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Baby colic

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This page is about Baby colic. For other types of colic, see Colic.
"Cholic" redirects here. For cholic acid, see Cholic acid.
Baby colic
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Colic (also known as infant colic, three month colic, and Infantile colic) is a condition in which an otherwise healthy baby cries or screams frequently and, for extended periods, without any discernible reason. The condition typically appears within the first two weeks of life and almost invariably disappears, often very suddenly, before the baby is three to four months old, but can last up to 12 months of life.[1] It is equally common in bottle-fed and breastfed babies.[2]

The crying often increases during a specific period of the day, frequently this happens in the early evening (the so-called “witching hour”).

The medical definition of colic is a healthy baby with periods of intense, unexplained fussing/crying lasting more than 3 hours a day, more than 3 days a week for more than 3 weeks.[3] However, many doctors consider that definition, first described by Dr. 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).[4]

Persistent infant crying is much more than a parenting nuisance. Crying and the exhaustion associated with it can trigger serious problems, such as marital stress,[5] breastfeeding failure,[6][7] shaken baby syndrome (also known as abusive head trauma - the leading cause of child abuse fatalities),[8][9][10][11] postpartum depression (affecting 10-15% of new mothers and many new dads),[12][13][14][15][16][17][18][19] excess visits to the doctor/emergency room (1 in 6 children are brought to the doctor/emergency rooms for evaluation of persistent crying),[20] unnecessary treatment for acid reflux[21][22][23][24][25][26][27] and maternal smoking.[28] Crying and exhaustion may also contribute to 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),[29][30][31] infant obesity,[32] maternal obesity[33] and even automobile accidents.[34]

The total financial burden (medical costs, lost productivity, legal/penal, adverse long term health effects, etc) of the 500,000 infants/year in the United States with colic may exceed $1 billion dollars/year, paralleled by even greater human and emotional costs.[citation needed]

Causes

Over the decades, researchers have offered various hypotheses for colic including the exposure to cigarette smoke,[35][36] insufficient melatonin production (until 12 weeks of age, the time colic usually ends),[37][38] circadian rhythms,[39] and stress of the mother in the third trimester.[40]

Some have said that babies cry because they sense their mother’s anxiety.[41] but this is highly unlikely. They simply don’t 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.[42] 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. For thousands of 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).[43] In fact, even the word “colic” is derived from the ancient Greek word for intestine (sharing the same root as the word “colon”).

At first glance, a gastrointestinal (GI) theory of colic seems logical because fussy babies often: grunt/pass gas/double-up/cry after eating; have noisy stomachs; improve with tummy pressure, warmth or massage; may improve with pain medication (e.g. paregoric, also referred to as tincture of opium)[44] or sips of herbal teas used for stomach upset (e.g. mint, fennel).[45] However, 85-90% of colicky babies have no evidence of GI abnormality.[46] Today, few doctors believe colic is related to gas, cramps, or overfeeding. The prevailing medical view is that colic is just the extreme range of normal. In other words, the 10-15% loudest, most persistent, “shriekiest” of all healthy babies are diagnosed with “colic.”[47]

The main reason experts no longer believe colic is caused by stomach upset are:

  • Fussiness peaks at about 6 weeks and reliably ends by 3–4 months, yet infants continue to experience plenty of burps, flatus, BMs, etc. well beyond 4 months of age [48]
  • 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 “tooting” every day, he/she will have almost no fussing during the first three months.[49]
  • 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.[50] (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.[51][52]
  • Car rides and vacuum cleaner sounds may calm fussing, yet have no power to lessen GI pain (just as adults never use a car ride or vacuum to sooth a stomachache).
  • In 90% of cases, colic is unrelated to a baby’s diet.[53][54] 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).[55][56] 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).[57][58][59] Parents and doctors commonly switch fussy babies to a soy formula - however, it is not clear that soy reduces colic.[60]

Also, unlike older children and adults who have GI discomfort from lactose intolerance, there is little evidence that this causes crying among infants.[61][62][63]

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 one study,[64] 83 colicky babies given probiotics had reduced crying. After one week, treated babies had a mere 10% less crying (159 min/day vs. 177 min/day). By 4 weeks, treated babies had 65% less crying (51min/day vs. 145 min/day). However, a more recent study found no reduced colic in over 1000 babies who were given probiotics from birth.[65]

In 2009, a University of Texas study observed that colicky babies had a higher incidence of mild intestinal inflammation and a specific intestinal bacteria, Klebsiella.[66] But, a commentary in the same journal, noted that the inflammation and bacteria were most likely just an exaggerated variation of normal.[67]

Over the past 15 years, many thousands of fussy 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.[68] 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, but we simply call it “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 ½ ounce/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.

Fourth trimester theory

If your baby cries during feeding, the most logical reason is not acid pain, but rather that he/she is overreacting to a totally normal intestinal process, the gastro-colic (GC) reflex.[69] When your stomach fills with food it sends a message to the colon to start tightening (to squeeze out the feces and make room for the coming new food).

All of us have a GC reflex. In adults, it gets switched on about an hour after eating, but in babies it revs up within minutes of the start of a meal (often leading to a BM before the baby has even finished eating). Most of us have little or no awareness when the GC reflex is working, however some overly sensitive infants do feel it…and don’t like it. They often arch and cry as waves of intestinal squeezing move the partially digested food through the intestines. These cries are often misdiagnosed as acid reflux, gas cramps or overfeeding. But babies who cry from the GC reflex are usually just overreacting to a normal sensation. They’re the same sensitive infants who shriek after a sudden loud laugh or telephone ring. In fact, it’s easy to prove these cries are not from pain, simply by stopping them with correctly performed calming techniques (see the “5 S’s” described below).

