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From the paediatricians..
This interesting article will highlight the basics of colic in babies and will provide our parents with an approach of how to
manage the little one at home …….before it becomes a nightmare.
COLIC IN BABIES – WHOSE FAULT IS IT ANYWAY ?
The Basics:
Nothing is more distressing to a parent than a newborn who won’t stop crying. All babies cry. It's their only way of
communicating with us, so they cry for many different reasons. Sometimes they're hungry or thirsty. Sometimes
they're sleepy. Sometimes they want more attention, sometimes less. Sometimes they're over-stimulated, and
sometimes they're bored. Occasionally they are even sick or in pain. Often a baby doesn't know why it's crying - he
or she is just "out of sorts", in a bad mood. Is there always a specific reason why YOU feel cranky?
Usually, parents can find ways that work to soothe their babies when they cry. They do this by learning to read the
baby’s "signals", sense the baby’s needs, even through simple trial and error. Different babies soothe in different
ways. Some are easier to soothe than others. Even a difficult-to-soothe baby usually stops crying spontaneously
within a time not terribly distressing to its parents. This is not always the case, however. Some babies cry for
excessively long times and are particularly difficult to console. When no other major
symptoms are present, and a physical exam fails to reveal signs of any obvious disease, we refer to this phenomenon as "Infant Colic."
The Problem:
The definition of Infant Colic described above is necessarily a bit "slippery" & subjective. It relies on the word
"excessive", but excessive is in the eyes of the beholder. Parents differ in their tolerance for crying. For some,
anything more than a few minutes is "excessive", while for others it might take several hours for them to become
alarmed. Scientists have studied crying in infants and found that the "average" infant cries 2-3 hours per day. This
has led to definitions of Infant Colic for research purposes that depend on a crying time greater than four hours per
day. However, for a child’s parents, 4 hours can seem like an eternity, and minutes can seem like hours. Parents,
therefore, tend not to be very accurate in estimating infant crying times. In "real life", Infant Colic is defined by
whatever amount of crying seems excessive to the parent(s). This in turn is greatly affected by how successful they
feel at soothing their baby. It is very frustrating not to be able to soothe a baby. Therefore, babies who are
difficult to soothe may be more apt to be termed "colicky" even if their actual crying time is no different from
another baby who cries a lot but can be easily consoled.
Few conditions in early childhood are less well understood than Infant Colic. Parental vs.
medical perceptions of this problem tend to be quite different. The main reason for this is that most intuitive, "common sense" ways of
understanding and treating Colic just don't jive with the data or scientific research. Every theory ever put forth to
explain Infant Colic has either been proved wrong in studies, or by it's nature defies scientific analysis. Infant Colic
is thus one of those frustrating medical problems where we know more about what it isn’t than about what it is.
This is of course not helpful, or even satisfactory, to parents understandably upset by their infant's Colic. They
expect the physician to know what's causing it, and want an effective treatment to be prescribed! An honest
explanation that no proven treatment exists is easily misinterpreted by parents as reflecting a lack of caring on the
part of the physician. Knowing this, many otherwise good physicians unfortunately give in and are untruthful about
our ignorance & impotence with respect to this problem. Instead, they resort to perpetuating dubious or disproved
theories and/or to prescribing therapies that are at best unproven, are known to be no more effective than placebo,
or occasionally may even be dangerous.
Theories of Colic: Pain
It is quite natural to think that a colicky baby must be suffering from some sort of pain. Indeed, every parent or
grandparent who has taken care of such a baby for thousands of years has thought so. The very word "colic" is
derived from the ancient Greek word for pain. Other medical "colics" (renal colic, biliary colic) refer to very painful
diseases (kidney stones, gall stones). We know from scientific studies, however, that colic is not due to pain.
Modern pain experts have learned how to measure pain on a physiologic level using brain waves, hormone levels, and
other physiologic measures. Such measures have been used to prove such things as the fact that newborns do feel
pain, no different than adults do, during such procedures as needle sticks or circumcision. When colicky infants are
hooked up to such monitoring devices, however, they display a very different physiologic pattern. It looks
nothing like pain! It looks more similar to anger! What that means, we can only speculate…
Theories of Colic: Gas
The idea that colic must be in some way related to gas comes from the nearly universal observation that infants with
colic pass a lot of it. Sometimes this is in the form of flatulence, other times it is in the form of excessive
burping. Studies seem to indicate, however, that infants pass gas because they have colic - they do not have colic
because they have gas. The most direct evidence for this are studies in which infants without colic were made
"artificially gassy" using diet or benign medications. These babies passed a lot of gas as a result, but they did not
cry more. Further evidence against the gas theory of Colic comes from studies of "gas drops"
(Mylicon, Phazyme). Whether these drops work or not depends what you look at. If the study focuses on the amount of actual gas
passed, the drops are effective in reducing gas. However, if the study focuses instead on
total crying time and severity of Colic, gas drops have been shown to be no more effective than placebo. Today we believe that babies
who cry a lot swallow air when they are crying - what goes in must come out. The colic explains the gas, not vice
versa.
