Just Call It “Colic”: The Diagnosis That Isn’t

About a year ago, I was surprised to read that one of the two elephants at our local zoo had to be euthanized after a prolonged episode of colic. That news was shocking to me because I’ve taken care of lots of babies with colic, and I don’t tend to think of it as a life-threatening diagnosis (unless you count the increased risk for abusive trauma for fussy babies…and I’m pretty sure nobody shook the elephant). But I’ve never even considered putting one of my patients to sleep because of it–at least, not for more than a few hours. Perhaps the pediatric definition of “colic” is different from the one used by veterinarians. But what, exactly, is that definition?

That’s actually a pretty tough question. The party line is that an infant with “colic” is one who cries for at least 3 hours per day, at least 3 days per week, for at least 3 weeks. Sound pretty arbitrary? That’s because it is. The definition goes back to 1954 when Dr. Morris Wessel published a paper describing infants who cried excessively. It’s a classic study (although our research methodology has improved greatly since it was published), and it’s been cited by numerous other academic papers since it was written.

For the purposes of this study, a “fussy” infant was described as one who, otherwise healthy and well-fed, had paroxysms [episodes] of irritability, fussing or crying lasting for a total of more than three hours a day and occurring on more than three days in any one week. If an infant had no such paroxysms or if the paroxysms were less than the above in total duration, he was classified as “contented.”

There’s really no magic to this definition; it was made up in order to allow the researchers to dichotomize infants into two groups—“fussy” and “contented.” Do some babies cry more than others? Absolutely. Is it fair to make up a specific cutoff above which an infant has a “problem?” Not really—but it makes designing a study a lot easier. We do this sort of thing in medicine all the time. We have somewhat arbitrary criteria for all kinds of diseases, from lupus to ADHD, and everything in between. In most cases, though, they’re a little better-supported. In this study, half of the babies (48 out of 98) whose mothers returned the survey were considered to be “fussy.” (To put this in perspective, we’ve defined thresholds for unhealthy weights and blood pressures in pediatrics to be in the highest 5-15% of otherwise similar children.)  Today, colic is estimated to affect approximately 10-50% of infants, depending on the study. I can’t help but question the wisdom of choosing an arbitrary cutoff that defines up to half the population as “abnormal.”

One of the most interesting things about our understanding of colic is that it hasn’t changed in 60 years. That may not sound like a long time, but in the world of medical advances, it’s an eternity. Since 1954, we’ve developed vaccines for polio, measles, mumps, rubella, hepatitis A and B, HPV, and rotavirus (and then decided that we’d rather not use them). We’ve learned to transplant kidneys, livers, lungs, hearts, and faces. (Yes, faces.) We’ve eradicated smallpox. We discovered HIV and transformed it from a death sentence to a diagnosis with a nearly-normal lifespan. Our understanding of genetics progressed from simply knowing the shape of DNA to cloning a sheep and mapping out the entire human genome. It’s been a big 60 years. And yet, our understanding of this thing we call “colic” hasn’t changed a bit.

There are lots of theories for what causes colic, but the truth is that we just don’t know. The name itself comes from the same root word as “colon,” and implies that the source of the problem lies somewhere within the gut. This notion probably comes from the fact that many babies with colic will arch their backs, tighten their abdominal muscles, and appear as if they are having abdominal pain. Based on the appearance of abdominal discomfort, some theorize that colic is related to reflux, milk protein allergy, lactose intolerance, “gassiness,” or other causes inside the belly. But is it truly abdominal pain, or is this simply an infant’s physical reaction to some source of stress, just like you might experience jaw clenching or neck muscle tension? That’s tough for us to say, and it’s even tougher for babies who can’t talk yet.

It’s very likely that, in some cases, colic is more related to stress than abdominal pain. I’ve seen infants who “haven’t stopped crying for days” appear perfectly content when they are seen in the emergency room or admitted to the hospital. Did their abdominal pain magically disappear at the registration desk? I doubt it. Is it a change in the environment? Are the parents so relieved to have some help that their perception of their baby’s distress changes? Does the infant somehow sense a lower level of stress in those around him and mellow out a bit? Sadly, some babies come from less-than-ideal social circumstances where the stress levels are high. Infants living in homes where a parent struggles with uncontrolled mental illness, substance abuse problems, poor parenting skills, or domestic violence–or where the environment itself offers some sort of stress–are certainly at higher risk. And since colic tends to occur in the first 2-3 months of an infant’s life, the roles of maternal fatigue, postpartum depression, and hormonal fluctuations are undeniable.

