Excessive Crying and Colic: Clinical Evaluation & Management Learning Tool

Crying and Colic

Clinical History Assessment

Systematic approach to history taking for a child presenting with excessive crying or colic

Physical Examination Guide

Systematic approach to examining a child with excessive crying or colic

Diagnostic Approach

Initial Assessment

For an infant presenting with excessive crying, the initial assessment should include:

Detailed history focusing on pattern, duration, and timing of crying
Complete physical examination to rule out organic causes
Parental mental health screening
Assessment of feeding and weight gain pattern

Diagnostic Criteria for Colic

Different diagnostic criteria have been proposed for colic:

Criteria	Definition	Key Features
Wessel's Criteria (Rule of 3)	Crying for >3 hours/day, >3 days/week, for >3 weeks	Historical standard, focuses on duration
Rome IV Criteria	Recurrent and prolonged periods of crying without obvious cause that cannot be prevented or resolved	Includes behavioral signs, parental concern, and normal growth
PURPLE Crying	Peak pattern, Unpredictable, Resistant to soothing, Pain-like face, Long duration, Evening clustering	Emphasizes normal developmental pattern rather than medical condition

Differential Diagnosis

System	Conditions	Red Flags
Gastrointestinal	- Gastroesophageal reflux disease - Cow's milk protein allergy - Intussusception - Constipation - Intestinal obstruction	- Vomiting (especially bilious) - Blood in stool - Diarrhea - Failure to thrive - Abdominal distension
Infections	- Otitis media - Urinary tract infection - Meningitis - Osteomyelitis - Viral illnesses	- Fever - Irritability when handled - Ear tugging - Bulging fontanelle - Decreased urine output
Traumatic	- Hair tourniquet - Corneal abrasion - Child abuse - Fractures	- Localized swelling - Asymmetric movements - Bruising - Digital swelling - Eye discharge
Neurologic	- Increased intracranial pressure - Infantile migraine - Subdural hematoma	- Vomiting - Bulging fontanelle - Lethargy - Seizures - Abnormal head growth
Other	- Medication reaction - Immunization reaction - Teething - Overfeeding/underfeeding	- Temporal relationship to medication - Recent immunization - Gum swelling/redness - Abnormal weight gain

Laboratory Studies

Consider these studies when red flags are present:

Investigation	Clinical Utility	When to Consider
Complete Blood Count	Assess for infection or inflammation	Fever, irritability, suspected infection
Urinalysis/Urine Culture	Rule out urinary tract infection	Fever without source, male <6 months, female <12 months
Stool for Blood/Eosinophils	Evaluate for food protein allergy or inflammation	Diarrhea, suspected allergy, family history of atopy
Abdominal X-ray	Identify obstruction or constipation	Abdominal distension, bilious vomiting, constipation
Electrolytes	Assess hydration status	Vomiting, diarrhea, poor feeding, lethargy

Advanced Studies

Reserve for concerning presentations:

Investigation	Clinical Utility	When to Consider
Cranial Ultrasound/CT	Evaluate for intracranial pathology	Bulging fontanelle, abnormal neurological exam, suspected trauma
Upper GI Series	Evaluate for malrotation or reflux	Bilious vomiting, suspected anatomical abnormality
pH Probe/Impedance Study	Diagnose GERD	Suspected GERD unresponsive to empiric therapy
Skeletal Survey	Identify occult fractures	Suspected non-accidental trauma
Allergy Testing	Identify food allergies	Strong suspicion of cow's milk or other food protein allergy

Diagnostic Algorithm

A stepwise approach to diagnosing excessive crying:

Assess for red flags indicating organic pathology
Complete physical examination including digital inspection for hair tourniquets
Consider basic labs if red flags present (urinalysis, CBC)
Trial of formula change if formula-fed and GI symptoms present
Consider maternal diet modification if breastfed and suspected cow's milk protein allergy
Assess for Rome IV criteria for colic if no organic cause identified
Screen caregivers for postpartum depression and anxiety
Advanced testing only if guided by specific concerns

