infantile colic_ management and outcome

8/13/2019 Infantile Colic_ Management and Outcome

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6/2/2014 Infantile colic: Management and outcome

http://www.uptodate.com/contents/infantile-colic-management-and-outcome?topicKey=PEDS%2F612&elapsedTimeMs=0&source=search_result&searchT 1/10

Official reprint from UpToDate

www.uptodate.com2014 UpToDate

AuthorsTeri Lee Turner, MD, MPH, MEd

Shea Palamountain, MD

Section EditorMarilyn Augustyn, MD

Deputy EditorMary M Torchia, MD

Infantile colic: Management and outcome

Disclosures

All topics are updated as new evidence becomes available and our peer review processis complete.

Literature review current through:Jan 2014. | This topic last updated:Dez 9, 2013.

INTRODUCTION Persistent or excessive crying is one ofthe most distressing problems of infancy. It is

distressing for the infant, the parents, and the clinician [1]. The parents of the infant may view the crying as an

indictment of their caregiving ability or as evidence of illness in their child [ 2]. Colic is a benign, self-limited

condition that resolves with time. However, the family's beliefs concerning the cause of crying and their

interactions with the healthcare system related to the crying may affect theway in which they view the child and

the healthcare system long after the crying has resolved.

The management of infantile colic is reviewed here. The clinical features, proposed etiologies, and diagnosis are

discussed separately. (See "Infantile colic: Clinical features and diagnosis".)

TERMINOLOGY We broadly define colic as crying for no apparent reason (eg, hunger, soiled diaper, etc)

that lasts for 3 hours/day and occurs on 3 days per week in anotherwise healthy infant


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The recommendations within this topic are largely consistent with those of the National Institute for Health and

Care Excellence Clinical Knowledge Summaryfor infantile colic [19].

Parental support and education Parental support is the mainstay of the management of colic. It may

influence the way the parents view their ability to care for their child.

Important aspects of parental education and support include [9,13,19-23]:

Clinical studies of parental support/counseling for infantile colic usually find it beneficial [4,24-27]. In a controlled

clinical trial, in which parents of colicky infants were counseled regarding effective responses to crying, the

crying decreased from 2.6 to 0.8 hours per day [26]. In a randomized trial, parental counseling was more

effective than dietary changes (crying decreased from 3.2 to 1.1 hours per day in the counseling group and from

3.2 to 2.0 hours per day in the dietary change group) [ 25].

Home-based nursing intervention or contact with other parents who have or had infants with colic also may be

beneficial. In a randomized trial in 121 infant-family pairs, crying was reduced by 1.7 hours/day in infants

following a four-week home-based intervention program (consisting of reassurance, empathy, support, and time-

out) compared with infants who received routine care [24]. In another study of 92 mother-infant pairs, specific

care suggestions provided by a trained lay counselor was associated with greater reduction in crying (51

percent reduction) than empathetic counseling by a lay counselor (37 percent reduction) or no treatment (35

percent reduction) [27].

First-line interventions As first-line interventions for colic, we suggest changes to the feeding technique

and/or experimenting with a number of techniques to soothe the infant [23,28]. These interventions addresssome of the potential etiologies of colic (eg, swallowed air, overstimulation) and, although the benefits are

unproven, the interventions are unlikely to be harmful.

Feeding technique Feeding changes may be helpful for infants whose colic is associated with feeding

problems (eg, underfeeding, overfeeding, inadequate burping). Bottle-feeding the baby in a vertical position

(using a curved bottle) in combination with frequent burping may reduce swallowed air. Using a bottle with a

collapsible bag also may help reduce air-swallowing [29].

Changes to breastfeeding technique also may be warranted. However, the management of breastfeeding

problems should be individualized; consultation with a lactation specialist may be warranted. (See "Common

problems of breastfeeding and weaning".)

Soothing techniques We suggest that parents experiment with one or more of the following techniques

for soothing the infant and/or decreasing sensory stimulation. They should be instructed to continue those that

are helpful and discontinue those that are not [5,13,19].