Now, I’m certainly not saying that having a fussy baby means you’re a bad parent, or that every baby in a sub-optimal environment will be extraordinarily fussy. I’m just talking about risk factors, and a discussion of colic without mentioning the contribution of social stress would be incomplete. A fussy baby can turn a spa-like home into a war zone in a hurry. If parents aren’t able to cope with incessant screaming, it can turn into a self-perpetuating cycle of stress. And in rare (but not rare enough) instances, a parent’s frustration about a baby’s constant screaming results in abusive head trauma. The other side of this discussion is that a parent who manages this stress well may help the situation in a couple ways: both by perceiving the crying to be less of a problem, and possibly by decreasing the infant’s stress level as well.

One of the better explanations of colic that I’ve heard is that it isn’t caused by the same thing for every baby. That theory goes a long way to explain our inability to better define colic over the past sixty thousand years. It explains why a certain treatment may seem to work for some babies but not others, and it highlights the problem with creating an arbitrary diagnosis defined by a single symptom.

Here’s my definition: “Colic” is a dumpster of a diagnosis into which we toss crying that is felt by parents to be excessive, and that we can’t otherwise explain.

I have spent many hours trying to clarify what colic is (or isn’t) to parents who are understandably confused. Although colic is almost always a totally benign problem, diagnosing a fussy baby with colic without considering truly pathologic causes can be dangerous. And even after those things are taken off the table, giving the condition a name makes it seem like we know what’s going on, when we really don’t. The apparent legitimacy provided by a diagnosis also makes parents feel like they should be doing something about it–when in reality, colic is a self-limited condition that tends to resolve over a couple months with no intervention at all (although I’ll talk about potential treatments below). Rather than diagnosing an infant with colic, I try to call it “fussiness” or “excessive crying”–terms that differ only semantically, but which I feel don’t result in as much confusion. Not every symptom needs a diagnosis.

So, assuming your baby has colic (and assuming that “colic” is a thing), you’re probably wondering what you can do about it. First, as with any health-related issue, if you have serious concerns, you should call your pediatrician. There is a possibility that severe fussiness could be due to a truly pathologic cause that needs treatment. Once these more serious causes causes have been ruled out, there are a few things that might help and a lot that don’t. But be aware, some of them work for only a small subset of infants–quite possibly because they are crying for different reasons.

Simethicone (Mylicon drops): Probably the most widely used treatment for colic. Does it work? Sort of–but not any better than placebo. What this means is that your doctor could prescribe a pretend medication that you would think works equally well (although the consensus is that this would be unethical). So if Mylicon works for you, it probably has more to do with you feeling like you’re doing something than with the medicine itself. There’s very little risk of it harming your baby, so if you want to use it, go ahead. And remember, it works better if you believe.

Gripe water: Just like colic, “gripe water” isn’t really a single entity. It’s essentially any concoction marketed as being helpful for colic. The story started in 1851 when a dude named William Woodward hijacked the recipe for a malaria treatment and began to market it to mothers and doctors as a remedy for colic. The original formulation contained alcohol (3.6%), dill oil, sodium bicarbonate (baking soda), sugar, and water. Today, however, you can find “gripe water” containing any variety of ingredients purported to help with an equally large number of ailments. Many of the gripe water formulations available are homeopathic. I’ll write more on homeopathy later, but it relies on a fundamentally different philosophy than science-based medicine. It contradicts scientific principles and has never been proven to work better then placebo…for anything. Sorry to disappoint. Remember that just because something is labelled as homeopathic, all-natural, organic, or GMO-free doesn’t mean that it is safe. And it certainly doesn’t mean it’s effective.

gripe water

Alcohol: Yep, really. It was one of the original ingredients of gripe water, and I would have assumed it would work. But aside from the obvious safety concerns with getting your baby tipsy, this study showed that it isn’t effective either–good to know, because there would likely be some ethical concerns with doing that study today. To be clear, the alcohol was administered to the fussy infants; it may actually have some benefit–in moderation–if given to their mothers.

Dicyclomine: The only medication that has been convincingly shown to reduce crying in infants diagnosed with colic. However, it’s been implicated in more than a few infant deaths. It’s not approved for use in infants, and almost certainly not worth the risk.