Management Strategies

General Approach to Management

Key principles in managing excessive crying and colic:

Validate parental concerns: Acknowledge the stress and challenges
Reassurance: Emphasize benign, self-limiting nature if colic is diagnosed
Identify and treat organic causes: Address any underlying medical conditions
Support parents: Provide strategies for coping and preventing caregiver burnout
Regular follow-up: Monitor for resolution and development of new symptoms

Non-Pharmacological Interventions

Intervention	Description	Evidence Level
The 5 S's Technique	- Swaddling - Side/stomach position (when awake) - Shushing - Swinging - Sucking	Moderate; several controlled studies show benefit
Modified Feeding Approaches	- Smaller, more frequent feeds - Proper burping techniques - Upright positioning after feeds - Proper latch for breastfed infants	Low to moderate; clinical experience supports, limited studies
Environmental Modification	- White noise - Reduced stimulation - Consistent routines - Baby-wearing	Low to moderate; some controlled studies support specific interventions
Infant Massage	- Gentle massage techniques - Focused abdominal massage - Regular daily sessions	Moderate; several randomized trials show benefit
Parent Support Interventions	- Respite care - Education on normal crying patterns - Parental coping strategies - Support groups	Moderate to high; improves parental well-being and potentially infant outcomes

Nutritional Interventions

Intervention	Approach	Evidence and Considerations
Formula Changes	- Extensively hydrolyzed formulas - Partially hydrolyzed formulas - Amino acid-based formulas	- Trial for 1-2 weeks - Most beneficial when CMPA suspected - Moderate evidence for extensively hydrolyzed formulas - Limited evidence for partially hydrolyzed formulas
Maternal Diet Modification	- Elimination of cow's milk proteins - Low allergen diet - Trial of 2-4 weeks	- Consider when breastfeeding and CMPA suspected - Moderate evidence if symptoms of allergy present - Ensure maternal nutritional support - Calcium supplementation recommended
Probiotics	- Lactobacillus reuteri DSM 17938 - Dosage: 10⁸ CFU daily	- Most effective in breastfed infants - Moderate evidence from multiple RCTs - Safe intervention - Limited evidence in formula-fed infants
Pre/Postbiotic Formulas	- Formulas with added prebiotics (GOS/FOS) - Fermented formulas	- Limited evidence for colic management - May improve overall gut health - Consider as adjunctive approach

Pharmacological Management

Generally not recommended for uncomplicated colic:

Medication	Considerations	Evidence and Recommendations
Simethicone	- Anti-foaming agent - Thought to reduce intestinal gas	- Not recommended - Multiple RCTs show no benefit over placebo - Generally safe but ineffective
Proton Pump Inhibitors	- Reduces gastric acid production - Used for GERD	- Not recommended for colic without clear GERD - No benefit for irritability alone - Potential side effects include increased infections, micronutrient deficiencies
Anticholinergics (Dicyclomine)	- Smooth muscle relaxant	- Contraindicated in infants <6 months - Associated with serious adverse events including apnea - Not recommended
Herbal Preparations	- Fennel - Chamomile - Mixed herbal teas	- Limited evidence for fennel extract - Safety concerns with herbal preparations - Standardization issues - Not routinely recommended

Management of Specific Conditions

Condition	Management Approach	Follow-up Recommendations
Gastroesophageal Reflux Disease	- Positioning (upright after feeds) - Smaller, more frequent feeds - Thickened feeds if appropriate - Medication only for objective GERD	- Re-evaluate in 2 weeks - Adjust therapy based on symptom improvement - Consider referral if no improvement
Cow's Milk Protein Allergy	- Eliminate cow's milk protein (from maternal diet or infant formula) - Extensively hydrolyzed or amino acid formula - Allow 2-4 weeks for response	- Re-evaluate after 2-4 weeks - Challenge at 6-12 months to confirm diagnosis - Nutritional monitoring
Hair Tourniquet	- Immediate removal of constricting fiber - Examine all digits, genitalia - Depilatory cream or manual removal	- Immediate relief expected - Check for other tourniquets - Re-examine in 24-48 hours
Otitis Media	- Appropriate antibiotics if bacterial - Pain management - Supportive care	- Follow-up in 48-72 hours if severe symptoms - Consider routine follow-up in 2 weeks - Monitor for recurrence

