Swanson – Colic

Swanson’s Family Medicine 2017
Ch. 99 Colic 506
Nancy W. Dickey

1. The diagnosis of infantile colic (like appendicitis) is clinical and is established after a thorough history and physical examination. Although we tend to think of colic as an abdominal process, a complete evaluation of all organ systems must be performed. Other causes of inconsolable crying in an infant must be ruled out with a thorough history and physical. Laboratory and imaging tests are generally not necessary; diagnostic investigations should be guided by abnormalities noted on history and the physical exam. Parental reassurance will follow the establishment of a firm diagnosis. The history of possible pyloric stenosis with the first sibling does not change your approach. Although it predominantly affects boys, pyloric stenosis has a 3% to 9% recurrence in the first-degree sibling.
2. Organic causes must be ruled out. Colic is a diagnosis of exclusion. Because children in this age group do not localize infection like adults do, non-specific signs and symptoms are important; fever, decrease in food intake, excessive sleepiness, and the like should alert the physician. Of all the tests mentioned, a urinalysis has the highest yield (Fig. 99-1). You must rule out infections such as urinary tract infection, otitis media, pharyngitis, pneumonia, and meningitis; visualize the infant’s eye to exclude corneal abrasion; and exclude the possibility of abdominal processes, such as intussusceptions and volvulus. A complete dermatological examination should follow because a hair tourniquet (strangulation of a toe, finger, or penis by a knot of hair) is a frequent reason for inconsolable crying.
3. After all organic reasons for inconsolable crying have been ruled out, the Wessel criteria are used (the rule of 3’s). The child is described as crying more than 3 hours daily, for 3 days or more a week, during a 3-week period or longer. The infant is typically 3 weeks to 3 months old. Remember that crying for up to 2.2 hours a day is considered “normal.” Colic rarely continues beyond 3 months of age.
4. The point to remember is that there is no known or established cause of infantile colic. Although overfeeding and underfeeding, air swallowing, and cow’s milk have been implicated, none has been proved as the cause of colic. Maternal food allergy has been suspected in breast-fed children, and research suggests that changing to a low-allergen diet might decrease colic. The stress encountered by the parents should be dealt with, but it is not a causative factor. Cow’s milk allergy causes an enterocolitis in children during their first year of life. On occasion, these children are also allergic to soy and, unlike the patient described here, present with diarrhea, vomiting, and weight loss.
5. The key to understanding colic is that holding the child, riding in a car, and changing formula may reduce actual crying time but rarely stop it. Phenergan has a black box warning because of respiratory depression in children younger than 2 years with fatal consequences. Bentyl is contraindicated before the age of 6 months because of the increased risk of apnea.
6. Studies have shown that maternal smoking doubles the occurrence of colic. All the other choices have been speculated in the past or present to be possible contributing factors to infantile colic but not demonstrated to be so. Prevalence is not increased in different ethnic groups, and the average patient most commonly belongs to a middle-class family. Colic is slightly less frequent in breast-fed children.
7. Most medications are ineffective and might even be dangerous. Because we do not know what causes colic, our treatment is mainly supportive. Herbal teas including vervain, licorice, chamomile, and fennel are used by parents to relieve colic. They can cause malnutrition because of a decrease in formula intake, and they should be used with extreme caution.
8. Choice d is of particular interest. Colic can cause severe familial stress and may lead to child abuse so respite care or hospitalization (of the parent and child) may be necessary. In extreme cases, sedation may be offered. Calm the parents, relieve any guilt associated with colic, and reassure them that colic usually disappears by 3 months of age. Frequent scheduled visits might be particularly helpful with reiteration of the child’s normal development and good weight gain. Some families find it very difficult to have nothing to do whilst awaiting the spontaneous remission, so outlining some soothing strategies can be helpful (e.g., use of a pacifier, rocking the infant, warm bathes, taking the infant for a ride in the car) and can give the parents activities to pursue that may have some beneficial effect.

Summary of Colic

When faced with a child with inconsolable crying:

1. Rule out organic causes, that is, fever, pharyngitis, otitis media, nausea and vomiting, rectal bleeding, and abdominal mass.
2. Think of colic: 25% of all children have it
3. Apply the rule of 3’s: the child cries for at least 3 hours daily, 3 days a week, for at least 3 weeks, starting before 3 months of age.
4. Boys and girls are affected in equal numbers, and the condition crosses social lines
5. Encourage/assist smoking mothers to stop or not smoke in the house.
6. No medication is known to help.
7. Developing a supportive relationship with frequent visits helps parents feel supported.
8. The stress experienced by the entire family with an excessively crying infant is a major problem. Careful observation for signs of depression, or possible harm to the child in an attempt to stop the crying, should be a part of the ongoing support visits.
9. Some research supports changing to maternal low-allergen diet in the case of the breast-fed infant (elimination of nuts, milk, soy, and fish) and a possible change to whey hydrolysate in the formula-fed baby.

Suggested Reading

Crotteau CA, Wright ST, Eglash A. Clinical inquiries: What is the best treatment for infants with colic? J Fam Pract. 2006;55:634–636.

Douglas P, Hill P. Managing infants who cry excessively in the first few months of life. BMJ. 2011;343:1265–1269.

Fireman L. Colic (in brief). Pediatr Rev. 2006;27:357–358. Heird WC. The feeding of infants and children. In: Behrman R, Nelson textbook of pediatrics. Philadelphia: Saunders; 2004.

Roberts DM, Ostapchuk M, O’Brien JG. Infantile colic. Am Fam Physician. 2004;70:735–740.

Shaw T, Graber MA. Pediatrics. In: Graber MA, de Almeida KN, Atkinson JC, eds. The family medicine handbook. Philadelphia: Saunders; 2006.

Wade S. Infantile colic. Clin Evid. 2006:439–447.

Woodgate P, Cook L, Webster H. Medical therapy for infantile colic. Cochrane Database Syst Rev. 2003;(1):CD004382.