Learning Outcome

1. Describe the symptoms and timing of infantile colic.
2. Explain the Rome IV criteria for diagnosing infantile colic.
3. Summarize the management of infantile colic and the importance of teaching and supporting parents and caregivers.

Introduction

Infantile colic is characterized by persistent and often inconsolable crying episodes in an otherwise healthy and well-fed infant.[1] It is distressing and challenging for new parents and prompts up to 10% to 20% of pediatrician visits during the first few weeks of life. The condition typically presents in the second or third week, peaks around six weeks, and resolves by 12 weeks in 60% of infants and by 16 weeks in 90%. Inconsolable crying, irritability, and screaming without an apparent cause characterize colic. During these episodes, which often occur in the evening, affected infants typically appear red-faced, draw up their legs, and tense their abdomens. Traditional methods of soothing usually fail to relieve the infant's fussiness. Infantile colic is a clinical diagnosis based on history and physical examination after excluding potential pathologic causes of excessive crying.[2][3][4] This activity reviews colic's clinical features, etiology, evaluation, and the nurse's role in counseling and educating parents and caregivers.

Nursing Diagnosis

• An infant with excessive crying and irritability
• An infant with poor sleeping patterns
• An infant who appears distressed
• Parental anxiety and distress

Causes

Despite its prevalence, the cause of infantile colic remains elusive. There have been many theories regarding the etiology, but a lack of uniformity in study definitions of colic has made it challenging to isolate a single cause. The signs and symptoms may represent the final presentation of various contributing factors. "Colic" implies abdominal discomfort, but no gastrointestinal mechanism for the apparent pain has been identified. Increased intraluminal gas, gut dysmotility, visceral pain, and altered microbiome are all possibilities that have been considered. Many hypotheses focus on feeding techniques, the immaturity of the nervous and gastrointestinal systems, sleep disruption, hypersensitivity to the environment, sensory overload, food allergy, cow milk protein intolerance, and gastroesophageal reflux. Maternal diets containing cow's milk may contribute to infant distress in breastfed infants with colic. Some studies have suggested a link between colic and migraine, showing an association between infantile colic and the later development of migraine headaches during adolescence. Maternal smoking or nicotine replacement therapy, family stress, and parental anxiety have also been proposed as contributing factors. Colic is one of the most distressing problems of infancy for parents, babies, and clinicians, even though it is usually a benign, self-limiting condition. Parents may worry that their child is seriously ill and feel inadequate when they cannot console and care for their baby.[5][6][7][8]

Risk Factors

Infantile colic is estimated to affect 3% to 28% of infants worldwide.[9] The reported prevalence of infantile colic varies across studies; some say higher than 20%. Symptoms peak around six weeks of age and decline gradually after that. However, the recognition of colic depends on parental perception of crying intensity and duration, which is subjective and difficult to quantify. Parental well-being and cultural differences in acceptable crying may also affect these data. Regardless of the variability in prevalence, there is no proven association with gender, ethnicity, socioeconomic status, feeding preference, or birth order.

Assessment

Although colic is a benign and self-limiting condition, a thorough history and examination are essential to rule out more serious issues. Crying is often described as paroxysmal, high-pitched, and loud, and the infant appears in pain. During episodes, facial flushing, increased muscle tone, a tense or distended abdomen, and back arching may occur. After obtaining information regarding the frequency, circumstances, duration, and intensity of crying, the nurse should ask about fever, feeding patterns, weight gain, the presence of bilious emesis, constipation or diarrhea, bloody stools, lethargy, cough, wheezing, rash, loss of willingness to move one or more extremities, and breastfeeding difficulties. The physical examination should then look for signs of failure to thrive or severe illness. Findings such as poor weight gain, abdominal distension and tenderness, scrotal or inguinal swelling, suspicious bruises or burns, and evidence of dehydration should prompt further evaluation. Subtle findings such as hair wrapped around a digit or penis should not be overlooked. The nurse should also observe how the parents or caregivers attempt to comfort the infant and note signs of possible depression or difficulty coping.

