 |
|
Diagnostic Workup Before Diagnosing Colic
Carin E. Reust, MD
Center for Family Medicine Science
University of Missouri
Department of Family and Community Medicine
MA303 Health Sciences Center
Columbia, MO 65212
Robert L. Blake, Jr, MD
Columbia
Arch Fam Med. 2000;9:282-283.
QUESTION
What diagnostic workup is appropriate before making the diagnosis of colic?
ANSWER
SEARCH STRATEGY
A MEDLINE search (1966-present) was performed using the key word "colic," with limits to diagnosis, English language, and age group (newborn infants aged 0-1 month and infants aged 1-23 months). Seventeen articles were identified, of which 3 were specific for diagnosis. Two of these articles involved the diagnostic utility of acoustic analysis of crying, and 1 involved the use of a symptom diary. A similar strategy was used on MEDLINE (1996-present) to review infantile gastroesophageal reflux (GER).
Wessel et al1 and Illingworth2 defined colic in the early 1950s. Illingworth described an infant "who develops violent screaming attacks in the evening . . . his face flushes, his brow furrows, and then he draws his legs up, clenches his fist, and emits piercing, high-pitched screams. . . . Each attack lasts five minutes or more. . . . The attacks occur at regular intervals. . . ." Wessel's "rule of 3," excessive crying for 3 hours per day, 3 days per week, for 3 weeks, is a common definition used in both research and clinical descriptions of colic. Additionally, a motor component of colic is described by Illingworth. In a study of symptoms related to colic, mothers identified passing gas rectally, clenched fists, drawing up legs, crying in the late afternoon and evening, holding the body straight, and wanting to be held as symptoms of colic. Nurses in the same study focused on crying, inconsolability, drawing up legs, and wanting to feed.3 Incidence is variable across studies. In a prospective cohort study of full-term infants, it was estimated that 13% of infants have colic, and another 8% possibly have colic.4 Approximately 20% of infants have excessive crying for which the parents seek medical attention.3
Crying in infants reaches a peak around 6 weeks of age, and declines until about 4 months of age. A normal diurnal variation has been noted, with crying more often in the evening. Colicky infants are noted for their excessive crying by 2 weeks of age, with gradual resolution usually by 3 months. In case-control studies, which used Wessel's rule of 3, colicky infants cried for 241 to 300 minutes per day, whereas normal infants cried for 103 to 112 minutes per day.4-5 These studies also found that normal infants cry more in the evening, with 44% of all crying occurring from 6 PM to midnight when crying was categorized by 6-hour intervals. In the study by Lehtonen and Korvenranta,4 there was no difference between colicky and normal infants in nighttime crying. The study by Hill et al5 found that colicky infants cry more in the evening.
Risk factors for colic have been studied. In a case-control study of 100 infants, Illingworth2 found no association between the mother's age, parity, or pregnancy history and colic. Additionally, colic was not associated with an infant's sex, weight, feeding habits, allergies, weight gain, or whether the infant had diarrhea or vomiting. Subsequent studies have not identified consistent risk factors or clear causes. Colic has been ascribed to several causes, such as immaturity of the gastrointestinal system, inability of the central nervous system to handle the stimulus of the environment, allergies and hypersensitivity, parent-infant interaction mismatch, cultural expectations, and normal variations in behavior. In cross-cultural studies of infants, it has been found that infants cry longer in Western cultures, but at the same frequency as in other cultures.6
To diagnose colic, researchers have looked at the quantity and quality of an infant's crying. Several studies have focused on acoustic patterns in crying infants in an attempt to distinguish normal crying from colicky crying. Colicky infants cry longer with no more intensity than noncolicky infants.7 The nature of the crying does not allow parents or clinicians to distinguish an aroused or distressed infant from a colicky infant.8 A case-control study of 30 infants with and 30 without colic used a diary to record distress.
The criterion standard in this study for determining colic was clinical observation using Wessel's rule of 3. Total distress, defined as fussing or crying (vs sleeping, feeding, or being awake and content) that lasts 180 minutes or more in a 24-hour period, has a sensitivity of 77% specificity of 87%, a positive predictive value of 85%, and a negative predictive value of 79%.5 Predictive values are affected by prevalence, which was 50% in this study. In populations where prevalence is lower, the positive predictive value would be lower and the negative predictive value would be higher.
Anecdotal reports in the literature caution against diagnosing colic and missing a serious underlying medical problem such as anomalous left coronary artery, child abuse, urinary tract infection, esophagitis or GER, or migraine.
