Infantile Colic

Infantile Colic

Definition

• Excessive, inconsolable crying in otherwise healthy infants defined by the "rule of threes": >3 hours per day, >3 days per week, for >3 weeks

• Typically occurs in infants with no apparent organic cause and is a diagnosis of exclusion

• Peaks around 6–8 weeks of age and usually resolves by 3–4 months

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Presentation

• Episodes of intense crying, often in the late afternoon or evening

• Increased irritability and fussiness without other systemic symptoms

• Association with maternal postnatal depression and increased parental stress

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Differential Diagnosis

• Benign causes such as inadequate sleep or feeding difficulties; note newborns require ~16 hours of sleep, decreasing to ~15 hours by 2 months

• Cow’s milk protein intolerance: May present with vomiting, blood-streaked stools, or eczema

• Lactose overload: Watery diarrhoea with frequent feeds due to imbalanced foremilk/hindmilk ratio

• Gastro-oesophageal reflux disease: Regurgitation and feeding irritability

• Red flags warranting urgent referral include signs of raised intracranial pressure (vomiting, bulging fontanelle, abnormal eye movements), non-accidental injury (bruises, fractures, inconsolable crying), hernia (tender groin/umbilical swelling), urinary tract infection (fever, malodorous urine) and hair tourniquet syndrome (red/swollen digits or genitalia)

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History and Examination

• Feeding history: Frequency, adequacy, and presence of vomiting suggestive of CMPI or GORD

• Stool pattern: Presence of diarrhoea, blood, or mucus indicating potential CMPI

• Growth assessment: Expected weight gain of approximately 150 g per week in infants 0–4 months

• Skin examination: Look for rashes or eczema that may indicate allergic predisposition

• Urinary symptoms: Fever or malodorous urine to rule out UTI

• Sleep and crying patterns: Document timing, triggers, and duration of crying episodes using a diary

• Maternal health: Screen for postnatal depression as maternal well-being can impact infant behaviour

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Management

• Education

  • Normalise infant crying by explaining that colic peaks at 6–8 weeks and typically resolves by 3–4 months

  • Teach parents to recognise early signs of infant tiredness such as fussiness and yawning

  • Use a sleep and cry diary to identify patterns and triggers

• Settling Techniques

  • Encourage a consistent sleep environment with a dark room and white noise

  • Advise on gentle soothing methods such as rocking, swaddling, or offering a pacifier

• Parental Support

  • Emphasise the importance of caregiver breaks and involve family members in care

  • Refer to parent support groups if stress and frustration persist

• Medical Interventions

  • Probiotics (Lactobacillus reuteri) may be considered in breastfed infants under 3 months

  • For suspected cow’s milk protein intolerance, initiate an elimination diet for breastfeeding mothers or switch to a hypoallergenic formula for formula-fed infants

  • Advise against routine use of simethicone or antacids unless specific indications are present

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Notes

• Infantile colic is self-limiting and generally has no long-term adverse effects on development

• Regular follow-up is advised to monitor feeding, weight gain, and overall well-being

• Consider alternative diagnoses if red flag symptoms arise or if the pattern of crying deviates from typical colic patterns