Crying is a way that babies communicate with the environment. By crying, babies try to express that they are hungry, sweaty, cold or soiled, that they want to be held, that they are uncomfortable in the environment or that they are sick. Crying stops soon after the baby’s needs are met. Some babies cry longer in type and duration and do not calm down easily.
Infantile colic is seen between 1-4 months in well-developed healthy babies. It is defined as crying spells that are difficult to calm down without an underlying organic cause. This causes concern for those who care for the mother or child. *Wessel, on the other hand, defined infantile colic as the rule of thirds that begins in the third week of life, lasts for at least three hours, and then goes away spontaneously for more than three weeks.
1. The most important finding of infantile colic is excessively loud crying that starts especially in the afternoon and evening. The baby appears uncomfortable, distressed and fussy during crying attacks. He usually flexes the hip joints and brings his knees closer to his stomach, and his face turns red.
In the diagnosis of infantile colic, it is very important for the doctor to evaluate the patient with a detailed history and physical examination. When findings suggestive of organic disease are detected, possible causes should be examined in detail (Table 1).
Digestive system and non-gastrointestinal causes should be kept in mind in the differential diagnosis (Table 2). The diagnosis of infantile colic should be avoided if there are signs of bloody mucus defecation, decreased sucking, presence of blood and bile in the vomit, high fever, skin rashes, and growth retardation in the history.
2. Dyschesia is defined as straining, screaming, crying and flushing for 10-20 minutes before defecation. Painful defecation of infancy begins in the first months of life and resolves spontaneously after 3-4 weeks. It is seen in babies who do not have any other health problems.
3. In case of a temporary decrease in lactase enzyme activity, the diagnosis is confirmed by removing lactose from the diet and improving the symptoms. Stool pH<5, reducing agent positivity indicates carbohydrate absorption disorder. The sugar excreted in the stool is determined by stool sugar chromatography. While lactose is detected in the stool in primary and secondary lactase enzyme deficiency, glucose and galactose are detected in the presence of glucose and galactose malabsorption.
4.Physiological GER; It is a condition seen in most newborn babies. It is observed in a healthy-appearing baby. It is necessary to be careful about overfeeding. It heals without complications in about 6 months without treatment. The family should be told that the event is physiological.
5. GERD; It manifests itself with regurgitation, apnea, stridor, restlessness, irritability and vomiting in the neonatal period. As a result of interruptions in feeding, growth retardation, anemia, and hypoproteinemia develop. **Sandifer syndrome is a clinical condition that manifests itself as opistonic posture, retrocollis and involuntary head movements seen in severe reflux. In case of unresponsiveness to the medical treatment given in GERD in 2-4 weeks, the patient should be consulted with the pediatric gastroenterology department for further investigations.
6.CMPA is considered in the presence of frequent regurgitation, feeding refusal, feeding difficulty swallowing, reactive airway disease, atopic dermatitis, eczema, constipation, diarrhea with bloody mucus, and a family history of atopy. Fecal microscopy, fecal calprotectin, IgE and cow’s milk specific IgE should be checked. In the presence of these findings, foods containing cow’s milk are excluded from the mother’s diet in the infant who receives AS. On the other hand, infants who do not receive AS are fed with HF or AAF for 2-4 weeks. If the baby’s clinical findings do not improve, pediatric gastroenterology consultation should be requested.
7. Fissures in the perianal region should be considered in the differential diagnosis of infantile colic. Fissures can be found in any quadrant since the anus and rectum are aligned during infancy. On the other hand, in older children and adults, the fissures are in the posterior region because the sacrococcygeal slope develops. In inflammatory or infectious events, the fissures are located laterally (3-9 o’clock) and are more than one.
8. Urinary tract infection manifests itself in the neonatal period with symptoms of decreased sucking, feeding difficulties, and restlessness. Diagnosis can be made with a complete urinalysis and urine culture. In case of recurrent urinary tract infection, urinary system ultrasonography may be useful to detect urinary system anomalies. In addition, the patient should be consulted with the pediatric nephrology department for further investigations.