Probiotics: If you’re not really sure what “probiotics” are, they are living microorganisms like bacteria or yeast, thought to be the “good guys” of the microbe world. Your skin and gut (among other places) are colonized with hordes of these beneficial organisms, and it’s thought–based on scientific studies–that changes in their population (or “alterations in gut flora”) contribute to many disease processes. It’s important to remember that not every probiotic is the same, and studies are done using a specific species at a specific dose that may or may not be the same as what you can purchase over the counter. Many bacteria would die immediately upon entering the acidic environment of the stomach and their only benefit would be a financial one–to the company that sells them. They are, however, generally considered to be safe in people with normal immune systems, and a couple small trials (here and here) have suggested that a specific probiotic (Lactobacillus reuteri) may be effective at reducing colic, at least in breastfed infants. It’s available here, but run it by your doctor first.

Dietary changes: In some infants, fussiness may be reduced by dietary changes. For formula-fed infants, this can mean switching to a soy-based or partially hydrolyzed formula. These are typically more expensive and somewhat less tasty than standard infant formulas. Formulas with added fiber have not been shown to make a difference. For breastfed babies, this would involve changes in the mother’s diet to eliminate certain foods.

Fennel extract, herbal teas: Unlike homeopathic preparations, herbal supplements can actually be helpful in certain situations (if what’s inside the bottle is the same as what’s on the label). In fact, many medications are derived from natural substances, but produced in a way to control the amount of active ingredient. Fennel extract and certain herbal teas have shown some potential for reducing excessive fussiness.

Things that don’t work: massage (for the baby–but again, it may be helpful for moms), reflexology, chiropractic manipulation (which also carries significant risksplease don’t do this to your baby).


My bottom line: “colic” is a symptom, not a diagnosis. Just like headaches, abdominal pain, fevers, or rashes (all of which can be due to life-threatening causes or totally benign ones), our approach should be to rule out dangerous conditions, fix the things that we can fix, and then admit that we don’t know what’s going on. No baby’s symptoms should be tossed into the diagnostic dumpster of “colic” without considering other diagnoses. And if at any point, a reason for the infant’s crying is found (reflux, milk protein allergy, etc.), that should be the diagnosis, not “colic.” For those infants not found to have any identifiable problems other than excessive crying, emotional support and reassurance are probably the best treatments we can provide.

I know it’s hard–I’ve been there. Being a parent is exhausting sometimes. My wife and I had a baby that cried for hours weeks, but we all made it through alive. The most important thing to remember is that, assuming other causes have been ruled out, colic is not a life-threatening problem (evidently, unless your baby is an elephant). And while we don’t have a clue what colic is, we do know that it goes away–no matter what you do.

 

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-Chad

As always, your comments are welcomed (even if you happen to disagree). I'll get back to you as soon as I can. Please try to keep it civil--I reserve the right to delete comments that are offensive or off-topic.

8 thoughts on “Just Call It “Colic”: The Diagnosis That Isn’t

  1. I agree that colic is most likely different for every baby. Our baby had colic from stress. She was born 10 weeks premature and spent 6 weeks in the NICU. when we brought her home, we went with the recent trend in child rearing and allowed her to let us know when she was hungry and such. Unfortunately, as most babies do, if she was overstimulated she would sleep through feedings. She was (and still is as a high schooler) a baby that needed a schedule. Once we went back on the NICU schedule for feedings, playing and sleeping, she stopped crying from 9 PM- 2 AM every day. The change was immediate! It was miraculous and, even now, as long as we keep her eating and sleeping schedules pretty close to the same, she’s much happier. My niece was diagnosed with acid reflux. When she was treated for that, her colic stopped. Now, when someone I know has a baby with colic, I share these stories in the hopes that they will start on a quest to find out what will help their baby.

    • Diane–very true. Just like older kids and adults thrive in different situations, babies can have strong preferences as well. It’s no surprise that after several weeks of conditioning in the NICU, your baby didn’t do so well in a less-structured environment…or maybe that’s the way she was going to be no matter what. Stress can happen to infants even in good homes with great parents if they feel their little world isn’t as it should be.

      I think the biggest thing to remember is that babies should never be diagnosed with “colic” until other diagnoses have been considered. Reflux and milk protein allergy are on this list, as well as many other more threatening diagnoses.

      There aren’t very many diagnoses that are made based on having a single symptom for an arbitrary period of time. If we’re honest about it, “colic” is a symptom, not a diagnosis. And if it were up to me, we’d get rid of it altogether. Just like any other symptom (headache, abdominal pain, fever, etc.), we should be ruling out dangerous causes, fixing those that we can fix, and then admitting that we don’t know what’s causing it. Once we arrive at that point, our treatment should be providing reassurance to parents that this is a normal developmental stage, telling them that it won’t last forever, and providing emotional support until it goes away.

