The most widely accepted definition of colic follows the "rule of three": crying lasts for more than three hours per day, occurs on more than three days per week, and persists for more than three weeks (also known as the Wessel criteria).
Colic occurs in 8 to 40 percent of all infants. It occurs with equal frequency in the following groups:
- Males and females
- Breast- and bottle-fed infants
- Full-term and preterm infants
- The first and second child (and other siblings as well)
Normal crying patterns- All infants cry more during the first three months of life than during any other time. There is no standard definition for "excessive" crying; the average duration of crying during this period varies from 42 minutes to two hours per day. Infants without colic cry, although generally less frequently and for a shorter duration than infants with colic.
Colic- Colic may include more than excessive crying, at least in some infants.
- Onset- Each episode of colic has a clear beginning and end, and the onset is unrelated to what was happening before the episode started; the infant may have been happy, fussy, feeding, or even sleeping. The crying episode begins suddenly and often occurs in the evening hours.
- Differs from normal crying- Colic episodes are more intense, louder, and higher pitched than "normal" crying. Infants with colic may sound as if they are in pain or are screaming.
- Increased muscle tone- Infants with colic may have physical symptoms
- The face of the baby is flushed, with occasional pale skin colour around mouth
- The abdomen is distended and tense
- The legs are drawn up on the abdomen and the feet are often cold (the legs may extend periodically during forceful cries)
- The fingers are clenched
- The arms are stiff, tight and extended (the elbows may also be flexed)
- The back is arched
- Difficult to soothe- Infants with colic are difficult or impossible to soothe, no matter what the parents do.
- There may be periods of quiet, but infants often remain fussy. Crying may end after the infant passes gas or a bowel movement. For all infants, colic is a temporary problem. It resolves by three months of age in 60 percent of infants and by nine months in 90 percent of infants.
Causes- There are many theories about the causes of colic, although evidence supporting a single theory is scant. Most infants with colic do not have an underlying medical condition that causes them to cry excessively. Colic probably results from a number of different factors, including gastrointestinal, biologic, and psychosocial factors.
Gastrointestinal factors- Gastrointestinal factors have been proposed as a cause of colic for several reasons: some infants with colic have a tense or bloated abdomen, draw their legs up to the abdomen (as if their abdomen hurts), and stop crying after passing gas or a bowel movement.
Biologic factors- Feeding techniques - Underfeeding, overfeeding, infrequent burping, and swallowing air have all been described as possible causes of colic.
Smoking- Infants of mothers who smoke during pregnancy or after delivery have twice the risk of developing colic.
Temperament- Experts have proposed that infant behaviour and development are the result of a child's response (based on their individual characteristics) to their environment. However, there is limited evidence for this theory.
Parental variables- Family stress and tension have been suggested as a cause of colic but studies have shown conflicting results.
Other causes foe excessive crying- There are a number of reasons, other than colic, that an infant may cry excessively; these can range from simple problems such as hunger to more serious problems such as infection.
A parent should first check for manageable causes of crying:
Hunger- Try feeding the baby to see whether hunger is the problem. Although most young infants (younger than 3 months) feed every two to four hours, all babies go through periods when they will want to feed more frequently (usually during growth spurts).
Pain- Check to see if the baby is uncomfortable because of illness or physical injury. Feel the skin to determine if the baby is overheated or too cold. Check to see if the clothing or diaper is too tight or if a hair is wrapped around a finger, toe, or the penis (called a hair tourniquet).
Fatigue or overstimulation- Babies often cry when they become tired or overstimulated from playing or being handled. Swaddling the baby snugly, offering a pacifier, or a change of scene (such as a stroller or car ride) may help the baby to fall asleep.
How to swaddle a baby
The infant should be placed on a large blanket or sheet with the top corner folded down. The left side of the blanket should be drawn snugly across the infant's left shoulder and chest, and tucked under the right side of the body. The bottom of the blanket should be pulled up snugly and tucked behind the infant's right shoulder. The right side of the blanket is then pulled snugly across the infant's chest and tucked under the left side of the body.
Food sensitivities- Infants can have an allergy or sensitivity to foods in their mother's diet or a component of their formula. Foods such as milk, eggs, nuts, and wheat in a mother's diet have a direct effect on the composition of her breast milk; these foods can occasionally cause food reactions and digestive problems such as abdominal pain, cramping, and diarrhoea. Formula-fed infants can be sensitive or allergic to a protein in cow's milk-based formulas. Lactose (a type of sugar found in cow's milk) intolerance has little to no effect on the development of colic.
