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Childrens Medical Office
of North Andover, P.C. |
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The Basics
Nothing is more distressing
to a parent than a newborn who won’t stop crying. All babies cry. It's their only way
of communicating with us, so they cry for many different reasons. Sometimes they're hungry
or thirsty. Sometimes they're sleepy. Sometimes they want more attention, sometimes less.
Sometimes they're over-stimulated, and sometimes they're bored. Occasionally they are even
sick or in pain. Often a baby doesn't know why it's crying - he or she is just "out
of sorts", in a bad mood. Is there always a specific reason why YOU feel cranky?
Usually, parents can find
ways that work to soothe their babies when they cry. They do this by learning to read the
baby’s "signals", sense the baby’s needs, even through simple trial
and error. Different babies soothe in different ways. Some are easier to soothe than
others. Even a difficult-to-soothe baby usually stops crying spontaneously within a time
not terribly distressing to its parents. This is not always the case, however. Some babies
cry for excessively long times and are particularly difficult to console. When no other
major symptoms are present, and a physical exam fails to reveal signs of any obvious
disease, we refer to this phenomenon as "Infant Colic."
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The Problem
The definition of Infant
Colic described above is necessarily a bit "slippery" & subjective. It
relies on the word "excessive", but excessive is in the eyes of the beholder.
Parents differ in their tolerance for crying. For some, anything more than a few minutes
is "excessive", while for others it might take several hours for them to become
alarmed. Scientists have studied crying in infants and found that the "average"
infant cries 2-3 hours per day. This has led to definitions of Infant Colic for research
purposes that depend on a crying time greater than four hours per day. However, for a
child’s parents, 4 hours can seem like an eternity, and minutes can seem like hours.
Parents, therefore, tend not to be very accurate in estimating infant crying times.
In "real life", Infant Colic is defined by whatever amount of crying seems
excessive to the parent(s). This in turn is greatly affected by how successful they feel
at soothing their baby. It is very frustrating not to be able to soothe a baby. Therefore,
babies who are difficult to soothe may be more apt to be termed "colicky" even
if their actual crying time is no different from another baby who cries a lot but can be
easily consoled.
Few conditions in early
childhood are less well understood than Infant Colic. Parental vs. medical perceptions of
this problem tend to be quite different. The main reason for this is that most intuitive,
"common sense" ways of understanding and treating Colic just don't jive with the
data or scientific research. Every theory ever put forth to explain Infant Colic has
either been proved wrong in studies, or by it's nature defies scientific analysis. Infant
Colic is thus one of those frustrating medical problems where we know more about what it
isn’t than about what it is.
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Theories About Colic
This is of course not
helpful, or even satisfactory, to parents understandably upset by their infant's Colic.
They expect the physician to know what's causing it, and want an effective treatment to be
prescribed! An honest explanation that no proven treatment exists is easily misinterpreted
by parents as reflecting a lack of caring on the part of the physician. Knowing this, many
otherwise good physicians unfortunately give in and are untruthful about our ignorance
& impotence with respect to this problem. Instead, they resort to perpetuating dubious
or disproved theories and/or to prescribing therapies that are at best unproven, are known
to be no more effective than placebo, or occasionally may even be dangerous.
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Theories of Colic: Pain
It is quite natural to think
that a colicky baby must be suffering from some sort of pain. Indeed, every parent or
grandparent who has taken care of such a baby for thousands of years has thought so. The
very word "colic" is derived from the ancient Greek word for pain. Other medical
"colics" (renal colic, biliary colic) refer to very painful diseases (kidney
stones, gall stones). We know from scientific studies, however, that colic is not due to
pain. Modern pain experts have learned how to measure pain on a physiologic level using
brain waves, hormone levels, and other physiologic measures. Such measures have been used
to prove such things as the fact that newborns do feel pain, no different than adults do,
during such procedures as needle sticks or circumcision. When colicky infants are hooked
up to such monitoring devices, however, they display a very different physiologic pattern.
It looks nothing like pain! It looks more similar to anger! What that means, we can only
speculate…
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Theories of Colic: Gas
The idea that colic must be
in some way related to gas comes from the nearly universal observation that infants with
colic pass a lot of it. Sometimes this is in the form of flatulence, other times it is in
the form of excessive burping. Studies seem to indicate, however, that infants pass gas
because they have colic - they do not have colic because they have gas. The most direct
evidence for this are studies in which infants without colic were made "artificially
gassy" using diet or benign medications. These babies passed a lot of gas as a
result, but they did not cry more. Further evidence against the gas theory of Colic comes
from studies of "gas drops" (Mylicon, Phazyme). Whether these drops work or not
depends what you look at. If the study focuses on the amount of actual gas passed, the
drops are effective in reducing gas. However, if the study focuses instead on total crying
time and severity of Colic, gas drops have been shown to be no more effective than
placebo. Today we believe that babies who cry a lot swallow air when they are crying -
what goes in must come out. The colic explains the gas, not vice versa.