  2. Dr Hayes
    My siblings and I enjoyed your reference to our dad’s (Morris Wessel) ancient definition of colic. Although he has little short-term memory left, he still enjoys talking about the past at age 97 and we’ll share your column with him. So thanks…
    David

    • David, thanks so much for touching base. It was very interesting to read your father’s paper and see how our medical literature has changed since then (they used more colorful language than we do). Please give him my regards. I wish you and your family the best.

      -Chad

  3. read your article in the Post today,
    a few corrections I hope you will take seriously from one practicing with babies 35 years,
    homeopathic medicines do work try magnesium phos 30 c chamomillia 30 c for “colic” more than half my mom’s swear by it,
    osteopathic soft tissue work on the spine, not massage and not chiropractic, this also works, tried, true, studied, peer reviewed articles, look for them they are there.
    while I appreciate your trying to educate your parents you can only write what you know and as a resident, it ain’t much, cause we have all been younger in our careers, we think we know a lot and we don’t, so please preface your blogs with “i am only a resident, take what I write with a grain of salt”. otherwise, your article about colic was great, enjoyed reading it. sorry to be so tough on you, once you put out being an “expert” you will catch crap from us old folks who have been around for a while. I suggest your subscribe to the list serve for alternative pediatrics, and start paying attention to folks like Kathy Kemper, MD, who came from my alma mater, wake forest and is now at Ohio State. she knows what she’s talking about.

    peace out.
    greg

    • Dr. Gelburd,

      I certainly try to remain open to correction and do respect physicians with more experience than I have. However, while experience provides a great deal of perspective, it doesn’t necessarily make one right. Of all the “old folks” in the field that have commented on my writing, your remarks are by far the most critical. I make every effort to substantiate my assertions with the best quality medical and scientific data available. My level of experience is plainly stated in my bio, and despite my relatively recent entry into the field of pediatrics, I don’t feel the need to explicitly warn my readers not to trust me.

      The fundamental principle of homeopathy violates everything we know about physics and chemistry, and it has been shown time and again to be an ineffective treatment. That’s not me speaking from inexperience, it’s smarter and more experienced people than me reviewing all the currently available research. I have no doubt that many people feel that it works, but it doesn’t work better than a placebo (which can certainly be powerful in cases like colic, where parental stress plays such a large role).

      I’ve read some studies and a Cochrane review about osteopathic manipulation for colic. The studies (that I’ve read) seem to have very small numbers and a lack of adequate blinding that prevents them from making conclusive statements about its effectiveness. If you have references to better studies, I’d certainly be open to reading more.

      -Chad

  4. Dear Dr Hayes,
    Let me start by saying, I don’t disagree with everything you wrote in your article about colic. But I wrote a letter to the editor of my local paper following their publishing this article mostly in hopes of reaching parents of infants who might have read what you wrote. I am afraid I have to agree with Dr Gelburd who has already written to you. I have been practicing osteopathic manual therapies for over 20 years and have helped many babies with colic. I have also seen and experience astounding results with the use of homeopathic medicine.
    It upsets me that you discredit therapies that have helped and can help so many infants just because you don’t have experience with them. This is a disservice to us all and especially to the public you hope to be serving. Misinformation!
    Please, speak about what you know, your own experience with your own patients. It helps no one to make broad statements regarding therapies with which you have no experience. Just because you are not familiar with something or because it hasn’t been peer reviewed in one your professional journals doesn’t make it invalid!
    I have asked our local paper to discontinue carrying your column due to the misinformation you are spreading in the interest of being all knowing. I will ask you to please be more conscientious in your writing. When you aren’t familiar with something, please be humble and acknowledge that. You are in a position to help people by sharing helpful information. Please curb the damage you might be doing by not making broad judgements as if they were truths about interventions you are not familiar with. Those of us who work diligently to do what we can to help appreciate not being discounted by those who speak out of the realm of their experience.

    • Beth,

      I’m sorry I’ve been delayed in responding to your post–last month was busy. The article you read in your local paper was one that was published in a larger national newspaper and distributed to other news outlets; I have no continuing relationship with your local paper.

      Unfortunately, your arguments are not with my experience, but with science. I’m not discrediting therapies with benefit, I’m simply presenting the evidence (found in the links in my post above) about whether or not therapies are effective. I have no problem admitting when I don’t know something; but when that’s the case, I look for answers.

      I assure you, I work diligently as well, and providing evidence-based information to parents is a big part of that. However, the fact that you promote homeopathy makes me think that you don’t place much value in science (as the theory of homeopathy contradicts laws of physics and chemistry and has never been proven to work better than placebo).

      I appreciate your commitment to your patients, but fear that we won’t agree on our methods.

      -Chad

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