Education that colic is common and usually resolves spontaneously by three to four months of age (see

'Natural history'above)

Reassurance that the infant is not sick; this may require frequent follow-up (either by phone or in person)

(see 'Follow-up'below)

Education that colic it is not caused by something they are doing or not doing; it does not mean that the

infant is rejecting them

Acknowledging that the infant is difficult to soothe and that you know that they are doing the best they

can; this is essential in preventing the parents from feeling as if they have failed

Providing tips for techniques to soothe the baby (see 'Soothing techniques'below)

Encouraging the parents to take breaks from the crying infant (eg, taking turns with the infant during the

colicky period, asking a relative or friend to babysit so they can have a break, placing the crying infant in

his or her crib) and to have a rescue plana prearranged plan in which a relative or friend can step in if

the parents feel overwhelmed

Acknowledging that feelings of frustration, anger, exhaustion, guilt, and helplessness are normal
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These interventions are suggested by experts [5,13,19]. They have not been proven effective in randomized

trials, but are inexpensive, unlikely to be harmful, involve the parents, and may help to reduce parental or infant

anxiety [4,13,14,18,19]. In a large observational study, holding, walking, and rocking were found to be effective

in calming breastfed infants (with or without colic) younger than 16 weeks [34].

Second-line interventions A time-limited trial of second-line interventions may be warranted for infants who

do not respond to first-line interventions [19]. Second-line interventions vary depending upon whether the infant is

formula-fed or breast-fed.

Formula-fed infants A one-week trial of an extensive hydrolysate infant formula (eg, Alimentum,

Nutramigen, Pregestimil) is an option for formula-fed infants with colic that has not responded to first line-

interventions. A subgroup of infants with colic may have an allergy or intolerance to cows milk formula, although

infants with allergy or intolerance usually have associated clinical features (eg, bloody stool, vomiting, rash,

etc). (See "Milk allergy: Clinical features and diagnosis", section on 'Clinical features'and "Food protein-induced

enterocolitis syndrome (FPIES)", section on 'Clinical features'and "Introducing formula and solid foods to infants

at risk for allergic disease", section on 'Types of formulas'.)

Hydrolysate formula may be continued if there is a decrease in crying/fussiness. The response usually occurs

within 48 hours [35]. The original formula is resumed if there is no change in the infant's symptoms (hydrolysate

formulas more expensive than cow's-milk-based formulas).

Two 2012 systematic reviews of small randomized trials with methodologic limitations suggest that hydrolysate

formulas may reduce distress in infants with colic [15,17]. Additional studies are necessary to confirm these

results.

Breastfed infants A time-limited trial of a decrease in maternal milk product consumption or a

hypoallergenic maternal diet (eg, no milk, eggs, nuts, wheat) is an option for breast-fed infants with colic thathas not responded to first-line interventions and whose parents have difficulty coping. A subgroup of infants with

colic may have food allergy or allergy to cows milk, although infants with allergy usually have associated

clinical features (eg, rash, wheezing). Maternal dietary changes may be particularly beneficial if the mother is

atopic or the baby has symptoms of cow's-milk allergy (eg, eczema, wheezing, diarrhea, or vomiting) [36]. (See

"Milk allergy: Clinical features and diagnosis", section on 'Clinical features'.)

Two 2012 systematic reviews of small randomized trials with methodologic limitations suggest that a

hypoallergenic diet may reduce distress in infants with colic [15,17]. Additional studies are necessary to confirm

these results.

Other interventions A number of other interventions for infantile colic have been evaluated in randomized

trials with methodologic weaknesses or inconsistent results. Given these limitations, we generally do not

suggest these interventions for infantile colic. However, they may be suggested for some patients on a case-by-

case basis after a discussion of the potential risks and benefits.

Probiotics Although the data are insufficient to recommend probiotics for the routine management of

Using a pacifier

Taking the infant for a ride in the car or a walk in the stroller/buggy

Holding the infant or placing them in a front carrier [30]

Rocking the infant

Changing the scenery (or minimizing visual stimuli)

Placing the child in an infant swing

Providing a warm bath

Rubbing the infants abdomenHip healthy swaddling(ie, with room for hip flexion, knee flexion, and free movement of the legs [ 31-33]

(see "Developmental dysplasia of the hip: Epidemiology and pathogenesis", section on 'Swaddling')

Providing white noise (eg, vacuum cleaner, clothes drier, dishwasher, commercial white noise generator,

etc)

Playing an audiotape of heartbeats
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colic, especially in formula-fed infants, we occasionally suggest probiotics (specifically Lactobacillusreuteri) on

a case-by-case basis for breast-fed infants with colic.