9..In a baby who cries uneasily, fingers and toes should be checked for possible hair-thread tourniquet syndrome. If not noticed, it can cause gangrene in the fingers.
In the differential diagnosis of infantile colic, the following physical examination findings should be considered.
Ear-nose examination should be done for the newborn baby. The appearance of the eardrum should be evaluated. Middle ear infection and serous otitis should be diagnosed without delay.
In babies with a history of difficult delivery, breech presentation and macrosomic baby delivery, palpation of swelling on the bone on the fractured side and delayed stages of the unilateral Moro reflex should be a warning for clavicle fracture. PAAC radiograph, including the clavicles, is helpful for diagnosis.
The baby should be suspected of being in an extremely hot environment, with restless, excessive sweating, increased body temperature and redness on his body, and the baby should be comforted.
West syndrome should be considered in a microcephalic infant when sudden startle during falling asleep, head bends over the abdomen and arms are opened. The patient should be consulted with pediatric neurology.
In infants with feeding difficulties, tachypnea, dyspnea, wheezing, restlessness, cold sweats, and low weight gain, pediatric cardiology consultation should be requested in terms of possible cardiological problems.
10. Volvulus should be considered in a newborn infant with biliary vomiting, rectal bleeding, and abdominal distension. While intestinal gases are seen in the left part of the abdomen in ABKG, their decrease in the lower part of the abdomen is a finding in favor of volvulus. Pediatric surgical consultation should be requested. Congenital diaphragmatic hernias, duodenal atresia, intestinal atresia, biliary atresia, Meckel’s diverticulum, ***Hischsprung’s disease, anorectal malformations, congenital heart anomalies, esophageal atresia, ****Prune Belly syndrome, situs inversus and megacystis microcolon syndrome in cases with malrotation It should be kept in mind that they can coexist.
11. Child abuse should be considered in the presence of ecchymoses, lesions that occurred at different times, signs of smoking, hot water burns, rupture of the liver, spleen, and subdural hematoma in the examination.
The diagnosis of infantile colic is made according to the ROMA IV criteria, which were revised in 2016 (Table 3).
The diagnosis of colic is supported if the baby shuts up with rhythmic shaking or squeezing slowly 1-3 times per second in an environment without stimulants and starts to cry again when released.
TABLE 1. Alarm findings in infantile colic
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warning symptoms
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Warning signs
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TABLE 2. Differential diagnosis of infantile colic
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Stylish
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Rare
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TABLE3. Diagnostic criteria for infantile colic (ROMA IV)
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It should contain all of the following.
3. No signs of growth retardation, fever or disease in the baby
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*Wessel MA: American pediatrician.
**Sandifer P: American pediatrician.
***Hischsprung H: Danish doctor.
****Prune Belly syndrome: A syndrome seen with partial or complete absence of abdominal wall muscles, bilateral cryptorchidism and urinary system anomaly.
*****West WJ: British doctor.
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THINGS TO REMEMBER History and physical examination are important. If there are abnormal physical examination findings mentioned above, the diagnosis of infantile colic should be avoided.
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resources
- Benninga MA; Nurko S, Faure C et al. Childhood functional gastrointestinal disorders: Neonate/Toddler. Gastroenterology 2016;150:1443-1455
- Ertekin V. Infantile colic-Review. Pediatric Sciences, 2006;8 (1):69-74
- Beşer ÖF, Çokuğraş FÇ, Dalgıç B et al. Diagnosis and treatment of functional digestive system diseases. Digestion Guide, Istanbul 2017
ABBREVIATIONS
AS: Breast milk
GER: Gastroesophageal reflux
GERD: Gastroesophageal reflux disease
GIS: Gastrointestinal system
SPA: Cow’s milk protein allergy
eHF: Elemental hydrolyzed formula milk
AAF: Formula milk based on amino acids
PAAC X-ray: Posterior-anterior chest X-ray
ADKG: Standing direct abdominal X-ray
