Infant colic, while not a deadly disease by any stretch of the imagination, is an extremely troubling entity. Not only can it be quite distressing to caregivers, it is also a well-established risk factor for neglect and abuse of the child. Excessive crying in general, whether diagnosed as infant colic or not, is a frequent impetus for seeking advice from medical professionals. How science-based providers approach the evaluation of babies with excessive crying, and the management of infant colic if diagnosed, can have a powerful impact on how families perceive the health of their child and on future interactions with the healthcare system.
Infant crying is about as bread and butter as it gets in pediatrics. It is a problem which we are constantly exposed to during our training. We discuss it with families in our continuity clinics, where we learn how to truly be primary care providers. We address it on the inpatient wards, where children often cry because of illness or pain, and during our months of service in the newborn nursery. We frequently are called upon to talk anxious parents through it while taking overnight phone calls, and we learn over time with variable success the seemingly preternatural ability to understand what babies are trying to tell us with their cry.
Crying happens for a variety of reasons in young infants, ranging from the benign and expected to the life threatening. Discussing excessive crying, regardless of why it occurs, requires effective communication skills. And the evaluation of unexplained excessive crying often tests the limits of our ability to practice non-defensive medicine, avoiding unnecessary laboratory testing and imaging. Because of all this, I believe that infant crying, and in particular the entity known as infant colic, serves as a useful entry point into a discussion of the differences between a science-based approach to medicine and one based on pseudoscience like chiropractic.
Readers of this blog should be well aware of the push by alternative medical practitioners for recognition as primary care providers, with the chiropractic community leading the charge. In this post I will compare and contrast the common understanding of the etiology and treatment of infant colic held by conventional medical doctors and doctors of chiropractic. You will see that in some ways they do not differ as much as we might expect, but have little in common where it truly matters.
What is colic?
With rare exceptions, all babies cry. Infant crying is typically an intermittent phenomenon related to hunger or an environmental insult like cold air or a dirty diaper. Many babies cry only when really bothered by something while some seem to cry all the time. In general, babies get most of their crying out of the way during the first three months of life, with estimates of the average total duration in the range of two hours a day during the first six weeks. Crying trends down after that. But how much a baby should be allowed to cry before a parent should worry, or before giving them a diagnosis, is very hard to peg down and risks ignoring the infant’s environment and the caregiver concerns when a baby falls short of diagnostic criteria.
So what is infant colic? In many instances, it is simply regular crying that crosses what is essentially an arbitrary threshold while in others it may appear more consistent with actual underlying pathology. And to further confuse our understanding of the concept, the designation of an infant as “colicky” has been rendered nearly meaningless by its widespread use as a nebulous word for any young baby who is fussy for unclear reasons. The obvious linchpin of the diagnosis is the perception by caretakers that the crying is excessive and requires intervention beyond normal soothing techniques, feeding or changing. Naturally, this is a highly subjective determination that is influenced by environment, experience and culture.
Despite these difficulties, there is a classic definition that is at least generally agreed upon by most pediatricians if not actually put into practice. The Wessel criteria, or “rule of three”, states that colic is an appropriate designation when an otherwise healthy infant cries for more than three hours per day, more than three days a week, and it lasts longer than three weeks. But when the parents of a young infant who has had long and intense bouts of crying but doesn’t meet these criteria come in for help, they tend to want an answer. So there is motivation to diagnose something when a baby that is less than about three months old cries a lot. Colic is an all-too-convenient something.
Though we lack truly evidence-based diagnostic criteria, based on piles of anecdotes involving young babies that cry a lot and aren’t sick there are certain signs that most pediatricians would describe as consistent with infant colic. Crying spells with colic tend to have an equally abrupt beginning and end, with no obvious relationship to the events surrounding the spell. They often seem to cluster in the evening (“the witching hour“) and are often felt to be qualitatively different than “normal” crying in that they are more intense and turbulent in nature. For example, the cry is often described as more painful, urgent and irritating by caregivers. Colic spells are often associated with stiffness, arching the back, flushing and a tense abdomen. Finally, young infants who are having what is thought to be a colic “attack” are very hard to calm.