A 2013 systematic review of five trials of the efficacy of probiotics in reducing crying found inconsistent results,

depending upon probiotic strain and feeding method [37]:

Seven trials (1554 infants) that evaluated the effectiveness of probiotics in preventing colic also had inconsistent

results (two suggested possible benefit; five found no difference) [37].

Soy protein formula We do not suggest changing from cows milk to soy protein formula for formula-fed

infants with colic. The benefits of soy versus cows milk protein in the prevention and management of colic are

unproven [43]. Studies comparing the effects of soy and hypoallergenic formulas on the reduction of colicky

symptoms are lacking.

Based on four small randomized trials with methodologic limitations (eg, inadequate blinding) [35,44-46], a 2012

systematic review concluded that soy protein formulas may improve colic symptoms, but additional studies are

necessary [15].

Neither the American Academy of Pediatrics Committee on Nutrition nor the National Institute for Health and

Care Excellence recommend soy protein formula for the treatment of infantile colic [19,43].

Fiber-enriched formula We do not suggest fiber-enriched formulas for formula-fed infants with colic. In a

randomized cross-over trial in 27 term infants in which the investigators were blinded but the parents were not,

fiber supplementation of soy-protein formula did not affect the average daily duration of crying [47]. However, the

parents of 18 infants found the fiber-supplemented formula beneficial in alleviating colic symptoms.

Lactase We do not suggest lactasefor the treatment of infantile colic. The benefits of lactase remain

unproven. Randomized trials of lactase treatment for infantile colic have conflicting results [48-51].

The National Institute for Health and Care Excellence Clinical Knowledge Summary for infantile colic suggests a

one-week trial of lactaseas an option for infants of parents who feel unable to cope despite advice and

reassurance [19].

Sucrose We do not suggest sucrose for the treatment of colic. Although oral sucrose appears to reduce

some types of pain in neonates, the evidence that it is beneficial in reducing crying in colicky infants is limited.

(See "Prevention and treatment of neonatal pain", section on 'Oral sucrose'.)

In a randomized crossover trial in 19 infants, 12 improved subjectively with sucrose [52]. However, the effect was

short-lived (30 minutes to 1 hour maximum). A separate case-control study found that the duration of response

of colicky infants to sucrose was3 minutes [53].

Infant massage We do not suggest infant massage for the treatment of infantile colic. A 2010

systematic review found no evidence of benefit and the potential harm of unsettling or over-stimulating colicky

infants [18].

In a randomized trial comparing four weeks of treatment with infant massage and a crib vibrator, crying

decreased from baseline in both groups [54]. The authors attributed the decrease in crying to the natural course

of colic (ie, resolution by three to four months of age) rather than to the specific interventions.

Simethicone We do not suggest simethiconefor the treatment of infantile colic. Simethicone is a

medication that causes gas bubbles to coalesce, facilitating expulsion [ 21]. However, a 2012 systematic review

of small randomized trials with conflicting results [55-57] found little evidence to support its use in the treatment

of infantile colic [17]. Simethicone is generally considered to be safe, but it may interact with levothyroxinein

Three trials [38-40] concluded that L. reuteriis effective in breast-fed infants; meta-analysis of these trials

(209 infants) found that L. reuterireduced median crying time by 65 minutes (95% CI 44 to 86 minutes) at

21 days compared with baseline

One trial concluded that L. rhamnosusis not effective for breast-fed infants [41]

One trial concluded that L. rhamnosusis possibly effective for formula-fed infants [42]
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infants being treated for congenital hypothyroidism resulting in hypothyroidism [58].

The National Institute for Health and Care Excellence Clinical Knowledge Summary for infantile colic suggests a

one-week trial of simethiconeas an option for infants of parents who feel unable to cope despite advice and

reassurance [19].

Herbal remedies We do not suggest herbal remedies (eg, herbal teas, fennel seed, Gripe water [a

mixture of herbs and water]) for the treatment of infantile colic. Although a few randomized trials suggest that

specific herbal remedies may be beneficial in reducing crying compared with placebo [59-61], the benefits are

largely unproven. Given the lack of standardization and regulation of herbal products, the benefits do not

outweigh the potential risks (eg, contamination with bacteria, toxins, or particulate matter; unlabeled

ingredients, such as alcohol) [62,63]. Prolonged ingestion of herbal teas may lead to decreased milk intake

[61].

Homeopathic remedies We do not suggest homeopathic remedies for the treatment of colic. They have

not been proven to be effective.

