The Rule of 3s
Colic is traditionally defined by the Wessel criteria (published in Pediatrics in 1954):
- An otherwise healthy, appropriately-fed infant who cries for >3 hours per day, >3 days per week, for >3 weeks duration*
*Most parents are not able to go a full 3 weeks before the child is evaluated by a pediatrician, or they attempt some sort of intervention on their own. As such, most pediatricians do not necessarily use the 3-week duration when making a diagnosis. Often, the third rule in the Rule of 3s is changed to <3 months of age.
But Don’t All Infants Cry?
The average infant cries for 2.2 hours per day.
Colic may differ from normal crying in several ways:
- Difficult to console
- Higher-pitched, louder cry
- More “distressed” cry than anticipated
- Paroxysmal (distinct periods of crying, abrupt start and stop seemingly without any triggers)
- Associated with hypertonia (clenching, arching of back), abdominal distension, and facial flushing
- Not associated with hunger or discomfort
Excessive crying typically occurs in the late afternoon/evening, which can disrupt sleep.
Prevalence estimates widely vary: 8-40% of infants in various studies (this wide range results from differences in diagnostic criteria, study design, populations, and family perceptions of “excessive and prolonged” crying).
Colic may start as early as 2 weeks of age, peaks at 6 weeks, and typically resolves between 12-16 weeks.
Equal prevalence in breast vs bottle-fed infants and pre-term vs full-term infants.
Etiology remains unknown, but many causes have been speculated and indeed may be multifactorial:
- GI: air swallowing, infrequent burping, cow’s milk protein or lactose intolerance (both have conflicting studies), GI immaturity, intestinal hypermobility,*alterations in microflora*
- Multiple (small) RCT’s and a meta-analysis comparing administration of probiotics (Lactobacillus reuteri) vs placebo or simethicone to breast-fed infants with colic have shown positive improvement in colic symptoms
- Biologic: immature motor regulation, increased serotonin, tobacco/nicotine exposure, early form of migraine
- Psychosocial: hypersensitivity to environmental stimuli; some reported associations between colic and parental stress, confidence in parenting, maternal anxiety and satisfaction with delivery
Diagnosis of exclusion made clinically – usually confirmed in retrospect.
Other diagnoses to consider – history and exam are KEY!
- Constipation/anal fissures
- Feeding disorders/oral pathologies
- Infections (UTI, meningitis)
- Intussusception or other abdominal obstructions
- Accidental or non-accidental trauma
- Maternal drug effect (withdrawal)
- Hair tourniquet
- Corneal abrasion, foreign body, glaucoma
- Supraventricular tachycardia or other arrhythmias
- Testicular or ovarian torsion
Crying in and of itself is not dangerous.
Excessively fussy infants may be at increased risk for child abuse.
- A 2004 study from the Netherlands found via an anonymous survey of parents of infants aged 1-6 months that 5.6% of parents admitted to smothering, slapping, or shaking their baby at least once in response to crying
Parents have increased risk of postpartum depression and are more likely to stop breastfeeding early.
“Systematic reviews on the topic reveal >1700 articles and abstracts about colic that have been published, yet there are few randomized trials, and those that have been published span multiple treatment options of pharma- ceutical, dietary, behavioral, and com- plementary interventions. Significant methodologic flaws have hampered re- search in this area, and future studies need to focus on a research agenda to ensure the use of a consistent def- inition of colic (Wessel criteria), objec- tive outcome measures, and sufficient sample size and power to determine differences. Time will tell, but perhaps colic will be one entity that will remain elusive, and our current strategies of support and reassurance may be the best.” —In Brief: Colic, Pediatrics in Review
Mainstays of management are caregiver support and behavioral interventions.
- Once confident in colic diagnosis, reassure parents that they have a normal, healthy baby
- Remind parents this usually resolves by 4 months of age
- Acknowledge feelings of frustration, exhaustion, guilt or anger
- Enhance parenting self-esteem
Important questions for parents:
- What are you afraid of or worried about when the infant is crying?
- What do you do when the baby is crying?
- How do you feel when the baby is crying?
- Using a pacifier
- Taking a car ride or walk in a stroller/carrier
- Gentle rocking
- White noise (if using a noise maker, place as far from infant as possible, low volume)
- Decreasing visual stimuli around infant (lights, etc)
- Rubbing the abdomen
- Encourage parents to take breaks caring for the crying infant
- Taking turns with the infant during colicky periods
- Asking a trusted friend or relative to babysit for a break
- Place the crying infant in the crib
- Give permission to allow the infant to cry for a period of time in a safe place
- If first-line interventions don’t work, may consider changing feeding techniques
- Bottle-feeding the baby in a vertical position (using a curved bottle)
- Frequent burping
- Using a bottle with a collapsible bag inside
- Consultation with a lactation counselor (for breastfed infants)
Interventions that probably DON’T work (or at least are not proven):
- There is some evidence that treatment with Lactobacillus reuteri is associated with decreased crying time, but the evidence of benefit is inconsistent and must be weighed against the natural history of improvement in colic symptoms over time
- Hydrolysate formulas (Alimentum, Nutramigen, Pregestimil)
- Indicated for children with milk protein allergy
- Some small RCTs and systematic reviews have suggested that these formulas can help some infants with colic, but should really be reserved for patients with true symptoms of milk protein allergy (bloody stool, vomiting, rash, wheezing, weight loss, etc)
- Same goes for soy or lactose-free formulas and elimination diets for mothers in breast-fed infants
- Sucrose (Sweet-ease)
- Simethicone (safe, but relatively ineffective)
- Manipulative therapies, infant message, acupuncture
- Dicyclomine (anticholinergic agent that has some effectiveness, but also shown to cause apnea and seizures)
- Herbal remedies including Gripe Water (OTC liquid supplement of sodium bicarbonate and herbs such as fennel, ginger, chamomile, dill, lemon balm and/or peppermint)
- Colic = rule of 3’s (crying >3 hrs per day, >3 days per week, >3 weeks duration, and <3 months-old)
- May be different in quality than your usual infant cry
- Multiple proposed etiologies, none of which are definitive (may be multifactorial)
- Thorough history and physical exam are critical in ruling out other etiologies of distress and making this diagnosis of exclusion
- May increase risk of NAT, PPD, and early cessation of breastfeeding
- Firstline treatment: caregiver support and behavioral interventions (may try adjusting feeding techniques)
- Ongoing studies on probiotics – maybe something to consider in breastfed infants
- Many other therapies such as special formulas and OTC medications are ineffective at best and harmful at worst
Blog post based on Med-Peds Forum talk by Lindsey Mahoney, PGY4