Parent Support and Education

Education on normal crying patterns: PURPLE crying concept, developmental normality
Prevention of shaken baby syndrome: Discuss normal frustration, develop coping plans
Mental health screening: Assess for postpartum depression/anxiety in caregivers
Resources: Support groups, crisis hotlines, respite care options
Follow-up schedule: Regular visits to monitor progress and parental coping

When to Refer

Specialist referral: For concerning red flags or failure to improve with first-line interventions
Gastroenterology: Persistent GI symptoms, suspected CMPA not responding to elimination diet
Neurology: Neurological symptoms, concern for increased intracranial pressure
Mental health services: For caregivers with significant depression, anxiety, or coping difficulties
Social services: Concerns about family resources or child safety

Introduction to Infant Crying and Colic

Infant crying is a normal and essential part of early development, serving as a primary means of communication for babies. However, excessive or inconsolable crying can be distressing for both infants and caregivers, potentially leading to diagnosis of colic in some cases.

Key points about infant crying and colic include:

All infants cry, but the amount and intensity vary widely
Crying typically peaks around 6-8 weeks of age
Colic is characterized by excessive, unexplained crying in healthy infants
Understanding normal crying patterns and colic is crucial for parents and healthcare providers

This topic is of significant importance in pediatrics and early childhood development, affecting family dynamics, parental well-being, and infant health.

Normal Infant Crying

Normal crying patterns in infants follow a predictable trajectory:

1. Crying Curve

Crying typically increases from birth, peaking at around 6-8 weeks
After the peak, crying usually decreases and stabilizes by 3-4 months

2. Duration and Timing

Average crying duration: 2-2.5 hours per day in the first 3 months
Often clusters in late afternoon and evening ("witching hour")

3. Reasons for Crying

Hunger
Discomfort (e.g., wet diaper, temperature)
Tiredness
Overstimulation
Desire for physical contact

4. Characteristics of Normal Crying

Can be intense but is usually soothed by feeding, comforting, or addressing needs
May be accompanied by normal infant reflexes (e.g., clenched fists, drawn-up legs)

Understanding normal crying patterns helps differentiate between typical infant behavior and potentially problematic excessive crying or colic.

Infant Colic

Colic is a common condition characterized by excessive, unexplained crying in otherwise healthy infants. It is typically defined using the "Rule of Threes" or Wessel's Criteria:

1. Definition (Rule of Threes)

Crying for more than 3 hours per day
For more than 3 days per week
For at least 3 weeks
In an infant who is well-fed and otherwise healthy

2. Prevalence

Affects about 10-40% of infants worldwide
Usually begins around 2-3 weeks of age
Typically resolves by 3-4 months of age

3. Characteristics of Colic

Intense, inconsolable crying
May appear to be in pain (e.g., drawing up legs, clenching fists)
Often occurs at predictable times, especially evening
Crying episodes start and stop suddenly without clear reason

4. Impact

Can be highly distressing for parents and caregivers
May lead to feelings of inadequacy or frustration in caregivers
Can impact family dynamics and parental mental health

While colic is generally considered benign and self-limiting, its impact on families can be significant, necessitating support and management strategies.

Causes and Risk Factors

The exact causes of excessive infant crying and colic are not fully understood, but several theories and risk factors have been proposed:

1. Potential Causes

Gastrointestinal factors (e.g., gas, gut microbiome imbalance)
Food allergies or intolerances
Immature nervous system
Overstimulation or difficulty self-soothing
Maternal smoking or nicotine use during pregnancy

2. Risk Factors

Maternal factors:
- Stress or anxiety during pregnancy
- Postpartum depression
- First-time motherhood
Infant factors:
- Premature birth
- Low birth weight
- Male sex (slightly higher risk)
Environmental factors:
- Exposure to cigarette smoke
- High levels of environmental stress

3. Debunked Theories

Parenting style or skills (colic occurs across different parenting approaches)
Breastfeeding vs. formula feeding (both can be associated with colic)

It's important to note that many infants with colic have no identifiable risk factors, and the condition likely results from a complex interplay of multiple factors.

