Infantile Colic

Lauren Heydenrych - Lauren Heydenrych
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Introduction

Infantile colic is described as excessive crying with no clear cause in infants who otherwise present as healthy. Its presentation is widely reported - as little as 3% or up to 40% of infants worldwide. An Australian journal recently reported 20%, while the Singapore Medical Journal reported 40% presentation in the healthcare sector.

In the United Kingdom, and United States, infant colic is one of the most common causes of hospital emergency visits in the first few months of life.

It is generally described as a self-limiting condition, resolving after three to four months of life.

Etiology

While colic implies a gastrointestinal origin, research into conditions relating to the gastrointestinal system and the prevalence of colic has found inconclusive or weak associations.

Among the topics researched, the following were most prevalent:

• Microbiota and inflammatory markers (both in the gut and systemically)
• Lactose intolerance
• Gastro-oesophageal reflux

Other possible causes have included:

• Increased serotonin secretion
• Poor feeding technique
• Maternal smoking or nicotine replacement therapy
• Neurodevelopmental factors

It is interesting to note that no evidence has been found relating to psychosocial factors being a cause of colic. In studies where colicky infants were handled by trained occupational therapists, these infants cried twice as long as their counterparts who were not diagnosed with colic. These studies therefore propose that colic is not an early manifestation of a difficult personality.

Research has also suggested that colic could be a symptom of a migraine disorder. In 2020, a study by Adam-Darque et al. was performed, measuring the brain activity of newborns with MRI. The results showed that infants who were later diagnosed with colic showed greater sensitivity to olfactory stimuli, and presented with different neural activity when observing areas of the brain associated with pain processing, emotional valence attribution , and self regulation when compared to their typically developing counterparts.

Clinical Presentation and Diagnosis

Fussing and crying are typical in the first 3 months of life. In an article written in the American Family Physician, infants will cry an average of 2.2 hours a day. This most often peaks at 6 weeks and gradually decreases. It must be noted that these are statistics taken from a Westernized cultural demographic.

The "rule of three" has generally been used to diagnose colic:

1. Crying for more than 3 hours a day
2. For more than than 3 days per week
3. For more than 3 weeks

Modifications to this diagnosis have been introduced, with the most recent being the new Rome IV criteria.

For clinical diagnosis, this includes:

1. The infant is 5 months or younger when symptoms start or stop.
2. Caregivers report recurrent and prolonged periods of crying, fussing or irritability which occurs without obvious cause and cannot be prevented or resolved by caregivers.
3. No evidence of failure to thrive, fever or illness.

For research purposes this includes:

1. The above 3 points and...
2. Caregiver reported that the infant has cried or fussed for > 3 hours per day during ? 3 days out of 7 in a telephone or face-to-face screening interview with researcher or clinician.
3. Total of 24-hours of crying plus fussing confirmed to >3 hours measured by > 1 prospectively kept 24 hour behaviors' diary.

In addition, motor behaviors have also been used in the definition of colic, including

• A flushed face
• Furrowed brow
• Clenched fists
• Legs pulled up to the abdomen
• Infants emitting a piercing, high-pitched scream.

Generally, colic is seen to develop around 2 weeks of age, with resolution around the 4-month mark. Crying is usually concentrated around the late afternoon and evening for prolonged periods of time and is unpredictable and spontaneous. The child cannot be soothed, even by feeding.

Differential Diagnosis

Conditions that should be checked for unexplained crying in infants include:

• Hirschsprung disease
• Incarcerated hernia or testicular torsion
• Child abuse
• Gastroesophageal reflux
• Pyloric stenosis
• Anal fissure
• Corneal abrasion
• Cow's milk allergy
• Hair tourniquet syndrome
• Inadequate bottle feeding
• Inadequate breast feeding

The above causes are detailed in regards to findings, physical examinations, historical clues and diagnostic testing here.

Red flags which point to other more serious conditions are:

• Distended abdomen
• Fever
• Lethargy

Details are found here.

Management / Interventions

Because of its benign nature, the first recommendation for treatment is parental education, including the aspect that colic is benign and self-limiting. In addition, supportive resources can also be offered.It is important to acknowledge the difficulties of dealing with a colicky infant and to make further enquiry as to the well-being of the parents/ caregivers.

Generally, treatment has focused on:

• Probiotics
• Medications
• Dietary Modifications
• Physical Therapies
• Herbal Supplements

In terms of managing colic as a migraine condition, the following behavioral adaptions are advised for parents:

1. Turning down loud music and avoiding rattling or musical toys.
2. Dimming the lights in a room.
3. Having siblings or pets go into another room if possible.
4. Avoiding strong smells, such as those from cooking, perfume or cologne etc.
5. Gentle rocking of the infant instead of any vigorous bouncing.

Medical Management

Medications

Generally, few medications have demonstrated a significant improvement in infants diagnosed with colic.

From a migraine perspective acetaminophen has been recommended.

Allied interventions

Chiropractic interventions, including spinal or peripheral manipulations and/ or mobilizations is a common treatment. The treatment is directed to any restrictions in movement, potential biomechanical dysfunctions, tenderness or asymmetry in joints and/or muscles.

Occipito-sacral decompression (OSD), taught as an undergrad chiropractic technique, showed favorable outcomes in a study contrasting this technique with spinal manipulative therapy

Osteopathic intervention in colic makes use of light, tactile pressure on an affected area until there is a palpable release in the structures. It is focused on areas of dysfunction where there is a palpable increase in ligamentous or muscular tone or decreased or abnormal articular mobility. These areas include the cranium. In this treatment, the premise is that the manual therapy alleviates influences of childbirth contributing to the palpated dysfunctions.

Physiotherapy management

Exact treatment for infants with colic focuses' on manual contact, a hands-on approach to treat restrictions, asymmetries and places of tenderness.

In a study performed by NEU et al. (2014) infant massage performed by a trained professional on infants diagnosed with GERD (gastroesophageal reflux disease) improved the relationship dyad of mother and child. Massage given by mothers further assisted in this bonding.While those infants with colic may not always suffer from GERD, there is often a strain on parental-infant bonding in these cases. Interventions that can reinforce such bonds should not be neglected.