These particular signs are common in infants with certain medical conditions, such as gastroesophageal reflux and intolerance to various components of formula or breast milk, leading some experts to link these phenomena with colic. A number of interventions aimed at treating those underlying conditions have been studied in babies that were diagnosed with colic or felt to have excessive crying by parents. Not much has panned out but there are some promising leads. But the subjectivity of the diagnosis is such that it is extremely difficult to study, and there is a great deal of plausibility to claims that many infants are diagnosed with colic because parental perception of the crying has been warped by psychosocial factors. So is colic a disease, or is it simply one end of a spectrum of infant temperament? Or does reality lie somewhere in between? Should it even exist as a stand-alone diagnosis, where it might potentially serve as a convenient foot in the door for those who would take advantage of weary parents?
Which babies “get” colic?
Which infants actually have colic, if it even truly exists, is a very difficult question to answer. What do we base this determination on? Do we follow strict criteria, which is problematic because it relies on subjective reports from caregivers, or do we use a more relaxed approach where if the parents are worried about it, it is probably colic? Pediatric lore tells us that colic affects about a third of infants, but the literature reveals anywhere from 8 to almost 50 percent. We know that most children who are considered to have colic by the primary caregiver do not fit the strict criteria.
Unfortunately, there are no well-established clues to what infant colic might actually be buried in the numbers. There does not appear to be any variable that reliably influences the likelihood of an infant being diagnosed with colic. Researchers have looked at a number of possible factors, including birth order, gender, feeding practices, and gestational age at birth and the data has not fit well with any possible association. Even breast feeding versus formula feeding, which I would have put good money on, does not appear to matter.
Probably the closest we have to a solid association are psychosocial factors such as parental stress and a lack of parental self-confidence. It is very difficult to entertain any claims of causality though. Does stress somehow impact parental interactions with the infant, leading to more crying? Does it alter the intrauterine environment? Is it all just epigenetics/magic (that’s for you DG) at play? Or does stress and parental insecurity alter the caregiver’s perception of reality? I have absolutely experienced many discussions at the bedside where I wondered if a parent was looking at the same child that I was.
So what causes a condition composed of nothing but non-specific signs like crying, and that can be diagnosed in virtually any healthy baby on the planet? Not to mention that the diagnosis is subjective almost to the point of rendering it meaningless as a concept? And once diagnosed, what is the best approach to decreasing the amount of crying, or in some cases the caregiver perception of the crying? How do we help these families? There are no easy answers here, but let see who inspires the most confidence.
The science-based approach
What causes colic?
We don’t know what causes colic. We don’t really know for certain if it is real to begin with. Perhaps it is merely a wastebasket or a useful framing device to aid in discussions with families about parenting and psychosocial risk factors. But absolutely any discussion of etiology has to involve a possible parental role. Infant colic probably does exist as a unique entity with an underlying pathology in a small subset of kids that have been diagnosed, and some that haven’t, but many with the label are probably completely normal kids with hypersensitive parents that are set up to focus on crying.
There isn’t great evidence to support any of the proposed etiologies. That doesn’t mean that there isn’t any evidence, just nothing to support a confident claim that would help us to narrow things down a bit and focus treatment approaches. Proposed causes can be broken down into three categories: Gut specific, biologic and psychosocial. Here is the best of what we have so far:
Gut – while not implausible to think that colic stems from issues in the GI tract, I would like to point out that there is a general bias towards blaming gas every time a baby cries. I have lost count of how many times a very ill or injured infant’s pain, many times caused by a broken bone, was passed off as gas by a caregiver or medical professional. There should be a special term for anchoring related to gas. It should probably be German. They have the best words.
1. Allergy to cow milk protein – Some young infants develop inflammation of the intestines when exposed to casein or whey. They are often quite fussy and most, but not all, develop bloody stools. If the largely clinical diagnosis is correct, within a week or two of changing to a specialized formula, the symptoms completely resolve. This is a fairly common condition and it would be silly to think that there aren’t at least some children diagnosed as having colic who actually have a mild case of milk protein allergy causing excessive crying but no grossly bloody stool or failure to thrive.
