Crying and Colic
Geeta Grover, MD, FAAP
The parents of a 2-week-old neonate bring their son to the emergency department because he has been crying persistently for the past 4 hours. He has no history of fever, vomiting, diarrhea, upper respiratory tract infection, or change in feeding. The newborn is breastfed.
On physical examination, the neonate appears well developed and well nourished. His weight is 3.37 kg (7.4 lb), which is 0.20 kg (0.4 lb) more than when he was born. Although he is fussy and crying, he is afebrile with normal vital signs. The remainder of the physical examination is within normal limits.
1. What is the normal crying pattern in newborns and young infants?
2. What is colic?
3. What conditions are associated with prolonged crying in newborns and young infants?
4. What are key factors in the history of crying newborns and infants?
5. What tests or studies, if any, are indicated in crying newborns and infants?
6. What are a few of the management strategies that can be used by parents to soothe their crying or colicky newborns and infants?
Crying is an important method of communication between babies and caregivers; it is nonspecific, however, and many stimuli (eg, hunger, fatigue, pain) can provoke the same response. Parents report that they can discriminate among various types of cries in their babies. Crying can be divided into 3 categories: normal or physiologic crying, excessive crying secondary to distress (eg, hunger) or disease, and excessive crying without an apparent cause (eg, colic).
The difference between normal and excessive crying may be more qualitative than quantitative. Some investigators have used the mnemonic “PURPLE” to characterize crying during early infancy focusing on the qualities that make the crying particularly frustrating to caregivers: P, peak pattern (increases weekly until 2 months of age); U, unexpected bouts of crying; R, resistance to soothing measures; P, pain-like facial grimacing; L, long periods of crying; and E, evening clustering. Deciding whether crying is excessive varies based on parental expectations and thresholds. Expressed parental concern about extreme crying or fussiness requires attention. If parents complain that newborns and infants cry inconsolably or continuously as well as excessively, the crying may have an underlying organic etiology. Crying with no organic etiology or definable cause is often attributed to colic.
Colic is a poorly understood, benign, self-limited condition in which healthy infants experience paroxysms of inconsolable crying. It manifests as unexplained crying in newborns and infants that usually occurs in the late afternoon or evening. During an episode of colic, babies cry and may draw the knees up to the chest or rigidly stiffen the legs, flex the elbows, clench the fists, and turn red (Figure 49.1). Although neonates and infants may appear to be miserable during an episode of colic, they are otherwise healthy, eat well, and demonstrate good weight gain.
Figure 49.1. Illustration of a baby exhibiting characteristic physical signs of colic, such as crying, flexed elbows, and clenched fists.
Qualitatively, excessive crying is any amount of crying that concerns or worries parents. Quantitatively, definitions of excessive crying have been based on the results of Brazelton’s study of normal newborns and infants. Excessive crying begins at 2 weeks of age (median daily crying time, approximately 2 hours per day), peaks at 6 weeks of age (median daily crying time, approximately 3 hours per day), and decreases to less than 1 hour per day by 12 weeks of age. More crying occurs during the evening hours, especially between ages 3 and 6 weeks.
Although many neonates and infants exhibit a relatively similar pattern of fussiness that peaks at approximately 6 weeks of age, those with colic tend to be inconsolable for longer periods and cry with greater intensity. Colic affects 10% to 20% of newborns and infants younger than 3 months. Colic affects both males and females equally and has no correlation with gestational age (eg, full-term vs preterm), type of feeding (eg, breast vs bottle), socioeconomic status, or season. Postpartum depression and abusive head trauma have been associated with colic and the stressfulness of infant crying. Colic usually begins at 2 to 3 weeks of age, peaks at 6 to 8 weeks of age, and resolves by 3 to 4 months of age. In general, symptoms of colic last for more than 3 hours per day, for more than 3 days per week, and for more than 3 weeks’ duration (ie, rule of 3s).
Colicky babies are otherwise healthy newborns and infants younger than 3 months who cry or fuss inconsolably for extended periods, usually during the afternoon or evening. Typically, the crying resolves within a few hours.
Crying is a complex vocalization that changes during the first year after birth as babies develop. In the first few weeks after birth, crying is a signal that newborns are experiencing a disturbance in homeostatic regulation (eg, hunger, discomfort). As babies mature and begin to differentiate internal from external stimuli, crying may also be an indication of too little or too much environmental stimulation. During the second half of the first year, as infants mature neurologically and gain voluntary control over vocalizations, crying can be an expression of different affects (eg, frustration, fear).
Various explanations for the etiology of colic have been proposed, but the cause remains unknown. Some authorities believe that colic may not be a pathologic entity but instead may be simply an extreme variant of normal crying. Proposed causes of colic include cow’s milk protein or lactose intolerance, abnormal intestinal peristalsis, alterations in fecal microflora, gastrointestinal immaturity resulting in incomplete absorption of carbohydrates and resultant excessive gas production, increased serotonin secretion, poor feeding technique, and maternal smoking or nicotine replacement therapy. Recent studies have demonstrated increased levels of fecal calprotectin, a marker of colonic inflammation, in infants with colic. Others have proposed that colic is caused by problems in the interaction between babies and their environment, specifically their parents. This interactional theory requires not only excessive crying on the part of the newborn or infant but also an inability of the parents to soothe the crying baby. More than 1 of these factors may contribute to the pathogenesis of colic.
An acute episode of excessive crying may be secondary to disease (eg, fever, otitis media). An organic etiology should be suspected in newborns and infants who present with inconsolable crying of acute onset. Box 49.1 lists the most common causes of acute, unexplained, excessive crying in newborns and infants. Some conditions occur in a more chronic or recurrent pattern, particularly if the condition is not treated.
Box 49.1. Common Causes of Acute, Unexplained, Excessive Crying in Newborns and Infants
•Urinary tract infection
•Foreign body in the eye
•Hair tourniquet syndrome
•Persistent night awakening
•Immunization reactions (previously common with diphtheria-tetanuspertussis vaccine)
•Neonatal drug withdrawal (eg, narcotics)
•Long bone fracture
•Sickle cell crisis
•Arrhythmia (eg, supraventricular tachycardia)
•Congestive heart failure
•Anomalous left coronary arterya