What is colic?
Colic is a behavioral syndrome of excessive, paroxysmal crying in an otherwise healthy neonate or infant aged 2 weeks to 4 months who is difficult to console. It tends to occur in the evenings without an identifiable trigger. The classic definition, from Wessel et al, is the "rule of three": paroxysms of crying lasting more than 3 hours a day, occurring more than 3 days in any week, for at least 3 weeks. The current diagnostic standard is the Rome IV criteria, which describe an infant under 5 months of age with recurrent, prolonged crying, fussing, or irritability that has no apparent cause and cannot be prevented or resolved by caregivers, and no evidence of poor weight gain, fever, or other illness. Rome IV dropped the strict crying-duration thresholds for clinical diagnosis (StatPearls). It is equally likely in breastfed and formula-fed infants.
Pathophysiology
The term colic comes from the Greek kolikos or kolon, pointing at the GI tract, but the cause is not settled. Researchers have proposed nervous-system, behavioral, and psychologic origins. A meta-analysis suggested colic may be a form of migraine rather than a GI condition. That analysis used 3 studies (891 subjects total): one found colic more likely in infants whose mothers have migraine, and the other two found infants with colic more likely to experience migraine in childhood and adolescence. Using a pooled random-effects model, Gelfand and colleagues found an odds ratio of 5.6 for the migraine-colic association. A secondary analysis adding two studies that addressed a different primary question put the odds ratio at 3.2.
Statistics and Incidences
Colic is one of the common reasons parents seek a pediatrician or family practitioner in the child's first 3 months. It affects 10% to 30% of infants worldwide and occurs equally in males and females, typically at 2 weeks to 4 months. Some infants with colic show increased susceptibility later in childhood to recurrent abdominal pain, allergic disorders, and certain psychological disorders.
Causes
Demonstrated and suggested causes include GI factors (gastroesophageal reflux, overfeeding, underfeeding, milk protein allergy, early introduction of solids); incomplete or absent burping and incorrect positioning after feeding. Note that colic is not limited to firstborn children, which weakens the "inexperienced parents" theory. Other associations include exposure to cigarette smoke and its metabolites (maternal smoking and nicotine replacement therapy in pregnancy), food allergy including cow's milk allergy (CMA), low birth weight, and a characteristic intestinal microflora, with lower counts of intestinal lactobacilli seen in colicky infants.
Clinical Manifestation
The exam is normal, and that is the point. Infants with colic look normal and often have accelerated growth; failure to thrive should make you doubt the diagnosis. Diagnosis rests on excluding serious causes of crying. On acoustic analysis, colicky crying is more variable in pitch, more turbulent or dysphonic, and higher-pitched than regular crying, and mothers rate it as more urgent, discomforting, arousing, aversive, and irritating.
Assessment and Diagnostic Findings
Labs are usually not indicated unless another condition such as reflux is suspected. If stools are excessively watery, a Clinitest for excess reducing substances may be worthwhile; a positive result can point to an underlying GI problem such as acquired (postinfectious) lactose intolerance. Stool may be tested for occult blood to rule out CMA.
Medical Management
Start by ruling out common causes of crying. Tell parents not to exhaust themselves and to leave the baby with other caretakers for short respites. Consistent followup and a sympathetic physician are the cornerstones of management. Dicyclomine hydrochloride is an anticholinergic shown effective in trials, but its use is not recommended because of serious, though rare, adverse effects (apnea, breathing difficulty, seizures, syncope). A maternal low-allergen diet (low in dairy, soy, egg, peanut, wheat, and shellfish) may relieve excessive crying in some infants.
Pharmacologic Management
Drug therapy is still under study. Simethicone is a nonabsorbable agent that changes the surface tension of gas bubbles so they coalesce, disperse, and release gas for easier expulsion. Herbal remedies (chamomilla, bitter apple, fenugreek) are used in many cultures, but only a handful of studies exist and more safety and efficacy data are needed.