2. Fruit juice intolerance – Based on some small studies, fruit juices that contain sorbitol and a high fructose to glucose ratio might actually play a role in some infants with colic. This has decent plausibility as a possible etiology of some children diagnosed with colic. You shouldn’t give infants fruit juice anyway.
3. Differences in intestinal microflora – There are small studies showing that kids with colic have bad bugs and higher markers of gut inflammation. There are even small studies showing that providing good bugs might help some kids with colic. They may have been funded by Jamie Lee Curtis.
Biologic – Some of these make more sense than others (migraines, I’m looking in your direction).
1. Migraines – Yeah, probably not. This is based on asking if kids with migraines had colic as a baby.
2. Underfeeding, overfeeding, poor feeding technique, etc. – Hungry baby cry more than full baby. Vomiting baby cry more than not vomiting baby. Baby fed upside down or with a straw cry more than…well, you get the point. Makes sense to me. Of course many babies diagnosed with colic are fed just fine.
3. Immaturity – The brain, the gut, the gutbrain, etc. It is certainly plausible that some infants diagnosed with colic are more sensitive to external stimuli because of a general immaturity. Pediatrician to the stars and Jenny McCarthy punching bag Harvey Karp is a vocal proponent of this hypothesis. Immaturity of the gut, specifically gut motility, has also been proposed as a potential contributing factor.
4. Exposure to nicotine and/or tobacco smoke – This is very plausible and has some decent data in support of it. Both prenatal and postnatal exposure are implicated. What do you say to that Stephen Dorff!
Psychosocial – Who says that regular doctors don’t practice holistic medicine?
1. Temperament – Some babies just cry a lot. That makes sense. A lot of babies diagnosed with colic are helped by teaching parents how to better handle crying babies.
2. Hypersensitivity – Perhaps some babies are just stressed out after a long day and take some time to vent. Seriously, that’s a thing.
3. Parents – If there is anything we have learned in pediatrics, or during a trip to the Walmart, be very careful when you imply that any child’s behavior is the fault of their parents. But … maybe … based on some okay evidence … and I am really not judging here, but parental stress and parent-baby interactions almost certainly play a role in the diagnosis of colic in some babies.
How do we treat colic?
When a caregiver comes to a pediatrician or family doctor with concerns about their infant’s excessive crying, the most important initial step is to evaluate for any condition or environment that puts the child at risk of harm. This is regardless of whether or not the parent’s description meets any potential diagnostic criteria for infant colic. Even if the baby only cries for 30 minutes a week, it is vital to take any parent asking for help seriously.
To make sure that a baby is safe, and does not suffer from a serious illness or live in a home where caregiver stress is a possible risk factor for neglect or abuse, there are important questions to ask. Naturally these involve ascertaining the nature of the crying. What does it sound like, when does it happen, and for how long? It is vital to determine what soothing techniques the parents have been putting into use. Many young first time parents don’t know any, or what they do know might actually be making things worse.
Once while taking diaper duty in the middle of the night, I secured my screaming 1-month-old daughter’s pacifier in her mouth with Scotch tape during a particularly rough crying spell. I stood there, nearly delirious with fatigue, for about ten seconds before I took the tape off even though it was actually working. I was a 2nd year pediatric resident and luckily knew enough to realize that I was probably increasing her chance of dying from SIDS despite my foggy brain. Stress, fatigue and excessive infant crying can be dangerous combination. Even two pediatric residents needed help. What we learned from our daughter’s pediatrician and our own research improved our lives dramatically over the next few months.
How is the baby fed? How do the parents feel about the crying and about being a parent in general? How is the family unit as a whole reacting to the crying? What are any beliefs that the family has about why the child is crying? Answers to these questions might give insight into the possible cause of the child’s crying and greatly assist in determining what the next step should be.