Diagnosis and Assessment

Diagnosing colic and assessing excessive infant crying involves several steps:

1. Clinical History

Detailed account of crying patterns (duration, timing, intensity)
Feeding history
Sleep patterns
Family history

2. Physical Examination

To rule out other medical causes of crying
Assessment of growth and development
Check for signs of illness or injury

3. Crying Diary

Parents may be asked to keep a log of crying episodes
Helps quantify crying and identify patterns

4. Diagnostic Criteria

Application of Wessel's Criteria or modified versions
Exclusion of other medical conditions

5. Additional Assessments

Screening for postpartum depression in mothers
Evaluation of family dynamics and support systems

6. Potential Further Investigations

Usually not necessary but may include:
- Allergy testing if food allergy is suspected
- Gastrointestinal investigations in cases of suspected pathology

The diagnosis of colic is primarily one of exclusion, ensuring that no other medical conditions are causing the excessive crying. It's crucial to provide reassurance to parents while thoroughly evaluating the infant.

Management and Treatment

Management of excessive infant crying and colic focuses on supporting the family and attempting to soothe the infant:

1. Parental Support and Education

Reassurance about the benign and self-limiting nature of colic
Education on normal infant crying patterns
Strategies for coping with stress and fatigue

2. Soothing Techniques

The "5 S's" (Swaddling, Side/Stomach position, Shushing, Swinging, Sucking)
White noise or calming sounds
Gentle motion (rocking, walking, car rides)
Warm baths

3. Feeding Adjustments

For breastfed infants: maternal diet modifications (e.g., eliminating dairy)
For formula-fed infants: considering hypoallergenic formulas
Proper feeding techniques to reduce air swallowing

4. Environmental Modifications

Reducing stimulation
Establishing consistent routines
Creating a calm sleep environment

5. Pharmacological Interventions

Generally not recommended
Some studies on probiotics show mixed results
Simethicone drops are sometimes used but lack strong evidence

6. Alternative Therapies

Some parents report benefits from:
- Infant massage
- Chiropractic care (controversial and lacks strong evidence)
- Herbal remedies (caution advised due to lack of regulation)

7. Psychosocial Support

Referral to support groups
Screening and treatment for postpartum depression
Encouraging breaks and shared caregiving responsibilities

The key to managing colic is a multifaceted approach, focusing on supporting the family while ensuring the infant's needs are met. It's important to remember that different strategies may work for different babies.

Impact and Long-term Outcomes

Excessive infant crying and colic can have significant short-term impacts and potential long-term implications:

1. Short-term Impact

Parental stress and fatigue
Increased risk of postpartum depression
Strain on family relationships
Potential for early cessation of breastfeeding
In extreme cases, risk of shaken baby syndrome

2. Long-term Outcomes for Infants

Generally, no significant long-term effects on child development
Some studies suggest a slightly increased risk of:
- Behavioral problems in childhood
- Recurrent abdominal pain
- Migraine headaches
Most children with a history of colic develop normally

3. Long-term Impact on Parents

Potential for lasting effects on parental mental health
May influence decisions about family size
Can affect parent-child bonding, though often resolves

4. Positive Outcomes

Many parents report increased resilience
Can lead to development of effective coping strategies
May strengthen family bonds in the long run

5. Factors Influencing Outcomes

Quality of support received during the colic period
Parental coping skills and mental health
Overall family dynamics and resources

While the immediate impact of excessive crying and colic can be significant, it's reassuring that for most families, the long-term outcomes are positive. Early intervention and support can play a crucial role in mitigating potential negative impacts.