Theories of Colic: Allergy
One gastrointestinal problem that does have some association with Colic is food allergy. This association is mild,
however, and only applies to a minority of newborns with Colic. Babies with food allergy may initially seem to have
Infant Colic - however they will usually develop other symptoms of food allergy within a few weeks time. Theseother symptoms can include eczema, spitting up, diarrhea, bloody stool, and a failure to grow. The development of
these other symptoms makes the diagnosis of food allergy easy once they occur - and they do eventually occur inalmost all babies who have food allergy. While some babies with Colic (the ones who are really in the early stages of
developing food allergy) do respond to a switch to hypoallergenic formula, this is but a small percentage of all
infants with Colic. Because hypoallergenic formulas are very expensive and not as nutritionally complete as the more
standard infant formulas, however, switching colicky infants to them before they have developed other signs and
symptoms of allergy is not generally recommended.
Theories of Colic: Real GI Issues
Gastroesophageal Reflux can cause abdominal pain in a newborn, but is usually accompanied by abnormally severe
spitting up and sometimes coughing, gagging, and poor weight gain as well. Lactose intolerance is an inability to
digest the main sugar in milk. It is NOT a food allergy and bears no relationship to food allergy. It tends to run in
families and can sometimes present initially as Infant Colic. However, newborns with Lactose intolerance tend to have
other symptoms beyond crying - particularly spitting up and poor growth. Likewise,
simple Constipation can also present with Colic - but usually this is obvious because the child has firm stools. Thus, both Lactose
Intolerance and Constipation are usually fairly easy to recognize, and
respond to simple interventions such a change in formula or a stool softener. They therefore should be thought of separately and not lumped
together with Infant Colic.
Theories of Colic: Other GI Concerns
Some parents blame dietary iron for Colic, or believe that some other aspect of food "tolerance" (besides allergy)
may be at work. Many physicians encourage this by engaging in random formula changes trying to treat Colic.
However, the amount of iron in breast milk or even iron-fortified formula is NOT enough to cause stomach upset.
Studies have shown that switching formula (in any direction) in the absence of clear clinical signs of Allergy,
Constipation, or Lactose Intolerance is no more effective than placebo in curing Colic. Many other aspects of
gastrointestinal function in infants with colic have been studied as well. Such infants are no more or less likely than
other infants to grow normally. They are no more or less likely than other infants to be able to digest common
foods.
The entire GI tract of colicky infants who have died from other causes (e.g. motor
vehicle accidents) have been studied "from stem to stern" under electron microscopes and no difference between them and other normal
infants has been found. Children with a history of Infant Colic have been followed through childhood and out into
adulthood. Their rates of later GI diseases (such as Inflammatory Bowel Disease, Irritable Bowel Syndrome, Ulcers,
Gallbladder Disease, Liver Disease or Pancreatic problems) are no different than the population "at large" or from
individuals without a history of Colic.
Theories of Colic: Psychosocial
Another theory of Infant Colic, which held some popularity in the late 70's and early 80's, was that it had
something to do with poor maternal-infant bonding. This was an era when much research on infant bonding was being
done and we understood more and more about this phenomenon. It seemed logical that colicky infants were having
difficulty with this process. Mother-infant pairs including both colicky and non-colicky infants were observed in
many psychological research protocols and it was found that there was no correlation between the quality of infant
bonding and daily total crying time. Indeed, some very poorly bonded and even neglectful parents had very quiet
babies while some of the most attentive and well-bonded parents had the most colicky babies. Indeed, more
generally, it was found there was really no correlation between parent behavior towards the baby and Infant Colic
whatsoever.
Theories of Colic: Temperament
Another idea has been that Colic is an early expression of a "difficult" personality. Babies who have had Infant
Colic have been studied later in life. It has been found that there is no correlation between a history of Infant
Colic and I.Q., personality, school success, juvenile delinquency, or a whole host of psychological difficulties
including depression, anxiety, and personality disorders. In short, Infant Colic has
nothing to do with psychology.