After discussing the problem, a thorough exam is necessary. How is the child growing? Are there any concerning physical finding that could be a clue to illness or abuse? Are there any signs of pain that might not be related to possible colic? I once took a direct admission from a local pediatrician who was unable to determine the cause of a young infant’s persistent crying. After a thorough history and exam, she wasn’t convinced that infant colic was the right call. She didn’t anchor on the suggestion of it and asked for me to watch the child closely in the hospital after a reasonable work-up. The only reason I caught the clavicle fracture and she didn’t, luckily before labs were drawn, was that I had the benefit of time and multiple examinations. Infant colic is a diagnosis of exclusion.
There is no one-size-fits-all treatment approach to infant colic. But if after a thorough evaluation and assessment of the need for parental support infant colic is the diagnosis, a reasonable approach in many cases is to do exactly nothing. Infant colic will stop on its own, often by 3 months of age, and nearly all infants have significantly improved by 4 months. This is why infant colic is such a perfect condition for practitioners of irregular medicine. Colic will get better, and whatever is being done when it does will get the credit.
So what is the appropriate approach when a pediatrician and family decide together that an intervention is necessary? I do not think anyone would describe any of the proposed treatments as well-supported in the pediatric literature, but some have a better evidence base than others. First and foremost is addressing and managing parental stress. This may lead to a new perspective on the crying and remove the desire to intervene medically. Teaching simple soothing techniques can be an instant cure in many cases.
Based on the available evidence, which isn’t great, the additional intervention that has the best chance of helping decrease the duration and intensity of crying episodes is a trial of specialized formula which contains no intact cow milk protein or having a breast feeding mother observe a hypoallergenic diet. After that it goes downhill fast and any interventions likely work via parental placebo. These include feeding techniques to reduce swallowed air, probiotics, and distracting techniques. Distracting techniques involve things like pacifiers, baby swings and massage.
No medication is both effective and safe for use in the treatment of infant colic and drugs are rarely prescribed. Still, I wish all pediatricians and family doctors would have the concept of a pharmaceutical intervention for infant colic wiped from their minds, including even the ever-present simethicone (Mylicon). Though an uncommon practice now, I have seen anticholinergics, antihistamines, barbituates and opiates all used for healthy babies with infant colic. Herbal remedies, as they often do, show some promise in small and poorly designed studies but are poorly regulated. There are many examples of them being contaminated and/or adulterated.
What about other alternative approaches? The big ones when it comes to colic are homeopathy and chiropractic, which I lump together with cranial osteopathy as “manipulative techniques”. Homeopathy has no effect beyond parental placebo. Bet you didn’t see that coming. The manipulative techniques don’t hold up to scrutiny either. They follow the expected pattern of small and poorly-designed studies showing equivocal to weakly positive effects, while larger and better-controlled studies show no benefit.
The study that I found to be most commonly touted by chiropractors involved the unblinded use of spinal manipulation on roughly 300 infants diagnosed, using strict criteria, with infant colic. Based on maternal diaries and interviews, 94% of the infants showed significant improvement in crying after an average of 2 weeks of treatment, which persisted until the end of the study (at least 3 months post-treatment). None of this is surprising. It is merely another in a long line of examples of pragmatic pediatric studies that rely on parental placebo to achieve positive results. Add to that the fact that at 6 weeks most infants with colic are at the peak of their crying. Remember it typically starts at 3 weeks and is usually gone by 12 weeks.
Interestingly, some well-known traditional approaches that are still frequently recommended haven’t stood up to randomized study. Going for a drive doesn’t work, for instance. And speaking of things that don’t work…
The chiropractic approach
What causes colic and how do they treat it?
Most coverage of colic in the chiropractic literature or on individual practice websites will state much of what I just covered, although not in such detail and with considerably less accuracy. They keep it simple, speaking more in absolutes. None of the information discussed so far comes from chiropractic researchers of course. As with chiropatter about almost any topic, the first half to two-thirds is comprised of information derived from scientific investigation and the last bit consists of bashing conventional medicine while offering up a chiropractic solution. The most glaring difference is the lack of any discussion of the nuance and complexity of the diagnosis of infant colic.
