Colic

Recurrent excessive crying in an otherwise healthy infant is often termed colic. This diagnosis can only be made if the pattern is recurrent and stereotypical³ and a careful history, examination and period of follow up have ruled out important causes. The definition of colic varies but is frequently arbitrarily defined as a total of more than 3 hours per day of irritability, fussing and crying on at least 3 days a week for at least 3 weeks.⁴ This pattern typically occurs in the afternoon or evening, ceasing by 3 to 4 months of age.³

Management

Current specific dietary, drug and behavioural strategies meet with limited success; however, cows’ milk protein intolerance may have a role in a small proportion of infants.^4,5 The positive effects of changing from cows’ milk based formula to casein hydrolysate formula have been noted to diminish with time, suggesting that colic is not related to allergy.⁵ A trial of hydrolysate (e.g. Pepti-Junior, Alfare) may be appropriate in a formula-fed baby but its long-term use is likely to be unnecessary. It is notable that soy protein formulas may have similar adverse effects to those of cows’ milk formulas.⁵ Mothers of breastfed babies can exclude all dairy products (but ensure calcium supplementation) for 2 weeks as a trial.

Gastro-oesophageal reflux (GOR) is frequently cited as a possible cause of infant crying. Feeding difficulties and frequency of regurgitation (> five times daily) are associated with pathological GOR as defined on oesophageal pH monitoring – there is a place for an empirical trial of proton pump inhibitors in this group.⁶

Anticolic medications should be avoided, as they have been shown to at best have no effect (simeticone) or risk serious adverse effects (anticholinergics).⁴

Behavioural interventions, including advice to reduce stimulation in combination with permission to leave the infant when the crying was no longer tolerable was effective when compared to a non-specific empathic interview.^4,7 Reduction of stimulation advice includes avoiding excessive patting, winding, lifting, vigorous jiggling and loud noises or toys. Carers were advised not to intervene in the early part of sleep when the infant may appear restless and also given an assurance that a certain amount of crying is normal.^4,7 It is important to remember that even if behavioural interventions do not change the infant’s temperament, they may well alter the impact colic has on the carer and on carer–infant interactions.⁸

Carers very reasonably assume that there must be something wrong either with the child or their parenting for an infant to cry frequently and excessively. Much reassurance that the child is healthy can be gained from witnessing the conduct of a complete history and thorough examination. Similarly, an explanation that this is a common problem that does not reflect on their parenting, that some babies may be assisted by some simple behavioural techniques and that the carers will be supported by appropriate referral will also reduce anxiety considerably.