Food sensitivities may be suspected if an infant cries or spits up a large amount within an hour of feeding or if a baby has constipation or diarrhoea. Symptoms of cow's milk allergy include eczema, wheezing, diarrhoea, or vomiting.
If these causes have been eliminated and the baby continues to cry excessively, parents should speak with their healthcare provider. Most infants who cry excessively do not have a serious underlying medical problem; a healthcare provider can help to make this determination.
Diagnosis- The diagnosis of colic is often made after it has run its typical three- to four-month course. Parents who are concerned about their infant's crying should visit a healthcare provider to discuss their concerns and possible management strategies. Other causes of excessive crying must be considered in any infant who is suspected to have colic.
The provider may perform a physical examination, including measurement of the infant's height and weight. These measurements are used to monitor an infant's growth pattern, and may show abnormal changes if there is an underlying medical problem.
Home monitoring- Parents can monitor the characteristics of their infant's crying; it may be helpful to keep a written record of the following information. This information can be shared with a healthcare provider to help determine the cause of an infant's crying as well as the best ways to manage it.
- When does crying occur and how long does it last? Crying that occurs directly after feeding may be caused by gastroesophageal reflux (heartburn) or swallowed air.
- Does the crying begin at the same time every day? Does the infant cry at other times of the day?
- What seems to trigger an episode of crying? What helps to stop crying?
- What do you do when the baby cries? Parents who respond to their crying infant by yelling, shaking, or hitting can prolong crying and potentially harm an infant.
- What does the cry sound like? As mentioned above, infants with colic often have a higher pitched, louder, and more intense sounding cry.
- How and what do you feed the baby? As mentioned above, overfeeding, underfeeding, and feeding inappropriate foods have been described as a cause of colic.
- Is the crying getting better, worse, or is it about the same? Parents may be reassured that for all infants, colic is a temporary problem. It resolves by three months in 60 percent of infants and by nine months in 90 percent of infants.
- How do you feel when the baby cries? Parents' experiences of living with a colicky infant vary; some parents feel overwhelmed and incapable of caring for their infant, while others blame the infant for being difficult.
- How has colic affected your family? Colic affects all members of a household, and it is important to consider input from everyone.
- Why do you think the baby cries? Parents should feel comfortable discussing thoughts and concerns about their infant with a healthcare provider.
Colic Myths and Facts
There are a number of myths about the causes and treatments of colic. Myths often develop to explain problems that are not well understood. Parents can learn to separate myths from facts through education and support from respected sources, including healthcare providers.
- Babies do not cry to manipulate their parent(s).
- It is not possible to spoil a baby by holding or comforting them.
- Rice cereal does not improve colic. Infants should be given only breast milk or formula until they are 6 months old, unless told otherwise by a healthcare provider.
- Studies show that simethicone (Mylicon®) and lactase (the enzyme that helps to digest lactose, the sugar in milk) are of no benefit.
- Sedatives, antihistamines and motion-sickness medications are not safe or effective. Dicyclomine can temporarily stop breathing or cause seizures or coma.
Colic affects the whole family, and treatment is individualized based upon an infant's symptoms and the family's response. The goals of colic management are to decrease the infant's crying, help the family cope, and prevent long-term difficulties in the family's relationships.
No single management strategy has proven to be successful for all infants, thus many providers recommend trying several strategies at once. One or more strategies are beneficial for up to one-third of infants.
Parental support- Parents of infants with colic often feel frustrated, angry, exhausted, guilty, and helpless because of their child's crying. These feelings are normal, and do not indicate that a parent is incapable or unworthy of caring for their child.
Take a break- It is normal for parents to need a break from a child who cries excessively. A parent who is alone and needs a break may leave the infant in a safe place for a few minutes; the infant should be placed on his or her back in a crib or bassinet with side rails. Loose blankets, pillows, and toys that could potentially suffocate the child should be removed.
Taking a break allows a parent to call a friend or relative for help, get away from the crying, and can prevent them from potentially harming the child. Shaking, smothering, or slapping will not stop an infant's crying but can seriously injure or even kill the child.
Shaken baby syndrome is the term used to describe the injuries suffered by infants who are violently shaken, often by a parent or adult caretaker, who has become overwhelmed by excessive crying. Infants do not have sufficient strength in their neck to limit head movement, and shaking causes the head to move suddenly and uncontrollably. As the head moves backwards and forwards, the brain hits the inside of the skull, causing serious damage and even death.