The fact that many hyperirritable babies calm with simple soothing maneuvers has given birth to an engaging new theory of colic, the “missing 4th trimester.” This theory, described by California pediatrician, Dr. Harvey Karp[70][71][72] is recommended by many leading pediatricians and parenting books.[73][74]

The “missing 4th trimester” is based on the fact that our newborns are very immature at birth.[75] Baby horses, by comparison, can walk and even run on the very first day of life. However, since human fetuses have such large brains, they must be born before they are mature enough to stand, run, or even smile. Babies held inside longer would never get through the birth canal and they (and their mothers) would die in childbirth. (The head of a newborn chimpanzee is only 80-90% of the mother chimp’s pelvic opening. On the other hand, a human baby’s head totally fills the pelvic outlet and requires some distortion to fit)

Another theory by Karp suggests that infant crying is related to under-stimulation. He believes babies cry because the "rich symphony of womb sensations" has been replaced by the profound stillness of our homes. He argues that in the womb, fetuses experience non-stop hypnotic rhythms (e.g. stroking against the soft uterus walls; frequent tiny, jiggly movements; constant warmth; and continual sound - louder than a vacuum cleaner - created by the whooshing of blood through the placental arteries).[76][77] He states that this explains why babies can fall asleep at crowded parties and noisy basketball games better than adults. Karp postulates that all babies are born with a “calming reflex” that is a relative “off-switch” for crying and “on-switch” for sleep. This unique response is activated when parents perform 5 techniques (the “5 S’s”), which closely mimic the rhythmic sensations in the uterus. Duplicating the baby’s womb experience and turning on the “calming reflex” may explain how traditional calming methods (for example, car rides, vacuum cleaners, bouncy dancing, warm baths, carrying babies in slings, etc) work to reduce fussing.

It is argued[by whom?] that the“calming reflex” is very predictable like the knee reflex. One can activate it hundreds of times in a row, but only if it is done correctly. Similarly, it is argued, that only parents who have been trained to do the "S's" correctly (see below - section on treatment) can turn on the “calming reflex.”

Babies who continue crying despite the “5 S’s” being done correctly may 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).[78]

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 ten “red flag” symptoms:[79]

  • Persistent moaning or weak crying
  • High-pitched, shrill cry (sharp and more dramatic than usual)
  • 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)
  • Fussing during eating (twisting, arching, or crying that begins during or just after a feed)
  • Abnormal temperature (a rectal temperature less than 97.0°F or over 100.2°F)
  • 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)
  • Bulging soft spot on the head (even when the baby is sitting up)
  • Poor weight gain (gaining less than ½ ounce 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:[80]

  • 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.[81]

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 at especially high risk of experiencing a serious reaction to their infant’s crying, include teens, drug addicts, military families, foster parents, parents of premies and parents of multiples. Families living in dense housing projects, such as apartment blocks, may also suffer strained relationships with neighbors and landlords if their babies cry loudly for extended periods of time each day.

Treatment

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-effect, including death.

Currently, the first approach most commonly recommended in healthy babies (without any “red flag” symptoms) is to use non-medicinal, noninvasive treatments like emotional support[82][83] or the rhythmic calming of the “5 S’s.”

There is a broad body of evidence showing that soothing measures, such as pacifiers,[84][85] strong white noise[86][87][88][89][90] and jiggly rocking[91][92][93][94] are effective in calming babies during crying bouts. These techniques form the core of the “5 S’s” approach: 1st S - Swaddling[95][96][97][98][99][100](safe swaddling carefully avoiding overheating, covering the head, using bulky or loose blankets,[101] and allowing the hips to be flexed[102][103][104]); 2nd S - 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); 3rd S - Shhh sound (making a strong shush sound near the baby's ear or using a CD of womb sound/white noise);[105][106][107][108][109] 4th S - Swinging the baby with tiny jiggly movements (no more than 1” back and forth) always supporting the head and neck;[110][111][112][113][114][115][116][117][118][119] 5th S - Sucking (Letting the baby suckle on the breast, your clean finger or a pacifier)

Numerous studies mentioned above have shown that when key components of the “5 S’s” (e.g. swaddling, shushing, swinging) are used all night they can improve sleep or reduce crying; and, when the “5 S’s” are done correctly and in combination, they offer significant potential to promptly reducing infant crying and promote sleep.

In a study conducted by the Boulder Colorado Department of Public Health home visiting nurses taught the “5S’s“ to 42 at-risk families (teen parents, addicts, parents of premature babies, etc) with fussy babies. After a single, one-hour visit to teach parents this approach 41/ 42 (98%) families reported a dramatic improvement in their ability to calm the fussing, even in babies with acid reflux and those whose mothers used methadone or methamphetamine. Many parents also reported that their babies slept longer.[120] In an NIH funded pilot project by researchers at Penn State University, 80 new mothers were taught the “5 S’s." Breastfeeding mothers taught this method reported that their babies had significantly increased sleep (30-45 min/avg) and significantly reduced trend to obesity at 1 year of age (when combined with simple dietary advice).[121]

Crying from an overreaction to the gastro-colic reflex (described above) is usually easy to resolve with the “5 S’s.” And, since pain does not disappear with simple calming measures, the rapid reduction in crying when using the “5 S’s” makes it unlikely that the fussy baby is in pain.

The most common medical causes of colic are food related. 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.[122][123] 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.[124][125]

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).[126]

See also

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