Evaluation

In 1994, gastrointestinal experts gathered in Rome and created a classification system for diagnosing functional gastrointestinal disorders in adults using symptom-based criteria. Subsequent revisions included pediatric patients, resulting in the Rome IV criteria to evaluate infantile colic in 2016.[10] The guidelines include the following:

• An infant younger than five months of age when the symptoms start and stop
• Recurrent and prolonged periods of infant crying, fussing, or irritability without apparent cause that cannot be prevented or resolved by caregivers 
• No evidence of poor weight gain, fever, or illness

The Rome IV criteria replaced the 1954 Wessel "rules of three," requiring crying more than three hours daily for at least three days a week for at least three weeks. Three weeks was considered arbitrary, and it is unreasonable to require worried parents/caregivers to wait that long before intervening.

When the history is consistent with the Rome IV criteria or the "rules of three," and there are no significant physical examination findings, clinicians diagnose infant colic. Laboratory testing and imaging studies are unnecessary. However, fever may necessitate a workup for sepsis, with blood and urine cultures, radiographs, and possibly lumbar puncture. Abdominal distension may indicate the need for abdominal radiography or ultrasonography, and positive fecal occult blood testing suggests a diagnosis of cow milk allergy. Skeletal surveys and computed tomography (CT) of the head should be performed if there is suspicion of traumatic injury. Additional evaluation is indicated if the crying begins after the third month of life or persists beyond the fourth month since that is not the typical age range for infantile colic. 

Medical Management

Management of infantile colic focuses on interventions to provide caregiver support and decrease infant crying. No universal evidence-based guidelines exist. Individualized treatment begins with nurses and clinicians listening to caregiver concerns and letting them "tell their story." Parents need to understand that their baby is not ill and that the symptoms are not caused by anything they did wrong or failed to do correctly. Nurses should acknowledge they know that parents are doing their best and reassure them that symptoms usually resolve by three to four months of age. They can empathize that feelings of exhaustion and frustration are normal and provide suggestions about soothing techniques. Examples include car or stroller rides, pacifier use, rocking, using a swing or front carrier, gentle abdominal massage, soft white background noise, decreased stimulation, warm baths, and swaddling. However, there is a concern about an increased risk of hip dysplasia with frequent or tight swaddling, so the latter is controversial.[11][12]  Reducing ambient lighting, turning down loud music, keeping siblings and pets in another room, avoiding strong-smelling odors or perfumes, and feeding the infant in a darkened room may facilitate infant sleep and decrease crying. Parents should be encouraged to develop coping responses for fussiness, minimizing the likelihood that they will become frustrated and injure their infant. Parents upset by the bouts of inconsolable irritability should place the baby safely in a crib and walk away briefly to avoid shaking the infant and causing harm. They can take breaks, take turns, or accept extra help from friends or family if offered.[13][14] Families usually benefit from the reassurance that their infants are growing well and meeting expected developmental milestones. 

When these first-line measures have failed to improve colic symptoms, additional strategies can be considered on a case-by-case basis. However, there are limited data to support these interventions, which can be inconvenient and costly for families. Dietary modifications have been explored in some detail. A minority of breastfed infants with colic may have significantly reduced crying time if the mother follows a hypoallergenic diet, eliminating dairy foods, eggs, nuts, wheat, soy, and fish. Bottle-fed infants who are switched from traditional cow milk formulas to soy-based or fiber-enriched infant formulas show no improvement, and soy-based infant formulas are not recommended for infants younger than six months of age due to the high concentrations of phytates, aluminum, and phytoestrogens.[15] However, several studies confirm the usefulness of hydrolyzed formulas in reducing crying times for a minority of infants with colic, especially if cow milk allergy is the underlying cause. Unfortunately, these formulas are expensive and may not be covered by health insurance.[16] 

There are no medications proven to relieve colic symptoms. Studies examining the effectiveness of simethicone show inconsistent results, but most demonstrate no effect. The use of the anticholinergic dicyclomine demonstrated decreased infantile colic crying time in the 1990s. However, its potential side effects of respiratory depression, apnea, seizures, and muscular hypotonia make it unsafe in young infants, and the medication is not approved for use under six months.[17] Proton pump inhibitors such as omeprazole are no better than placebos in reducing colic symptoms. Other approaches aim to adjust the infant's gut microflora. While several studies demonstrate a reduction in crying time among bottle-fed infants with colic who receive Lactobacillus reuteri supplements, other reports contradict those findings. However, there seems to be more substantial evidence regarding the possible positive effects of Lactobacillus reuteri supplementation among breastfed infants. At this time, no evidence-based treatment recommendations exist. Probiotics have not been evaluated by the US Food and Drug Administration (FDA) and can be costly for families. 