Dietary and feeding technique changes
Bottle-fed infants- A number of devices (nipples, bottles) have been designed to decrease the amount of air swallowed during feeding. Parents may try positioning the infant in a vertical (sitting up) position while feeding. A curved bottle or collapsible bag, in combination with frequent burping, also may be tried. These techniques can reduce the amount of air swallowed, which may reduce colic in some infants.
Some studies suggest that infants with colic improve when their formula is switched to a soy-based or hypoallergenic formula. However, the results of these studies are inconclusive. Parents should consult with their infant's healthcare provider to determine if a formula change might be helpful.
Some providers suggest a trial of a different formula for one week (for bottle-fed infants). The original formula should be restarted if there is no change; low allergy (hypoallergenic) and soy-based formulas are more expensive than traditional formula and do not need to be continued if an infant's crying does not improve after a one-week trial of the new formula.
Breast-fed infants- Mothers who breastfeed may try consuming a hypoallergenic diet to reduce their infant's colic. A hypoallergenic diet eliminates potentially aggravating food groups, including milk, eggs, nuts, and wheat.
To try a hypoallergenic diet, a single food group is eliminated during a one-week trial period while the infant's crying patterns are monitored. The food may be restarted if no improvement is seen. This type of diet appears to be more effective for infants whose mothers have eczema, asthma, or allergic rhinitis, or if the infant has symptoms of cow's milk allergy (including eczema, wheezing, diarrhoea, or vomiting). There is some evidence that having an infant empty one breast completely before switching sides may reduce colic.
There is no evidence that stopping breastfeeding and starting formula is of any benefit in babies who have colic. There are a number of benefits to breastfeeding and breast milk that are not available with formula.
Carrying- Some parents find that carrying their infant in their arms, a sling, or a front carrier can decrease the infant's and parents' anxiety. Although studies have not proven carrying to be effective for all infants, it may be beneficial for infants who have not responded to other treatments. In addition, many parents find that using a sling or front carrier frees their hands and arms and allows them to move around while monitoring their infant.
Change in environmental stimuli- Parents may try a number of techniques to increase environmental stimuli: a pacifier, ride in the car, change of scenery, infant swing, and warm baths have been suggested and may help to soothe an infant with colic. However, none of these suggestions have been supported in clinical trials.
Infants also may benefit from decreased stimuli; swaddling, or placing the infant near a white noise machine or clothes drier may soothe an infant who is hypersensitive to noise.
Herbal remedies- Herbs such as chamomile, fennel seed, and balm-mint are thought to have anti-spasmodic properties and have been used in infants with colic. Although a few studies have shown improvement in infants given a tea made with a specific mix of herbs, parents should be cautious about trying this type of treatment.
Gripe water is a mixture of herbs, primarily dill, and water that has been promoted for its ability to cure colic. However, various types of gripe water have been found to contain dangerous ingredients, including glass particles and alcohol.
A healthcare provider should be consulted BEFORE any herbal remedy is used; herbal remedies may not be appropriate and could be dangerous in some cases.
Infant massage- Infant massage has been recommended to parents of infants with colic, although no studies have proven it to be of clear benefit.
When to seek help?
Parents should call their child's healthcare provider during the day or night if any of the following occur:
- The baby has cried for more than two hours
- The parent is afraid he or she may hurt the baby, or if the parent has shaken the baby
- If crying could be the result of an injury or fall
- The baby has a fever of ≥100.4ºF (38ºC). Parents should call their infant's healthcare provider or go to an emergency department immediately. Table 4 describes how to take a child's temperature.
- The infant refuses to eat or drink anything for more than a few hours, vomits excessively, has bloody stools, or has a change in behaviour, including lethargy or decreased responsiveness.
A parent should call their child's healthcare provider's office during normal office hours if any of the following occur:
- Parent cannot soothe their baby's crying or has questions or concerns about how to manage their crying baby
- Excessive crying continues after the infant is older than 4 months
- The infant fails to gain weight
Long term outcome
Colic can take a toll on families. Some researchers have suggested that colic interferes with child-parent interactions and can have a long-term effect on the family and child.
Long-term studies have examined the possible relationships between colic and features of later childhood, including temperament, sleep patterns, family functioning, asthma, and cognitive development. However, no significant relationship between colic and these features of later childhood have been proven.