Crying - Dr.

Shwan

All babies cry, but when is it too much, and when is it colic?
One of the most challenging aspects of pediatric medicine is dealing with a child (usually < 1 y of age) presenting
with nonspecific symptoms, such as crying and irritability.
Crying is a normal primitive protective reflex that serves as an alarm to alert parents to a problem & to get their
attention.
However, infants who have colic cry excessively without an identifiable need.
Such babies are difficult to console and provoke much parental anxiety.
Sleep is interrupted for both infant and caregiver.
Mothers experience increased risks of breastfeeding failure, postpartum depression, and marital conflict.
When infants cry excessively, they are at a much greater risk of child abuse.
Parents become desperate for resolution and accept advice and therapies from a wide variety of resources,
including physicians, family, friends, the media, and the Internet.
It is estimated that between 16% and 26% of all infants experience colic.
Although colic occurs in all socioeconomic, racial, & ethnic groups with no sex preference, the cause remains
unknown.

Causes?!

Gastrointestinal causes (e.g., gastro-esophageal reflux disease [GERD], over- or underfeeding, milk protein allergy,
early introduction of solids)
Inexperienced parents (controversial) or incomplete or no burping after feeding
Exposure to cigarette smoke and its metabolites.
Food allergy.
Low birth weight, Characteristic intestinal microflora

Features

Colicky infants cry more than 3 hours per day, more than 3 days per week, and for more than 3 weeks.
Excessive crying begins at 2 weeks of age, peaks at 6 weeks, may decrease by 8 weeks, and usually resolves
completely by 16 weeks.
Crying spells are episodic, unrelated to feeding.
Even though parental comforting may lessen the intensity, crying continues.
The pattern is diurnal, with increased crying in the evening and night.

History

The child's medical history, including surgeries, hospitalizations, illnesses, pregnancy complications, allergies, and
birth events, should be obtained.
Present medicines and recent illnesses should be reviewed.
An explanation of events, including feeding habits, bowel movements, urination, fever, sick contacts, level of
activity, degree and duration of concerns, and ability to be consoled, should be obtained.

Physical Examination

A complete and thorough physical examination should include the following: overall appearance, ability to be
consoled, stability of vital signs.
Skin Rashes, perfusion, or bruising.
Head, ears, eyes, nose, and throat (HEENT) examination for anterior fontanel fullness and retinal hemorrhages
Dental examination for new tooth eruptions.
Abdominal evaluation for tenderness and bowel activity, left lower quadrant (LLQ) masses suggestive of
constipation, or vertical sausage mass consistent with intussusception
Genitourinary examination for hernias, torsion and strangulations by hair tourniquets
Evaluation of extremities for focal tenderness, arthritis, or hair tourniquets.
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Diagnosis

Normal physical findings

Weight gain: Infants with colic often have accelerated growth; FTT should make one suspicious about the diagnosis
of colic
Exclusion of potentially serious diagnoses that may be causing the crying
Although all infants exhibit a similar pattern of fussiness in the evening that peaks at 6 weeks of age, infants who
have colic often are inconsolable for longer intervals and cry with more intensity.
Babies who have colic draw up their legs while they cry, have tense abdomens, arch their backs, and are gassy,
which suggests a GI origin.
Anytime a baby cries excessively, there is aerophagia.
The presentation of aerophagia and gas does not coincide with the timing of colic.
Gas does not cause colic.
Rather, the excessive crying that accompanies colic usually leads to aerophagia.
Formula intolerance such as lactase deficiency or cow milk allergy often is implicated in the differential diagnosis,
but is associated with additional symptoms such as emesis, diarrhea, blood in the stool, severe eczema, or
urticaria.

Investigations

Laboratory tests, imaging, and invasive procedures in an infant who only has colic are not indicated.

Management

Although colic resolves predictably in the first 4 postnatal months, parents and physicians feel compelled to
attempt treatment.
Many remedies have created a large market for both pharmaceutical and formula companies, but few randomized
controlled trials (RCTs) show benefit from any intervention.
Simethicone, often suggested for gas and colic, has not been shown to be more effective than placebo in RCTs.
Dietary changes for a breastfeeding mother or multiple formula changes have not been shown to have benefit for
colic in otherwise healthy infants.
There may be a subgroup of infants who have colic that may be caused by allergies.
If the history suggests formula intolerance, a short trial of hydrolyzed formula may be appropriate.
If symptoms consistent with GER are present, conservative measures of positional therapy, thickening of the
formula, and potentially, a brief trial of antireflux medication may be considered.
Management of colic should be directed toward supportive interventions.
Many clinicians recommend simulating the previous fetal environment.
This includes tight swaddling, rapid swinging or jiggling motion, nonnutritive sucking, and steady loud white noise
such as hushing.
Combining these techniques may calm both caregiver and infant.
Lactobacillus reuteri endogenous to the human GI tract was found to relieve colic symptoms in breastfed infants
within one week of treatment. This was compared with simethicone, which suggests that probiotics may have a
role in treatment of infantile colic.
Hospitalization for observation may be necessary for children with unclear etiologies.

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