- Colic is a description of a cluster of common but distressing symptoms, the cause is multifactorial, one solution does not fit all
- Food allergens may be responsible for colic symptoms in a small group of infants
- NICE Clinical Knowledge Guidelines provide a stepwise approach on how to support parents with colic
Crying in the early weeks of life is one of the most common reasons parents seek health professional advice, with an estimated annual cost to the NHS of £65 million pounds.1 Colic is one of a number of reasons that babies may cry. Colic is a description of a cluster of common symptoms of more than one origin, and therefore more than one solution. This articles looks at the role allergens may play in colic symptoms.
What is colic?
In the 1950s Wessel defined colic as: ‘crying for at least three hours a day on at least three days per week for at least three weeks.’2 The ‘rule of threes’ persists as a useful diagnostic guide. NICE Clinical Knowledge Summaries3 describe colic as “repeated episodes of excessive and inconsolable crying in an infant that otherwise appears to be healthy and thriving”. Other than crying, signs of colic can include drawing up of knees, back arching, fist clenching and abdominal distension.3,4
Fussiness is included in many updated definitions of colic, rather than exclusively crying.5-7 In one study parents defined fussing as ‘awake but not content’.8
Colic can start at two weeks of age and persist up to four months of age,3,4 and often occurs in the early evening.
Prevalence is estimated to be between 5-20%3 and 10-40%.9 Variation occurs due to differences in data collection and how infant crying is perceived by parents.9 No difference in prevalence has been found between breast and formula fed babies.10
What causes colic?
The range of signs and symptoms that may lead to a diagnosis of colic are thought to be multifactorial.4 Theories include baby-parent behaviours, extreme normal crying or gastrointestinal problems, such as gas, allergy or intolerance.11
Organic disease as an underlying cause of colic symptoms is thought to account for less than 5% of presentations.12
The role of dietary allergens
Health professionals will be familiar with parental perception that colic is a gastrointestinal or dietary problem however the evidence for the role of food allergens in colic symptoms is not straightforward. Herman et al (2007) offer discussion on some of the methodological problems which plague investigation into isolating dietary and gastrointestinal influence on colic.13
One study reported a 37% risk reduction in cry/fuss behaviour for a sample of breastfed babies with diagnosed colic.14 The case group of mothers had all major dietary allergens removed from their diet, compared to the control group whose diet included common allergenic foods. While this suggests dietary allergens play a role in colic symptoms, the study has limitations, acknowledging that as mothers were aware of diet allocation, outcomes may have been affected by the placebo effect. A blanket removal of major dietary allergens would not be practical or safe frontline advice.
Evidence demonstrates that colic symptoms may be an early indictor of cows milk protein allergy (CMPA) in a few infants. A sample of 114 breastfed infants, aged three weeks to three months, with diagnosed colic, were subject to a skin prick test (SPT) for CMPA. Three infants had a positive SPT and all crying resolved following removal of dairy foods from the mothers diet. The remaining 111 infants were divided into two groups. The case group mothers were instructed to remove dairy, cow and goats milk from their diets, the control group were not advised to remove dairy. There was no difference in crying between the two groups.15 The bulk of the infants with colic symptoms did not respond to maternal dietary dairy restriction.
Another study attempted to correlate infant behaviour during the first twelve weeks of life with atopic disease at two years. The parents of 116 newborns with at least one close relative with atopic disease recorded their infants behaviour using a validated tool for 12 weeks. At two years of age atopic disease was diagnosed in 38% of the children. Using the parent records, crying at seven weeks was similar between those who developed atopic disease and those who did not. At 12 weeks total distress was more common in those who developed atopic disease.16 The difference was attributable to a decrease in crying by those who did not develop atopic disease. There was no difference in frequency of atopic disease in those breast, mixed or formula fed.16 This study recommended further research between infant behaviour and maturation of the gut barrier function.
Colic symptoms may be attributable to CMPA in a few babies, and if suspected, practitioners should follow National Institute of Health and Care Excellence (NICE) guideline 116, Food allergy in children and young people.17 However, in these studies, dietary manipulation of maternal diet did not alter colic symptoms for most breastfed babies.
A review of a number of studies that challenged formula fed babies with extensively hydrolysed formula (EHF), concluded that some babies benefit from the introduction of EHF.6 In an interesting, albeit older, randomised, double blinded multiple crossover trial, babies were subject to three formula changes between an EHF and cows milk formula. The first change from cows milk formula to EHF bought benefits, the second change bought a reduction in colic but not crying and the third change to EHF found no benefit.18 The lack of effect sustainability is interesting given a key diagnostic criteria for allergy is that the symptoms disappear when an allergen is removed but return when the allergen is reintroduced and of course, that colic is known to be self limiting. This may suggest that even if an EHF is initially beneficial for alleviating colic, it does not indicate a diagnosis of CMPA. It highlights the question of whether the short-term benefit is attributable to maturation of gut barrier function.16
For parents, having a baby who cries inconsolably, despite their best efforts can be very stressful. It is suggested that between one and four hours of crying per day is ‘normal’ for newborns.19 For parents, ‘problem’ crying is the point at which their baby’s crying exceeds their expectations.
As well as offering advice to alleviate the baby’s discomfort, the parents ability to cope with crying should be assessed. The relationship between postnatal depression (PND) and colic is often raised; a study of 1015 mothers reported a positive correlation between PND and prolonged crying and colic.20 It is easy to see how a mother may feel depressed if she is unable to comfort her baby, and while an assessment of mood may help identify depression in the mother, it is important to note this is association not causation, and the reason for baby’s crying must still be thoroughly investigated.
What can health professionals do to help?
Dietary allergens may produce colic symptoms in some babies, however this is often not immediately apparent and parents can try other strategies before dietary manipulation.
If there is concern that the baby has an underlying health problem the parents should be advised to see their GP.
A review of infant feeding, including sufficiency of milk offered, technique, and post feed winding and changing should be completed, ideally by the family health visitor.
NICE Clinical Knowledge Summaries3 suggest that the single most important action is to acknowledge the distress of the parents and baby, and reassure them that colic does resolve. Offer advice to cope with crying such as holding, motion, being put in the bath, or letting someone else look after the baby while parents have a rest.
NICE CKS3 goes on to recommend that only once these measures have been exhausted without effect, other treatments can be offered, which includes a one week trial of diet modification: dairy free for breastfeeding mums or hypoallergenic formula for formula babies, (see reference for full list of recommendations). It is important to advise parents that this does not mean their baby necessarily has a CMPA, that they should reintroduce dairy after a week and should do this in conjunction with their GP. Breastfeeding mothers who stop dairy foods for longer than the trial period will need calcium supplementation.
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12 Barr R. Colic and Crying Syndromes in Infants. Pediatrics 1998;102:5:1282-1286.
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16 Kalliomäki M, Laippala P, Korvenranta H, Kero P, Isolauri E. Extent of fussing and colic type crying preceding atopic disease. Archives of Disease in Childhood 2001;84:349-350
17 NICE. NICE Clinical Guideline 116: Food allergy in children and young people. London: NICE; 2011.
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