Colic: Lots of theories, not many answers

About a year ago, I was surprised to read that an elderly elephant at our local zoo had to be euthanized after a prolonged episode of colic. That news was shocking to me because I've taken care of lots of babies with colic, and I don't think of it as a life-threatening diagnosis.

The definition of an infant with colic is one who cries for at least three hours per day, at least three days per week, for at least three weeks. Sound pretty arbitrary? The definition goes back to 1954, when physician Morris Wessel published a paper describing infants who cried excessively. It's a classic study (although our research methodology has improved greatly since it was published), and it's been cited by numerous other papers.

There's really no magic to this definition; it was made up to allow the researchers to dichotomize infants into two groups: “fussy” and “contented.” Do some babies cry more than others? Absolutely. Is it fair to make up a specific cutoff above which an infant has a “problem”? Not really — but it makes designing a study a lot easier.

We have somewhat arbitrary criteria for all kinds of diseases. In most cases, though, they're a little better supported. In Wessel's study, half of the babies whose mothers returned the survey were considered to be fussy. To put this in perspective, we've defined thresholds for unhealthy weights and blood pressures in pediatrics to be in the highest 5 to 15 percent of otherwise similar children. Today, colic is estimated to affect approximately 10 to 50 percent of infants, depending on the study. I can't help but question the wisdom of choosing an arbitrary cutoff that defines up to half the population as abnormal.

One of the most interesting things about our understanding of colic is that it hasn't changed in 60 years. That may not sound like a long time, but in the world of medical advances, it's an eternity. Since 1954, we've developed vaccines for polio, measles, mumps, rubella, hepatitis A and B, HPV and rotavirus. We've learned to transplant kidneys, livers, lungs, hearts and faces. We've eradicated smallpox. We've cloned a sheep. And yet our understanding of this thing we call colic hasn't changed a bit.

There are lots of theories for what causes colic, but the truth is that we just don't know. The name itself comes from the same root word as “colon,” and it implies that the source of the problem lies somewhere within the gut.

This notion probably comes from the fact that many babies with colic will arch their backs, tighten their abdominal muscles and appear as if they are having abdominal pain. Based on the appearance of abdominal discomfort, some theorize that colic is related to reflux, milk protein allergy, lactose intolerance, “gassiness” or other causes inside the belly.

But is it truly abdominal pain, or is this simply an infant's physical reaction to some source of stress, just as you might experience jaw clenching or neck muscle tension? That's tough for us to say.

It's very likely that, in some cases, colic is more related to stress than abdominal pain. I've seen infants who “haven't stopped crying for days,” as their parents report, appear perfectly content when they are seen in the emergency room or admitted to the hospital.

Did their abdominal pain magically disappear at the registration desk? I doubt it. Is it a change in the environment? Are the parents so relieved to have some help that their perception of their baby's distress changes? Does the infant somehow sense a lower level of stress in those around him and mellow out a bit?

Infants living in homes where the environment itself offers some sort of stress are certainly at higher risk. And since colic tends to occur in the first two to three months of an infant's life, the roles of maternal fatigue, postpartum depression and hormonal fluctuations are undeniable.

One of the better explanations I've heard is that colic doesn't have the same cause in every baby. That theory goes a long way to explain our inability to better define the condition. It explains why a certain treatment may seem to work for some babies but not others, and it highlights the problem with creating an arbitrary diagnosis defined by a single symptom.

Here's my definition: “Colic” is a dumpster of a diagnosis into which we toss crying that is felt by parents to be excessive and that we can't otherwise explain. It's a self-limited condition that tends to resolve over a couple of months with no intervention at all. I try to call it “fussiness” or “excessive crying” — terms that differ only semantically but which I feel don't result in as much confusion. Not every symptom needs a diagnosis.

As with any health-related issue, if you have serious concerns, you should call your pediatrician. There is a possibility that severe fussiness could be due to a truly pathologic cause that needs treatment. Once these more-serious causes have been ruled out, there are a few things that might help and a lot that don't. But be aware: Some of them work for only a small subset of infants — quite possibly because they are crying for different reasons.

• Simethicone (Mylicon drops): Probably the most widely used treatment for colic. Does it work? Sort of — but not better than a placebo. There's very little risk of its harming your baby, so if you want to use it, go ahead. And remember, it works better if you believe.

• Gripe water: This includes a variety of concoctions marketed for colic. The story started in 1851 when a dude named William Woodward hijacked the recipe for a malaria treatment and began to market it to mothers and doctors as a remedy for colic. The original formulation contained alcohol (3.6 percent), dill oil, sodium bicarbonate (baking soda), sugar and water. Today, many of the formulations are homeopathic, meaning that they rely on a theory that is fundamentally opposed to science-based medicine and not proven to work better than a placebo. Sorry to disappoint.

• Alcohol: Yep, really. It was one of the original ingredients of gripe water. But aside from the obvious safety concerns with getting your baby tipsy, a study showed that it isn't effective, either.

• Dicyclomine: This is the only medicine with evidence for effectiveness; unfortunately, it has been implicated in more than a few infant deaths. It's not approved for use in infants, and almost certainly not worth the risk.

• Probiotics: These are living microorganisms, including bacteria and yeast, thought to be the “good guys” of the microbe world. Not every probiotic is the same, and studies are done using a specific species at a specific dose that may or may not be the same as what you can purchase over the counter. A couple of small trials have suggested that a specific probiotic (Lactobacillus reuteri) may be effective at reducing colic, at least in breast-fed infants. Run it by your doctor first.

• Dietary changes: In some infants, fussiness may be reduced by dietary changes. For formula-fed infants, this can mean switching to a soy-based or partially hydrolyzed formula. These are typically more expensive and somewhat less tasty than standard infant formulas. For breast-fed babies, this would involve changes in the mother's diet to eliminate certain foods.

• Fennel extract, herbal teas: Unlike homeopathic preparations, herbal supplements can be helpful in certain situations (if what's inside the bottle is the same as what's on the label). Fennel extract and certain herbal teas have shown some potential for reducing excessive fussiness.

• Things that don't work: massage (for the baby — but it may be helpful for moms), reflexology, chiropractic manipulation (which also carries significant risks; please don't do this to your baby).

My bottom line: Colic is a symptom, not a diagnosis. Our approach should be to rule out dangerous conditions, fix the things that we can fix and then admit that we don't know what's going on. Then, emotional support and reassurance are probably the best treatments we can provide. We may not have a clue what colic is, but we do know that it goes away — no matter what you do.

Being a parent is exhausting sometimes. My wife and I had a baby who cried for weeks, but we all made it through alive.

• Hayes is a resident physician in pediatrics in Greenville, S.C.