Infantile colic- An Overview

What is an Infantile Colic

Infantile colic is a benign, self-limited process in which a healthy infant has paroxysms of inconsolable crying. 

The standard diagnostic criteria—known as the “rule of three”

  • crying more than three hours per day, 
  • more than three days per week, 
  • for longer than three weeks

Symptoms typically resolve by three to six months of age. Colic affects 10% to 40% of infants and typically peaks at about 6 weeks of age, and is often associated with significant parental guilt, frustration and multiple pediatrician visits. 

The incidence is equal between sexes, and there is no correlation with type of feeding (breastfeeds vs. formula), gestational age (full term vs. preterm), socioeconomic status, or any season of the year. 

What causes an Infantile Colic

What exactly results in a colic, still remains a medical dilemma but few hypotheses have been proposed by researchers, which include- 

  1. Poor feeding technique or any oral restrictions resulting in a shallow latching leading to aerophagia and feeding dominantly of foremilk.
  2. Alterations in fecal microbiota- Varies with type of delivery (vaginal vs LSCS and type of milk used)
  3. Intolerance to cow’s milk protein or lactose
  4. Gastrointestinal immaturity or inflammation
  5. Increased serotonin secretion #
  6. Maternal smoking or nicotine replacement therapy

# It has been hypothesized by many researchers* that in the evening, peak serotonin concentration causes intestinal cramps associated with colic because serotonin increases intestinal smooth muscle contractions. Melatonin has the opposite effect of relaxing intestinal smooth muscles. Both serotonin and melatonin exhibit a circadian rhythm with peak concentrations in the evening. However, serotonin intestinal contractions are unopposed by melatonin during the first 3 months because only serotonin circadian rhythms are present at birth. Melatonin circadian rhythms appear at 3 months of age. The cramps of colic disappear at 3 months of age.*

*Infant colic: the effect of serotonin and melatonin circadian rhythms on the intestinal smooth muscleL WeissbluthM Weissbluth PMID: 1461181 DOI: 10.1016/0306-9877(92)90180-k

Evaluation of infant with suspected colic

Infantile colic is a diagnosis of exclusion

  • Thorough history and physical examination to rule out underlying organic disorders and to determine the need for further investigations
  • Look for any Red flag signs – Failure to thrive/poor weight gain, Abdominal distension, Fever, Lethargy, Vomiting, Diarrhea etc. and consider alternative diagnoses.
  • Feeding Assessment by a trained Lactation Expert for a shallow latch and any oral restrictions(Tongue tie, Lip Tie, etc), that result in excess aerophagia.
  • Distinguishing a Colic form a severe Gastro-Esophageal Reflux

Once these above issues are ruled out and infant meet the criteria of ‘rule of three” then diagnosis of infantile colic is made.

Management of Infantile Colic

Infantile colic is a benign self limited condition. There is no proven therapy for it. Parental reassurance is the main measure to manage an infant with colic. 

Probiotics & Medications

Recent meta-analyses and one systematic review found that L. reuteri significantly decreased colic only in Exclusively breastfed infants but it increases crying or fussing in formula fed infants. 

So, L. reuteri (DSM 17938) (Protectis*) may be considered as a treatment option for exclusively breastfed infants only and not in formula-fed or infants on mixed feeding, that too in selected cases if parental distress persists despite of reassurance.

There is no role of semethicone, proton pump inhibitors in infant with colic. 

Dicyclomine is better than placebo but it is safety in infants less than 6 months of age is not established so its not FDA approved for use in < 6 months. 

Dietary modifications

Prevalence of colic is similar in breastfed and top fed infants. So suggesting a modification(except in cases of suspected CMPA) will bring more stress than any benefit. Elimination of food allergens from maternal diet in breastfed infants with colic and role of hypoallergen formula in infantile colic is also controversial.

Environmental Modifications

Colic is often reported more during late evening to early morning hours, which are the hours of wakefulness of many infants and absence of routine day time distractions. 

Providing distractions to an Infant, like light rocking, lying on tummy, traditional practice of applying oil/heeng on navel, soothing music, creating background white noises often help many parents to handle the situation better.

Also, it has been hypothesized that daily regular exposure of Infant to Sunshine may modify  the Circadian rhythms of Melatonin- Serotonin and phase of colic may get shortened Though, there is lack of any scientific studies on these hypotheses.

*Disclaimer “All product and company names are trademarks™ or registered® trademarks of their respective holders. Use of them does not imply any affiliation with or endorsement by them” 

Matter drafted by Dr Mridul Das, Pediatric Gastroenterologist, Formerly at BLK Centre for Child Health.

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