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Theories of Colic: Allergy
One gastrointestinal problem
that does have some association with Colic is food allergy. This association is mild,
however, and only applies to a minority of newborns with Colic. Babies with food allergy
may initially seem to have Infant Colic - however they will usually develop other symptoms
of food allergy within a few weeks time. These other symptoms can include eczema, spitting
up, diarrhea, bloody stool, and a failure to grow. The development of these other symptoms
makes the diagnosis of food allergy easy once they occur - and they do eventually occur in
almost all babies who have food allergy. While some babies with Colic (the ones who
are really in the early stages of developing food allergy) do respond to a switch to
hypoallergenic formula, this is but a small percentage of all infants with Colic. Because
hypoallergenic formulas are very expensive and not as nutritionally complete as the more
standard infant formulas, however, switching colicky infants to them before they have
developed other signs and symptoms of allergy is not generally recommended.
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Theories of Colic: Real GI Issues
Gastroesophageal Reflux
can cause abdominal pain in a newborn, but is usually accompanied by abnormally severe
spitting up and sometimes coughing, gagging, and poor weight gain as well.
Lactose
intolerance is an inability to
digest the main sugar in milk. It is NOT a food allergy and bears no relationship to food
allergy. It tends to run in families and can sometimes present initially as Infant Colic.
However, newborns with Lactose intolerance tend to have other symptoms beyond crying -
particularly spitting up and poor growth.
Likewise, simple Constipation
can also present with Colic - but usually this is
obvious because the child has firm stools. Thus, both Lactose Intolerance and Constipation
are usually fairly easy to recognize, and respond to simple interventions such a change in
formula or a stool softener. They therefore should be thought of separately and not lumped
together with Infant Colic.
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Theories of Colic: Other GI Concerns
Some parents blame dietary
iron for Colic, or believe that some other aspect of food "tolerance" (besides
allergy) may be at work. Many physicians encourage this by engaging in random formula
changes trying to treat Colic. However, the amount of
iron in breast milk or even iron-fortified formula is NOT enough to cause stomach upset.
Studies have shown that switching formula (in any direction) in the absence of clear
clinical signs of Allergy, Constipation, or Lactose Intolerance is no more effective than
placebo in curing Colic. Many other aspects of gastrointestinal function in infants with
colic have been studied as well. Such infants are no more or less likely than other
infants to grow normally. They are no more or less likely than other infants to be able to
digest common foods. The entire GI tract of colicky infants who have died from other
causes (e.g. motor vehicle accidents) have been studied "from stem to stern"
under electron microscopes and no difference between them and other normal infants has
been found. Children with a history of Infant Colic have been followed through childhood
and out into adulthood. Their rates of later GI diseases (such as Inflammatory Bowel
Disease, Irritable Bowel Syndrome, Ulcers, Gallbladder Disease, Liver Disease or
Pancreatic problems) are no different than the population "at large" or from
individuals without a history of Colic.
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Theories of Colic: Psychosocial
Another theory of Infant
Colic, which held some popularity in the late 70's and early 80's, was that it had
something to do with poor maternal-infant bonding. This was an era when much research on
infant bonding was being done and we understood more and more about this phenomenon. It
seemed logical that colicky infants were having difficulty with this process.
Mother-infant pairs including both colicky and non-colicky infants were observed in many
psychological research protocols and it was found that there was no correlation between
the quality of infant bonding and daily total crying time. Indeed, some very poorly bonded
and even neglectful parents had very quiet babies while some of the most attentive and
well-bonded parents had the most colicky babies. Indeed, more generally, it was found
there was really no correlation between parent behavior towards the baby and Infant Colic
whatsoever .
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Theories of Colic: Temperament
Another idea has been that
Colic is an early expression of a "difficult" personality. Babies who have had
Infant Colic have been studied later in life. It has been found that there is no
correlation between a history of Infant Colic and I.Q., personality, school success,
juvenile delinquency, or a whole host of psychological difficulties including depression,
anxiety, and personality disorders. In short, Infant Colic has nothing to do with
psychology.