As you might guess, the primary purpose of any article on colic placed on a chiropractic website is to convince parents to seek out chiropractic care for their children. There are many blatant factual errors and misleading statements employed to do just that.
One website uses the following definition of colic:
Colic is defined as severe, often fluctuating pain in the abdomen caused by intestinal gas or obstruction in the intestines and suffered especially by babies.
This is the textbook medical definition of colic in general, rather than infant colic. While they do share a name, they are not the same. One is a descriptive term for pain localized to the abdomen and one is what I have been writing about. Any healthcare professional desiring to be a primary care practitioner who sees children should be aware of the difference.
There are two extremely common chiromemes evident when researching the chiropractic approach to infant colic. The following quotes are prime examples of the measures taken to paint physicians in a negative light and make chiropractors out to be caring and competent healers:
Chiropractors address the underlying cause of your baby’s colic; they don’t just treat symptoms.
Medical doctors haven’t discovered the cause or solution to this common problem. The medical solution is not promising. Medical recommendations include drug therapy that is not very effective.
Treatment within mainstream medicine often includes drug therapy or simply waiting for your baby to outgrow this condition.
This doesn’t exactly do justice to the science-based approach and it does a disservice to parents. It simply isn’t true. Chiropractors haven’t discovered the cause of infant colic either and clearly have no understanding of it. They pay homage to some of the possible causes of excessive crying in some kids, like milk protein allergy, but they mindlessly recommend many of the treatments discussed above that have been disproven or have no good evidence to support them. They believe that the primary cause of infant colic is the vertebral subluxation and resulting nerve irritation or dysfunction. They see science-based discussion of immaturity of the nervous system as a possible but unproven etiology of colic in some infants and twist it to their advantage:
From a chiropractor’s perspective many of the resulting symptoms of colic may be due to nerve dysfunction, which results in poor communication between the brain and digestive organs.
The one true treatment according to chiropractors is of course the spinal adjustment:
Chiropractic adjustments for the correction of vertebral subluxations (nerve dysfunction) have long been acknowledged as an excellent therapeutic tool for infantile colic. In fact Chiropractic has been shown to have a 94% success rate with Colic.
I have yet to see a rational discussion of the role of psychosocial factors in the diagnosis of infant colic in anything written by a chiropractor. Many websites provide tips on how to soothe a crying infant which are borrowed from conventional medical recommendations. There is also a very good chance that the parent of a child with excessive crying will be offered herbal or homeopathic remedies.
Infant colic is a complicated clinical entity. It has the potential for negatively impacting an infant’s environment, thus indirectly causing harm, but in many cases is likely nothing more than a wastebasket diagnosis. The scientific consensus is that while some infants diagnosed with colic may have an underlying organic condition like an allergy to cow milk protein, or are manifesting symptoms of general immaturity of the brain and/or intestines, most are probably responding to their specific environment in a way that simply does not fit well with their caregiver. There is likely a spectrum of normal infant crying and some just fall on one end of it. And some infants may have what the majority of parents would consider normal crying but their caregivers have an altered perception of the duration and intensity because of psychosocial factors.
Most of the treatments aimed at improving infant colic are not supported in the literature but can appear to work because infant colic is self-limiting and does not last longer than two to three months. The best intervention is parental support and education in the hopes of improving skills to soothe a crying infant, and the development of a contingency plan when those skills fail. Changing parental expectations about infant crying in a positive way and reducing family stress as much as possible is also a vital aspect of management.
In contrast, the chiropractic community displays an overly simplistic understanding of infant colic that makes use of scientific knowledge which fits into its world view while ignoring the rest. Treatment recommendations unique to chiropractic are unsupported by well-designed studies. I believe that using infant colic as a litmus test for the readiness of chiropractors to act as primary care providers for children is a reasonable thought experiment, and one that reveals serious inadequacies in their knowledge base and ability to interpret the medical literature.
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