What is colic?
The term “colic” is used rather broadly by doctors and parents to refer to prolonged excessive crying or unsettled periods for no apparent reason in the first few months of life. The “rule of three” is the most widely used definition of colic referring to crying that lasts for more than 3 hours a day, more than 3 days per week, and persisting for longer than 3 weeks in a child with normal growth patterns. The crying episodes in colic are usually of abrupt onset, often clustering during the evening hours. The cry is more intense and high pitched than normal with a “piercing” or “grating” quality.
Parental perception/expectations certainly play a role in defining a child as colicky, and it is important for parents to understand a “normal” pattern of crying. Colic goes beyond “normal” crying, and the persistent or excessive crying is distressing for the infant, the parents and the health care workers.
However, by definition a colicky baby is thriving and developmentally normal.
Who gets colic?
Colic is common and occurs in up to 40% of babies. It occurs equally amongst males and females, firstborns and subsequent children, breastfed and formula fed babies, term and preterm babies; and there is no good evidence for an increase after caesarean section. It can run in families, and seems more common in populations in which “expectations” for babies are perhaps higher.
What causes colic?
There are many theories as to the causation of colic with no overriding evidence for any of the theories. It probably represents a combination of gut and brain immaturity. Colic may well be a final common pathway for many factors, including one or more of the following:
- “Immaturity” of the gut
- hypersensitivity to environmental stimuli (leading to the baby crying it out in the early evenings to “offload”)
- abnormal movement of the bowel (“motility issues”)
- trapped wind
- feeding difficulties, e.g overfeeding, underfeeding, swallowed air, foremilk abundance
- infant temperament, family stress and emotional tension during pregnancy may contribute
- exposure to tobacco smoke in pregnancy or after birth
- disturbance in the bacteria of the gut
More pathological causes can contribute, including:
- reflux of stomach contents into the oesophagus
- cow’s milk protein allergy plays a role in a subset of patients
- lactose intolerance may play a minimal role
Symptoms of colic resolve (often quite abruptly) in 60% of 3 month olds and 90% of 4 month olds. However, in the mean time, families of colicky babies will need plenty of support and reassurance, and tips on management strategies which may ease the crying spells.
Management needs to be individualised according to the characteristics of the baby and the immediate family, to help the parents cope with the child’s symptoms. In all cases, the child should be examined thoroughly to rule out other causes of pain or irritability such as infection or fractures. The parents should be reassured that the colic has nothing to do with their parenting abilities, and the difficulty that a colicky baby brings into a family should be acknowledged. Parents should also be reassured that the colic will eventually be outgrown, and that the child will come to no long term harm as a results of the colic.
A number of management/coping strategies are available to manage colic but most are of unproven benefit. Each child responds differently to different strategies, depending on the main cluster of factors causing their colic, and most individual strategies work in about 1/3 of patients. The important thing is to use strategies that are as safe as possible: certain antispasmodic drugs and homeopathic remedies have been associated with harm to the baby. Generally, if colic medications do not make a difference after a week or 2, stop them.
Management strategies include:
- Parental support. Family and friends come in very useful at this stage, if only to give the parents a quick “break” from the stress of the crying. If the mother is feeling at the end of her tether, she should leave the baby safely in a cot and have a quick break rather than run the risk of harming the baby.
- Changing feeding techniques: e.g. In breastfed babies, emptying one breast completely during each feeding block may reduce the intake of lactose from the foremilk. In bottle-fed babies sitting them more upright during feeds and changing the bottle to an anti-colic one may help.
- Carrying the baby during crying spells may help, especially in an upright carrier.
- Gently swaddling the baby to contain it may help.
- Regular motion such as a car ride or a safe baby swing may help.
- White noise may help, e.g. sound of a washing machine or radio.
- A warm bath or baby massage may help.
- A dummy or pacifier may help and can be used once feeding is well established.
- If the baby is breastfed, the mother may try a dairy and caffeine free diet for a week. Once again, if there is no difference, the mother should revert back to her normal diet.
- Some practitioners advise mothers to cut out sequentially other “highly allergenic” foods such as wheat, egg and nuts from their diet, but there is not much evidence for this. Cutting out “gassy” foods (e.g. onions; cauliflower), spicy food and citrus may help, but once again the mother should abandon this diet if there is no response after a week or two (life is hard enough without having to follow a strict diet!)
- The lactase enzyme which helps break down lactose (the sugar in cow’s and human milk) is available commercially, but clinical studies have shown conflicting results.
- Simethicone drops in theory help the baby pass winds more easily and are safe; but do not have a proven track record in all cases of colic.
- Antispasmodics, popular “colic mixtures” and homeopathic medications should be used sparingly as they may cause side effects.
- Certain safe herbal ingredients such as fennel or chamomile may be tried.
- Chiropractors or craniosacral therapists may be consulted to align the bony structures, which may help ease colic or constipation, but there is not much evidence to back this. Similarly, baby massage may help relax the baby and ease the tummy gripes.
- If symptoms are suggestive of severe reflux, (such as excessive vomiting or excessive pain associated with feeding), a trial of an anti-acid treatment may be given. This should be a short trial initially, under medical supervision. Anti-acids are used far too much and can cause side effects, so a baby really needs to “deserve” them.
- In severe colic in a formula fed baby, a one week trial of extensively broken down formula milk may be tried to make sure the child is not reacting to the cow’s milk protein (consult your healthcare practitioner for suggestions of a suitable formula). If this makes no difference, go back to the baby’s regular formula, which is less costly.
- In some cases the health care practitioner may suggest soya milk, but remember that a “delayed type” cow’s milk and soya allergy may exist together in at least 50% of cases. (see section on Food Allergy)
When to worry? (could it be more than just colic?)
By definition, babies with colic are thriving and developmentally normal. Parents should seek medical attention if:
- Crying is truly excessive, more than 4-5 hours a day, and the baby seems to screams all the time (think allergy or reflux)
- If the baby is not putting on adequate weight (? Feeding problems or digestive difficulties)
- If there are persistently runny stools, or blood/mucous in the stools (? Allergy)
- If the stools are green or frothy (? Lactose intolerance)
- If there is excessive vomiting with pain, back-arching or feed refusal (? reflux disease)
Talking about VOMITING, most babies vomit as they have an immature valve at the top of their stomachs which lets milk go up again. This is normal. Vomiting, in fact, only peaks at 4 months. However, if the vomiting seems excessively painful, the baby back-arches a lot, refuses to lie on the back, and is extremely miserable after feeds or fusses excessively during feeds, reflux “disease” should be considered and discussed with your healthcare practitioner.
To sum up, the first 3-4 months of a baby’s life are filled with gripes and groans in a large proportion of babies, mainly due to an immature gut and an immature brain. Patience, love and cuddles, and remembering that this can be normal for the so-called 4th trimester, go a long way in dealing with this difficult time. If you feel that symptoms are excessive, or you are not coping, then please seek medical help.