Theories of Colic:
Neuro-development
This is the theory that we believe here at Children's Medical Office. It is perhaps the least well-known, but it is
the most logical and scientifically appealing theory about Infant Colic (and the only one that hasn't been completely
disproved). It holds Colic to be a phenomenon of neurologic immaturity. It has been observed that infants with Colic
are more easily over-stimulated than other babies. Once they become "worked-up", they have a much harder time
being "brought back down" by themselves or others. State-control is the neurological skill felt to be relatively
immature in these babies. This is the ability of a person to maintain a comfortable mental "state" (such as being
awake & alert or soundly asleep) and the ability to transition out of an "uncomfortable state" in the direction of a
more comfortable one (e.g. someone who is "drowsy" either tries to fall asleep or wake up, someone who is crying
tries to soothe themselves). This ability, like memory or language, gets better with age. Most adults are far better
at it than children. Older children are better than younger children. Some newborns are better at it than others.
The neurodevelopmental theory is supported by several observations. The first is that all babies with Infant Colic
outgrow it, usually by 4 months of age. The second is soothing strategies which involve a good deal of stimulation
(such as rocking, singing, talking, feeding, changing diapers, etc.) usually are
counter-productive for colicky babies. In contrast, strategies which involve
reduction in stimulation (swaddling, placing in a dark room, "white noise") tend
to be more successful. This theory has led to the development of a device known as the "Sleep Tight" which
combines a vibrator with a monotonous tone and attaches to the crib simulating a car cruising at 55mph on the
highway. The makers of this device sell it with a money-back guarantee to cure colic (it can be obtained by calling
1-800-NO-COLIC). In our experience, this works for many babies, but not all. It has the advantage over other
potential therapies of being harmless, at least. Current proponents of the neurodevelopmental theory propose
relatively benign treatments such as the Sleep Tight, swaddling, and avoiding over-stimulation.
HISTORICAL PERSPECTIVE:
Not so long ago, in the middle part of this century, tranquilizers and sedatives were the "treatment of choice",
routinely prescribed by doctors for Infant Colic. There is no doubt that such medicines worked quite well. They
were abandoned in the 1960’s, however, when we began to appreciate that they
had adverse long-term developmental consequences. The idea persists to this day, however, in some quarters. Not only do some older doctors persist in
prescribing such medications (Paregoric, Phenobarbital, Bentyl) but some recent research has
shown that small quantities of alcohol given to colicky babies result in a reduction in crying time. It should be noted, however, that
alcohol is really in the same pharmacologic category as all of the tranquilizers previously used, and likely
would have the same adverse developmental consequences.
WHAT TO DO:
As you can see, we know a lot about what colic isn’t. We still know relatively little about what it is or what to do
about it. A small minority of babies who initially seem to have Colic will actually turn out to have Constipation,
Lactose Intolerance, or a Food Allergy. This will become clear to you & your doctor in time. You should not "jump to
conclusions" about these diagnoses before they are symptomatically apparent. The only theory about Colic that has
not been completely disproved is the neurodevelopmental one, but it hasn't been proven either. As medical
professionals, we want to avoid doing harm to the baby, making false statements, or hold out false hopes. As a
parent, you should focus on the following:
Never hesitate to bring a baby with Infant Colic into see us for an exam to rule out possible medical causes of
crying unrelated to colic. Babies initially thought to have colic sometimes
turn out to have not only food allergies later (proven by the development of diarrhea, blood in the stool and growth difficulties) but sometimes they have
something as simple as an ear infection which can be easily treated. Sometimes other medical problems are found,
but these are almost always apparent in a complete history and physical exam.
There is light at the end of the tunnel. Infant Colic tends to start at a few weeks of age and
builds to a crescendo between 2-3 months and then subsides and is almost always gone by 4-5 months of age. You should rest assured
that if we have done an examination and found no medical problems, the baby will outgrow the colic and subsequent
to that, there will be no long-term consequences for the child.
Colic is not associated in any way with later physical or emotional disease
It is not your fault your infant has Colic, and your inability to sooth this newborn is not a reflection on your
parenting ability.
You should seek out the support of other parents who have been through this before.
You should avoid trying measures to soothe the baby which are over-stimulating in nature.
Try swaddling, reducing stimulation, "white noise", or the SleepTight device. Avoid resorting
to treatments which have been proven not to work (formula changes, gas drops) or which are dangerous (tranquilizers). Always consult with
your doctor before trying a new treatment.
Give yourself a BREAK. Leave the baby with your partner, a grandparent, friend or babysitter when you need to get
away from the crying.
You should always call the office if new symptoms beyond the crying develop.
© 1999, David A. Ansel, M.D
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