Management of infantile colic
: BMJ 2013;347:f4102

Although infantile colic is considered to be a self limiting and benign condition, it is often a frustrating problem for parents and caregivers. It is a frequent source of consultation with healthcare professionals and is associated with high levels of parental stress and anxiety.1 2

Several published reviews of the literature have explored dietary, pharmacological, complementary, and behavioural therapies as options for the management of infantile colic. Here, we assess whether these management options are supported by the literature and if there are any novel treatment options.

About infantile colic
Infantile colic has been defined as paroxysmal uncontrollable crying in an otherwise healthy infant less than 3 months of age, with more than three hours of crying per day in more than three days a week and for more than three weeks. It is known to have a significant impact on infants and their families, with up to one in six families with children with symptoms of colic consulting healthcare professionals.

Background
Despite the prevalence of the condition, the pathogenesis remains incompletely understood. One hypothesis has suggested that infantile colic is caused by the impact of abnormal gastrointestinal motility and pain signals from sensitised pathways in the gut viscera.Another hypothesis is that inadequate amounts of lactobacilli and increased amounts of coliform bacteria in the intestinal microbiota influences gut motor function and gas production, which subsequently contributes to the condition.

More controversially, behavioural issues such as family tension, parental anxiety, or inadequate parent-infant interaction have also been explored as causative factors for infantile colic.1 In addition, little is known about concomitant risk factors; however, maternal smoking, increased maternal age, and firstborn status are thought to be associated with the development of infantile colic. No association with feeding method has been noted.1

As a consequence of the lack of understanding of the cause of the condition, a wide spectrum of treatment modalities have been suggested, with each one targeted to address a postulated cause.

Diagnosis
Although infantile colic is by definition a benign condition, healthcare professionals should address parental concerns carefully, as the diagnosis is made by exclusion of more sinister causes. Examples of conditions to be excluded are listed .

?Differential diagnosis of colic symptoms in infants
Infection
Meningitis, urinary tract infection, otitis media

Gastrointestinal
Constipation, cow’s milk protein allergy, gastro-oesophageal reflux disease, inguinal hernia, intussusception, anal fissure

Metabolic
Hypoglycaemia, inborn errors of metabolism

Neurological
Hydrocephalus

Trauma
Non-accidental injury, accidental trauma

A careful generic paediatric history should be taken. In particular this should include the relationship between an infant’s behaviour and time of day and duration of crying episodes. Additional red flag features such as apnoeic episodes, cyanosis, respiratory distress, vomiting, or bloody stools should be elicited as these may be suggestive of more uncommon but serious causes, such as intussusception and pyloric stenosis. In addition, other more common conditions such as cow’s milk protein allergy or gastro-oesophageal reflux disease, should be considered.

?Red flags signs and symptoms
Signs

Irritability, tachycardia, pallor, mottling, poor perfusion
Petechiae, bruising, tachypnoea, cyanosis, nasal flaring
Hypotonia, meningism, full fontanelle
Weight <4th centile for age (or decreasing on the centile charts)
Head circumference >95th centile (or increasing on the centile charts)

Symptoms
Bilious or projectile vomiting, bloody stool
Fever, lethargy, poor feeding
Perinatal risk factors for sepsis (premature rupture of membranes, maternal fever or infection, group B streptococcus)

Routine observations such as pulse, respiratory rate and temperature should be performed. The infant’s weight should be plotted and compared against previous measurements. In the absence of serial measurements, follow-up weight measurements recorded by a healthcare professional may be necessary to identify infants with faltering growth.

A complete physical examination should be undertaken with full exposure to assess the presence of bruises or trauma and identify any visible evidence of non-accidental injuries If non-accidental injury is suspected, the local clinician responsible for child safeguarding should be contacted immediately.

Management options, and Full review- Ref: As above.

G Mohan.