Other unproven treatments include the following:

• Lactose-free infant formulas or lactase supplements
• Sucrose
• Whole body massage with risk of overstimulation
• Herbal remedies such as gripe water or camomile tea 
• Homeopathic preparations with the possibility of toxic ingredients
• Chiropractic manipulation
• Acupuncture

In summary, parents of colicky infants often feel inadequate and worry that something is seriously wrong with their baby. Nurses who listen to caregivers' concerns, reassure them that their baby is healthy, and recommend specific comfort measures will help families cope with this distressing but self-limited condition. 

Nursing Management

• Check stools and urine for blood.
• Monitor vital signs.
• Ensure that the baby is breastfeeding or bottle feeding effectively.
• Obtain laboratory data when ordered, and notify the clinician promptly of the results 
• Educate the family about colic symptoms and comfort measures.
• Examine the abdomen for tenderness or distention.

When To Seek Help

If the infant has:

• Fever
• Blood in stools or urine
• Abdominal tenderness or vomiting
• A palpable abdominal mass
• Difficulty feeding
• Abnormal laboratory results

If the parents or caretakers 

• Show signs of depression
• Exhibit unsafe behavior with the infant

Outcome Identification

Reduced infant crying and irritability

Improved infant sleep

Decreased parental/caregiver anxiety 

Increased parental/caregiver knowledge about helpful comfort measures

Monitoring

• Assess the quality, volume, and frequency of stools and voids
• Monitor vital signs regularly
• Observe how the infant is feeding
• Examine the abdomen regularly for distention or tenderness
• Observe how parents/caregivers comfort the infant

Coordination of Care

Managing infants with colic requires an interprofessional team of healthcare professionals, including nurses, lactation consultants, primary care practitioners, pharmacists, and physician specialists. There is evidence that home-based nursing interventions may help parents learn comfort measures and infant care. Lactation consultants can recommend changes in breastfeeding techniques if feeding issues are involved. Pediatricians, gastroenterologists, nurse practitioners, and primary care clinicians can minimize parental anxiety by discussing colic and reassuring caregivers that it is a benign, self-limited disorder. Infants should be closely followed to assess growth and screen caregivers for symptoms of depression. The interprofessional team can educate parents to place their infant safely in the crib to avoid shaking or injury when they feel overwhelmed. Pharmacists and nurses should advise against dicyclomine and unsafe or unproven over-the-counter medications, as the risks outweigh the potential benefits.

In summary, infantile colic is a common, distressing, benign, and self-limited condition. It typically presents in the second or third week of life, peaks around six weeks, and usually resolves between 12-16 weeks. Inconsolable crying, irritability, and screaming without an apparent cause characterize colic. It is a clinical diagnosis of exclusion based on history, lack of physical findings to suggest other conditions, and adequate feeding and growth. Management by the interprofessional team focuses on counseling, education, comfort measures, and reassurance that the vast majority of infants have an excellent outcome. 

Health Teaching and Health Promotion

While benign and self-limiting, infantile colic is distressing for caregivers and infants. Nurses can teach parents about the diagnosis and reassure them that it is not their fault. Nurses are vital in educating parents and caregivers about comfort measures and supportive care for managing colic symptoms. The condition is associated with maternal postpartum depression and shaken baby syndrome, so observing families for any concerning signs or behaviors is critical. Nurses can ensure that families are educated about infant safety and when to place an inconsolable baby in the crib when they need a break to prevent any action that might cause harm. Nurses can also reinforce that there are no proven medications to treat infantile colic, and some agents are known to cause serious side effects. 

Risk Management

• Observe for significant changes in vital signs, feeding pattern, stools, voids, and physical examination and notify the clinician when indicated.
• Note interactions between the infant and parents/caregivers and notify the clinician if significant concerns might endanger the infant. 
• Document teaching about supine sleep position, safe swaddling, and comfort measures to alleviate symptoms.

Discharge Planning

Infantile colic is a benign and self-limiting condition that typically resolves spontaneously between three and four months of age. The outcome for most infants is excellent. Infantile colic has also been associated with maternal depression and family stress, and families might benefit from additional resources in the community to address these concerns. Counseling parents about colic, helping them develop coping mechanisms at home, and offering specific suggestions for managing excessive crying will help families as their infant outgrows this self-limited condition.