DIAGNOSTIC APPROACH
Parents who have an infant who cries excessively or intensely are often concerned about an underlying medical problem. In a study of 56 infants aged 4 days to 24 months, with a median age of 3 months, who presented to an emergency room with unexplained crying, medical history provided clues to the diagnosis in 11 (20%) of the infants, and physical examination was helpful in 30 (54%).9 Infants who continue to cry throughout the initial assessment should be observed further or should be reexamined during normal periods. A infant presenting to the office late in the day may be irritable and inconsolable. The infant's crying behavior should be documented, including time of day, length of episodes, and how often the infant is well. A history and thorough physical examination should be performed. Frequency and quantity of spitting up should be noted, as should episodes of apnea, cyanosis, or struggling to breathe. In observing the infant, decreased muscle tone, lethargy, and poor skin perfusion should be noted. Rectal temperature higher than 38°C, tachypnea, and poor weight gain require further medical workup. Focal signs of infection in the ears, skin, soft tissues, bones, and joints should be sought. Staining of the cornea and eversion of the eyelid should be considered. Abdominal and rectal examinations should be performed when the infant is not crying to determine the presence of abnormal bowel sounds, diffuse tenderness, rigidity, masses, or fecal blood. An abnormal finding on focal neurologic examination, abnormal pupils, bulging fontanel, retinal hemorrhages, or a history of loss of consciousness, vomiting, seizures, or lethargy should prompt evaluation for occult intracranial injury.10
Gastroesophageal reflux is increasingly diagnosed in infants and should be a consideration in the colicky infant. Projectile, nonbilious vomiting is associated with pyloric stenosis, whereas bilious vomiting suggests more distal obstructions from congenital webs or malrotations. Gastroesophageal reflux can be associated with episodes of apnea, bradycardia, and respiratory difficulties. Sandifer syndrome, or abnormal posturing with tilting of the head to one side, has been associated with reflux.11 Orenstein et al12 describe the development of an infant gastroesophageal reflux questionnaire, a 25-item scale that can be completed by parents in about 15 minutes. A cutoff of more than 7 has positive and negative predictive values of 1.00 and 0.98, respectively. Of note, normal infants have a high prevalence of reflux symptoms such as daily regurgitation, arching of the back, crying for more than 1 hour per day, and hiccups. However, infants with GER are more likely to have more than 5 episodes of regurgitation per day (odds ratio [OR], 5.2), to regurgitate more than 28 g (1 oz) per episode (OR, 9.2), to refuse feeding (OR, 8.0), and to have episodes of apnea (OR, 21.5). In this study, normal infants did not have problems gaining weight, whereas 26% of infants with GER did; also, 3% of normal infants cried for more than 3 hours per day compared with 28% of infants with GER (OR, 9.3). Confidence intervals for ORs were not reported. To our knowledge, no studies have compared normal infants, colicky infants, and infants with GER.
BOTTOM LINE
Colic is a common condition in early infancy that causes a great deal of concern. Parents and caregivers should be encouraged to document crying and fussing spells for review by the physician. A period of wellness followed by specific periods of crying is reassuring. Diagnosis is by exclusion. Further workup should be considered in infants who have frequent regurgitation of more than 28 g (1 oz), apneic or cyanotic episodes, fever, respiratory difficulties, poor weight gain, or abnormal findings on neurologic examination. Serial examination of the infant during times of the day when the infant is less fussy may be necessary. Once a diagnosis of colic is made, therapeutic options include dietary changes, drug treatments, and behavioral interventions. A healthy dose of reassurance and support is necessary for the caregivers.
REFERENCES
| |
1. Wessel M, Cobb J, Jackson E, et al. Paroxysmal fussing in infancy, sometimes called "colic." Pediatrics. 1954;14:421-434.
FREE FULL TEXT
2. Illingworth RS. "Three months" colic. Arch Dis Child. 1954;29:165-174.
3. Field PA. A comparison of symptoms used by mothers and nurses to identify an infant with colic. Int J Nurs Stud. 1994;31:201-215.
FULL TEXT
|
ISI
| PUBMED
4. Lehtonen L, Korvenranta H. Infantile colic: seasonal incidence and crying profiles. Arch Pediatr Adolesc Med. 1995;149:533-536.
FREE FULL TEXT
5. Hill DJ, Menahem S, Hudson I, et al. Charting infant distress: an aid to defining colic. J Pediatr. 1992;121:755-758.
FULL TEXT
|
ISI
| PUBMED
6. Lehtonen L, Rautava P. Infantile colic: natural history and treatment. Curr Probl Pediatr. 1996;26:79-85.
FULL TEXT
| PUBMED
7. St James-Roberts I, Conroy S, Wilsher K. Bases for maternal perceptions of infant crying and colic behaviour. Arch Dis Child. 1996;75:375-384.
FREE FULL TEXT
8. St James-Roberts I. What is distinct about infants' "colic" cries? Arch Dis Child. 1999;80:56-62.
FREE FULL TEXT
9. Poole S. The infant with acute, unexplained excessive crying. Pediatrics. 1991;88:450-455.
FREE FULL TEXT
10. Greenes DS, Schutzman SA. Occult intracranial injury in infants. Ann Emerg Med. 1998;32:680-686.
FULL TEXT
|
ISI
| PUBMED
11. Hillemeier AC. Gastroesophageal reflux: diagnostic and therapeutic approaches. Pediatr Clin North Am. 1996;43:197-212.
FULL TEXT
|
ISI
| PUBMED
12. Orenstein SR, Shalaby TM, Cohn JF. Reflux symptoms in 100 normal infants: diagnostic validity of the infant gastroesophageal reflux questionnaire. Clin Pediatr (Phila). 1996;35:607-614.
FREE FULL TEXT
SECTION EDITOR: M. LEE CHAMBLISS, MD, MSPH
|