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Theories of Colic: Neuro-development
This is the theory that we
believe here at Children's Medical Office. It is perhaps the least well-known, but it is
the most logical and scientifically appealing theory about Infant Colic (and the only one
that hasn't been completely disproved). It holds Colic to be a phenomenon of neurologic
immaturity. It has been observed that infants with Colic are more easily over-stimulated
than other babies. Once they become "worked-up", they have a much harder time
being "brought back down" by themselves or others. State-control is the
neurological skill felt to be relatively immature in these babies. This is the ability of
a person to maintain a comfortable mental "state" (such as being awake &
alert or soundly asleep) and the ability to transition out of an "uncomfortable
state" in the direction of a more comfortable one (e.g. someone who is
"drowsy" either tries to fall asleep or wake up, someone who is crying tries to
soothe themselves). This ability, like memory or language, gets better with age. Most
adults are far better at it than children. Older children are better than younger
children. Some newborns are better at it than others.
The neurodevelopmental theory
is supported by several observations. The first is that all babies with Infant Colic
outgrow it, usually by 4 months of age. The second is soothing strategies which involve a
good deal of stimulation (such as rocking, singing, talking, feeding, changing diapers,
etc.) usually are counter-productive for colicky babies. In contrast, strategies which
involve reduction in stimulation (swaddling, placing in a dark room, "white
noise") tend to be more successful. This theory has led to the development of a
device known as the "Sleep Tight" which combines a vibrator with a monotonous
tone and attaches to the crib simulating a car cruising at 55mph on the highway. The
makers of this device sell it with a money-back guarantee to cure colic (it can be
obtained by calling 1-800-NO-COLIC or visting www.colic.com). In our experience, this works for many babies, but
not all. It has the advantage over other potential therapies of being harmless, at least.
Current proponents of the neurodevelopmental theory propose relatively benign treatments
such as the Sleep Tight, swaddling, and avoiding over-stimulation.
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Historical Perspective
Not so long ago, in the
middle part of this century, tranquilizers and sedatives were the "treatment of
choice", routinely prescribed by doctors for Infant Colic. There is no doubt that
such medicines worked quite well. They were abandoned in the 1960’s, however, when we
began to appreciate that they had adverse long-term developmental consequences. The idea
persists to this day, however, in some quarters. Not only do some older doctors persist in
prescribing such medications (Paregoric, Phenobarbital, Bentyl) but some recent research
has shown that small quantities of alcohol given to colicky babies result in a reduction
in crying time. It should be noted, however, that alcohol is really in the same
pharmacologic category as all of the tranquilizers previously used, and likely would have
the same adverse developmental consequences.
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What to Do:
As you can see, we know a lot
about what colic isn’t. We still know relatively little about what it is or what to
do about it. A small minority of babies who initially seem to have Colic will actually
turn out to have Constipation, Lactose Intolerance, or a Food Allergy. This will become
clear to you & your doctor in time. You should not "jump to conclusions"
about these diagnoses before they are symptomatically apparent. The only theory about
Colic that has not been completely disproved is the neurodevelopmental one, but it hasn't
been proven either. As medical professionals, we want to avoid doing harm to the baby,
making false statements, or hold out false hopes. As a parent, you should focus on the
following:
Never
hesitate to bring a baby with Infant Colic into see us for an exam to rule out possible
medical causes of crying unrelated to colic. Babies initially thought to have colic
sometimes turn out to have not only food allergies later (proven by the development of
diarrhea, blood in the stool and growth difficulties) but sometimes they have something as
simple as an ear infection which can be easily treated. Sometimes other medical problems
are found, but these are almost always apparent in a complete history and physical here in
the office.
There is
light at the end of the tunnel. Infant Colic tends to start at a few weeks of age and
builds to a crescendo between 2-3 months and then subsides and is almost always gone by
4-5 months of age. You should rest assured that if we have done an examination and found
no medical problems, the baby will outgrow the colic and subsequent to that, there will be
no long-term consequences for the child.
Try
swaddling, reducing stimulation, "white noise", or the SleepTight device. Avoid
resorting to treatments which have been proven not to work (formula changes, gas drops) or
which are dangerous (tranquilizers). Always consult with your doctor before trying a new
treatment.
Give yourself
a BREAK. Leave the baby with your partner, a grandparent, friend or babysitter when
you need to get away from the crying.
You should
always call the office if new symptoms beyond the crying develop.
© 1999, David A. Ansel, M.D. |
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