Homeopathic remedies often are considered nontoxic because of the low concentrations of active ingredients.

However, the labels of homeopathic products may not report all of the ingredients, some of which may have

toxic effects [64]. As an example, gas chromatography-mass spectrometry analysis of a homeopathic remedy

for colic that was associated with an increased risk of apparent life-threatening events found that it containedethanol, propanol, and pentanol, in addition to three potentially toxic substances that were listed as active

ingredients (colocynthis [bitter apple], Veratrum album [white hellebore], and strychnos nux-vomica [strychnine

tree]) [65]. Colocynthisis also found in Cocyntal and Hyland colic tablets.

Manipulative therapies We do not suggest manipulative therapies (eg, chiropractic, osteopathy, cranial

manipulation) for the treatment of colic. A 2012 meta-analysis of six randomized trials (325 infants) concluded

that methodologic limitations preclude definitive conclusions about the effectiveness or safety of manipulative

therapies for infantile colic [16].

Follow-up The frequency of follow-up for colicky infants is individualized. Some infants and families may

require frequent follow-up (by phone or in person) and reexamination to be reassured that the infant is continuingto do well and growing normally [5]. Other infants, whose parents are coping well and have strong support

networks can be seen less frequently (eg, at regularly scheduled health maintenance visits). In all cases,

parents should be counseled to return if the infant develops symptoms that were not present during the initial

evaluation (eg, vomiting, rash).

INDICATIONS FOR REFERRAL Most infants with colic can be managed by the primary care provider.

Referral to a developmental behavioral pediatrician or mental health provider may be warranted for parents who

are extremely anxious or in need of additional reassurance [28].

OUTCOMES Parents of colicky infants experience stress, fatigue, guilt, and depression [66]. Some

researchers have postulated that colic may disturb the child-parent interaction and thus have long-term effectson the family and child [67]. However, the data on the sequelae of colic are conflicting.

Temperament and behavior Several studies show that temper tantrums are more common among

formerly colicky infants. In two follow-up studies, parents of formerly colicky infants reported more frequent

temper tantrums at three and four years of age than parents of control children [ 67,68]. In a meta-analysis of

longitudinal studies, the risk of behavior problems in later childhood was increased when colic persisted at five

months of age [69]. The risk was greatest when persistent colic was accompanied by other regulatory problems

(eg, feeding, sleeping) and psychosocial risk factors, which makes it difficult to establish a causal relationship

[3].

Parents of formerly colicky children perceive their toddlers' temperaments as more difficult than parents of

noncolicky children. In a follow-up study, parents described their formerly colicky children as more emotional at

age four years (eg, "cries easily" or "tends to be somewhat upset") than noncolicky infants [68]. Mothers in

another one-year follow-up survey also rated their formerly colicky children as more difficult [ 70]. However, these

children did not differ from control children according to the Toddler Temperament Scale. The discrepancy
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goals are to help the parents cope with the child's symptoms and to prevent long-term sequelae in the

parent-child relationship. Parental support is the mainstay of the management. (See 'Overview'above and

'Parental support and education'above.)

Beyond parental support, we suggest changes to feeding technique and/or experimenting with a number of

techniques to soothe the infant (eg, rubbing the infants abdomen, providing white noise, etc) as first-line

interventions (Grade 2C). (See 'First-line interventions'above.)

A time-limited trial of second-line interventions (a trial of hydrolysate formula for formula-fed infants or

hypoallergenic diet for mothers of breastfed infants) may be helpful for infants who do not respond to first-

line interventions. (See 'Second-line interventions'above.)

A number of other interventions for infantile colic have been evaluated in randomized trials with

methodologic weaknesses or inconsistent results (eg, probiotics, soy protein or fiber enriched infant

formulas, simethicone, herbal teas, etc). Given these limitations, we generally do not use these

interventions for infantile colic. However, they may be tried on a case-by-case basis after a discussion of

the potential risks and benefits. (See 'Other interventions'above.)

The frequency of follow-up for colicky infants is individualized. Some infants and families may require

frequent (ie, weekly or bi-weekly) follow-up for reassurance, whereas other infants, whose parents are

coping well and have strong support networks, can be seen less frequently. (See 'Follow-up'above.)

The data on the sequelae of colic with respect to temperament, behavior, sleep patterns, family

functioning, asthma, and atopy are conflicting. However, colic does not appear to be related to cognitive

development. (See 'Outcomes'above.)
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