Nursing Management
Nursing Assessment
Take a detailed history of the timing and amount of crying and the family's daily routine, and emphasize the benign nature of colic. Rule out dangerous causes of excessive crying: a hair tourniquet in the eye, strangulated hernia, otitis, and sepsis. On exam, confirm normalcy; weight gain is typical, and failure to thrive should raise suspicion against the diagnosis.
Nursing Diagnosis
- Acute pain related to abdominal distention and tenderness.
- Deficient knowledge related to lack of exposure and unfamiliarity with information resources.
- Impaired parenting related to lack of knowledge and confidence in parenting skills.
Nursing Care Planning and Goals
The caregiver describes satisfactory pain control at less than 3 to 4 on a 0 to 10 scale; reports improved wellbeing with baseline pulse, BP, and respirations and relaxed muscle tone or body posture; explains the condition and the need for medications and treatments; and reports improved confidence in parenting.
Nursing Interventions
Relieve pain. Assess pain characteristics, acknowledge reports of pain immediately, provide rest periods for sleep and relaxation, and position the infant for comfort.
Educate caregivers. Assess their ability to learn, set learning priorities, and correct existing misconceptions. Provide a calm, uninterrupted environment, involve caregivers in setting learning objectives up front, give clear explanations and demonstrations, and allow repetition of the information or skill.
Improve parenting. Interview parents about their perception of the situation, teach normal child growth and development against those perceptions, involve them in activities with the infant they can succeed at, and give positive feedback for nurturing, protective behavior.
Evaluation
Goals are met when the caregiver describes satisfactory pain control at less than 3 to 4 on a 0 to 10 face scale, reports improved wellbeing at baseline pulse, BP, and respirations with relaxed tone, explains the condition and treatments, and reports improved parenting confidence.
Documentation Guidelines
Document individual findings (factors affecting the infant, interactions, nature of social exchanges, specifics of behavior); intake and output; cultural and religious beliefs and expectations; the plan of care and teaching plan; responses to interventions and teaching; and progress toward desired outcomes.
Frequently Asked Questions
What is infant colic? Colic is intense, prolonged crying or fussing in an otherwise healthy, well-fed infant that has no clear cause and that caregivers cannot soothe. It usually starts in the first few weeks of life, peaks around six weeks, and tends to happen in the late afternoon or evening (StatPearls).
How is colic diagnosed? It is a clinical diagnosis of exclusion. The classic Wessel "rule of three" describes crying more than 3 hours a day, more than 3 days a week, for at least 3 weeks. The current Rome IV criteria define it as recurrent, prolonged crying with no apparent cause in an infant under 5 months who is growing well and has no fever or other illness (StatPearls).
How common is colic? It is very common, affecting roughly 10% to 25% of infants depending on the definition used, and it occurs equally in boys and girls and in breastfed and formula-fed babies. It is one of the top reasons parents bring an infant to a pediatrician in the first three months (Rome IV review).
What causes colic? The cause is not settled. Proposed contributors include an immature nervous system, GI factors such as gas, reflux, or cow's milk protein allergy, feeding technique, exposure to cigarette smoke, and differences in intestinal microflora. One meta-analysis even suggested colic may be an early form of migraine rather than a GI problem.
When does colic go away? Colic is self-limited. It typically resolves by about 3 to 4 months of age, with roughly 60% of infants better by 12 weeks and about 90% by 16 weeks. Persistent symptoms or poor weight gain should prompt reevaluation for another cause.
What can parents do to cope with a colicky baby? First confirm the baby is healthy and rule out dangerous causes of crying. Then focus on the parents: encourage rest, allow other caregivers to take short shifts, try soothing techniques like holding, gentle motion, and a calm environment, and reassure them that colic is benign and temporary. Caregivers who feel overwhelmed should never shake the baby and should put the infant down safely and step away if needed.