal behavior, activated either by the infant's signals or directly by danger or by both in combination. Infant and maternal behaviors are adapted to each other, and thus the environment to which an infant's attachment behaviors are adapted includes a mother who responds to his signals without undue delay.
They concluded that, in contrast to an earlier tradition of permitting children to "cry it out", that "maternal responsiveness promotes desirable behavior rather than "spoiling" a child. Infants whose mothers have given them relatively much tender and affectionate holding in the earliest months of life are content with surprisingly little physical contact by the end of the first year; although they enjoy being held, when put down they are happy to move off into independent exploratory play."
There is evidence that leaving babies to cry alone can increase their emotional stress level. Researchers measured saliva cortisol levels in 25 infants during a sleep training program in which the infants were left to cry themselves to sleep over a three-day period. The infants’ cortisol levels were elevated when they were left to cry alone, indicating a state of high emotional stress. However, the cortisol levels remained high even on the third day, after the infants had stopped crying. This implies that, even though the sleep training program appeared to "work" and the infants fell asleep without crying, their stress levels were still high. Another study found that even brief separations between mothers and their 9-month-old infants can result in elevated infant cortisol levels, indicating emotional stress.
There is a broad body of evidence showing that colic symptoms can be eased through soothing measures, such as pacifiers, strong white noise and jiggly rocking are effective in calming babies during crying bouts. These techniques form the core of the "5 S's" approach:
- Swaddling (safe swaddling carefully avoiding overheating, covering the head, using bulky or loose blankets, and allowing the hips to be flexed);
- Side or stomach (holding a baby on the back is the only safe position for sleep, but it is the worst position for calming a fussy baby;)
- Shhh sound (making a strong shush sound near the baby's ear or using a CD of womb sound/white noise);
- Swinging the baby with tiny jiggly movements (no more than 1" back and forth) always supporting the head and neck;
- Sucking (Letting the baby suckle on the breast, a clean finger or a pacifier)
Although soothing techniques (such as movement, sucking, or shushing sounds) can lead to a short-term cessation of crying, it has been suggested that these techniques may serve only to postpone the crying. The absence of crying does not necessarily imply emotional well-being. It can also indicate dissociation, a state of psychological numbing seen in stressed or traumatized infants, during which stress hormone levels (such as epinephrine and cortisol) remain high, but the infants appear to be calm. Researchers have found that infants can have elevated cortisol levels in the absence of crying, while sucking on a pacifier.
Another approach to colic is the "crying-in-arms" approach, in which the parent lovingly holds the crying infant while letting the crying run its course (after all immediate needs have been met). This approach differs from the "cry-it-out" approach because the infant is never left to cry alone. It also differs from the soothing approaches because the goal is not to cut the crying short, but rather to accept the crying and support the infant through it. The "crying-in-arms" approach is based on the assumption that persistent crying during infancy can be the result of accumulated stress or unhealed trauma (such as a traumatic birth), and that allowing the infant to cry in arms will provide long-term psychological and physiological benefits. There appears to be some evidence for the effectiveness of the "crying-in-arms" approach, including an improvement in infant sleep.
In a breastfed baby, the doctor may suggest eliminating all stimulant foods (e.g. coffee, tea, cola, chocolate, decongestants, diet supplements, etc.) from a mother's diet for a few days to evaluate for improvements in the baby's condition. If food allergy is suspected, the doctor may suggest a hypoallergenic formula for a formula fed infant or, if the mother is breastfeeding, a period of elimination of allergenic foods (e.g. dairy, nuts, soy, citrus, etc.) from her diet in order to observe changes in the baby's condition. If the crying is related to a cow's milk allergy benefits are usually seen within 2–7 days. Mothers can then choose to add back small amounts of the suspected offending food a little bit at a time as long as persistent crying does not reappear. If crying reappears, the offending foods may need to be avoided for many months.
Persistently fussy babies with poor weight gain, vomiting more than 5 times a day, or other significant feeding problems should be evaluated by a healthcare professional for other illnesses (e.g. urinary infection, intestinal obstruction, acid reflux).
Several studies demonstrated benefits of herbal remedies containing fennel. In one study S. Savino et al. used extracts of three plants, including fennel. In another study Sergei Shushunov et al. successfully used fennel oil emulsion.
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