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The term infantile colic has come to be associated with these spells. Attacks are most common in the late afternoon or early evening. During the spells the infant cries persistently, cannot be placated, thrashes about and draws up the legs or arches backwards as though in pain. The spells diminish after the age of three months and there are no long-term after-effects.

But is the infant really experiencing “colic”, that is, painful spasms, presumably somewhere along the intestinal tract? Despite over 40 years of research this question remains unanswered.

Brazelton (1962) provided information on the duration and regularity of crying in healthy babies during early infancy. Even when all needs in terms of food, physical comfort, and close human contact have been met, many otherwise normal infants spend a considerable portion of the waking hours fretting and crying. As with infantile colic, such crying is most frequent between 18h00 and 22h00, at a time when the infant has perhaps accumulated a surfeit of stimuli from the environment.

Low threshold
It seems likely that the so-called “colicky” infant simply represents the extremity of a continuum of what is really normal behaviour. These infants have a low threshold for frustration and discomfort. They gulp air during feeds and cry when wind or a normal stool is passed. The behaviour is as common in breast-fed as in bottle-fed infants.

This pattern of behaviour in infancy is universal, being just as common in unsophisticated as in sophisticated communities. However, it appears to be perceived as a problem far more often among “Westernised” parents.

On questioning mothers and experienced health visitors in Cape Town child health clinics, it was evident that this pattern of early evening crying is just as common in black infants, but these mothers seldom seek advice for the behaviour, regarding it as perfectly normal and accepting it with a relaxed attitude. They do not seem to associate the crying with the concept of pain or colic.

It is of interest that the Xhosa word for such screaming in the evenings - uyazilinda - means “the child is guarding himself”. Infants are not offered the breast during attacks, but are either nursed against the mother's chest in the prone position or carried around on her back. On the other hand, studies by Richter (Richter, 1994) in Soweto showed that black mothers often make the assumption that their milk is not enough, or is bad for the baby and they offer solids or the bottle.

What about allergy to cow’s milk?
Allergy does not appear to play a role in the great majority of such infants. Atopic symptoms are neither more frequent in family members, nor more common subsequently in these babies than in the “non-colicky”.

A large study from Tucson, Arizona, showed that the prevalence of colic was similar in infants fed breast milk and those fed formula. There was no association between infantile colic and atopy, asthma, allergic rhinitis, wheezing or peak flow variability at any age (Castro-Rodriguez et al. 2001). An improvement in colic by eliminating cow's milk from the diet of breastfeeding mothers has been claimed, but disputed by others.

In a randomised, double-blind, parallel trial involving 43 healthy formula-fed infants who showed excessive crying, a significant reduction in crying occurred in those fed Whey Hydrolysate formula, compared with those on standard cow’s milk formula. It was noteworthy, however, that in one third of the study infants an improvement had already occurred in the observation period before starting the trial. This may reflect the natural history of “colic” or the Hawthorne effect (Lucassen et al. 2000).

Rule out organic causes!
The diagnosis of infantile colic cannot be considered if there is any deviation from normal physical or developmental progress. Underfeeding is another common reason for excessive crying.

Parental anxiety and anger, though clearly not causes of colic, do seem to aggravate the condition, as does rough handling. In the majority of cases there seems to be no family tension or disharmony.

What is the management?
Prolonged crying can be unnerving and exhausting for parents, whose inability to console their baby leads to frustration, anxiety and loss of self-esteem. Sometimes the difficulties in the mother/infant relationship may be primarily maternal. The infant is keenly sensitive to the mother's reaction, and lack of confidence and tension on her part may lead to excessive irritability in the infant. Less commonly, there may be more serious causes such as postpartum depression or difficulties with bonding.

Once the normality of the infant has been established, full explanation of the behavioural and benign nature of the crying, coupled with simple advice on handling, will generally go a long way towards allaying fears, improving parents' confidence and easing the situation.

• Attention to feeding techniques and the mother's method of bringing up wind may be fruitful.
• Overfeeding should be eliminated. Some parents get into a pattern of feeding the child every time it cries.
• Parents often need to be reassured that sucking a dummy or, better still, fingers or thumb, is a harmless and useful pacifying measure as long as hygiene is adhered to.
• A harness or sling to carry the infant on the mother's back or in front of her is a further very helpful measure.
• The mother needs the opportunity to catch up on her own sleep. A friend or relative may be needed to help her mind the family during these periods.

What not to do

• The prescribing of atropine-containing medication is to be vigorously discouraged because of potentially harmful side-effects.
• Many turn readily to soya formulae or other formula changes in such infants. This is, however, seldom justified - unless there is a strong history of food allergy in the family or if symptoms persist past the age of four months.
• Medications containing dill and bicarbonate of soda - gripe water - and the surface tension-lowering agent polysiloxane are of value only for their placebo effects.

Excessive crying can cause a serious crisis in the family and the doctor should be on the lookout for vulnerable families. He or she should then keep in regular contact until the troublesome behaviour improves. But, pending the discovery of a better explanation, “the best treatment for what we used to call colic may be a set of ear plugs!*”

References
Kibel MA Infantile colic and dicyclomine. South African Medical Journal 1985; 68(12):831-832
Brazelton TB Crying in infancy. Pediatrics 1962;29:579-588
Castro-Rodriguez JA et al Relation between infantile colic and asthma/atopy Pediatrics. 2001;108(4):878-882
Lucassen et al. Infantile colic: Crying time reduction with a whey hydrolysate. Pediatrics 2000;106:1349-1354).
*Goldbloom R. Pediatric Notes. 2001; p 162

- (Prof M.A. Kibel, Emeritus Professor of Child health, University of Cape Town)
 

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