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, measlesmumpsrubella, 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.

 

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 reuterimay 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).

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