MANAGEMENT
Overview — Management of the otherwise well infant with prolonged or excessive crying is individualized based upon the history, examination, and family characteristics. Some caregivers and families tolerate crying better than others.
Interventions are targeted to decrease crying and bolster the infant-family relationship. The goals of management are to help the caregivers cope with the child’s symptoms and to prevent long-term sequelae in the caregiver-child relationship.
Caregiver support is the mainstay of management. First-line interventions consist of addressing feeding problems and suggesting techniques to soothe the infant and/or decrease environmental stimuli. Caregivers can be encouraged to experiment with these interventions to see which, if any, work. Although the evidence supporting first-line interventions is limited, they are inexpensive, unlikely to be harmful, and may be helpful for caregivers who find it hard to have nothing to do while awaiting spontaneous remission (which confirms the diagnosis).
Several interventions for colic have been evaluated in randomized trials; however, most of the trials had methodologic weaknesses (eg, small sample size, inadequate blinding). The lack of strong supporting evidence for any one strategy, combined with the number of proposed etiologies, may lead practitioners to recommend a variety of interventions, alone or in combination. Each of the soothing techniques may work in some infants or in a given infant, some of the time, but none of the interventions work all of the time.
Caregiver support and education — Caregiver support is the mainstay of the management of colic. It may influence the way the caregivers view their ability to care for their child.
Important aspects of caregiver education and support include:
- Education that colic is common and usually resolves spontaneously by three to four months of age.
- Reassurance that the infant is not sick. This may require frequent follow-up (either by phone or in person).
- Education that colic it is not caused by something that they are doing or not doing. It does not mean that the infant is rejecting them.
- Acknowledging that the infant is difficult to soothe and that you know that they are doing the best that they can. This is essential in preventing the caregivers from feeling as if they have failed.
- Providing tips for techniques to soothe the baby.
- Encouraging the caregivers to take breaks from the crying infant (eg, taking turns with the infant during the colicky period, asking a relative or friend to babysit so that they can have a break, placing the crying infant in their crib) and to have a “rescue” plan (a prearranged plan in which a relative or friend can step in if the caregivers feel overwhelmed).
- Acknowledging that feelings of frustration, anger, exhaustion, guilt, and helplessness are normal.
Clinical studies of caregiver support/counseling for infantile colic usually find caregiver support/counseling beneficial, but the evidence is limited.
Home-based nursing intervention or contact with other caregivers who have or had infants with colic also may be beneficial.
First-line interventions — As first-line interventions for colic, we suggest changes to the feeding technique and/or experimenting with a number of techniques to soothe the infant. These interventions address some of the potential etiologies of colic (eg, swallowed air, overstimulation). We generally initiate changes to feeding and soothing techniques at the same time, explaining the theories of the etiology of colic that they are meant to address.
Feeding technique — Feeding changes may be helpful for infants whose colic is associated with feeding problems (eg, underfeeding, overfeeding, inadequate burping). Bottle-feeding the baby in a vertical position (using a curved bottle) in combination with frequent burping may reduce swallowed air. Using a bottle with a collapsible bag also may help reduce air swallowing. Changes to breastfeeding technique also may be warranted. However, the management of breastfeeding problems should be individualized. Consultation with a lactation specialist may be warranted.
Soothing techniques — We suggest that caregivers experiment with one or more of the following techniques for soothing the infant and/or decreasing sensory stimulation. They should be instructed to continue those that are helpful and discontinue those that are not. The soothing techniques can be tried in any order and/or combination. Caregivers can be instructed to try a technique for several minutes and if it does not work, move on to another soothing technique. The success or failure of individual soothing techniques may vary from one episode of colic to the next. We suggest that families experiment with soothing techniques for several days to weeks before moving on to other interventions.
- Using a pacifier.
- Taking the infant for a ride in the car or a walk in the stroller/buggy.
- Holding the infant or placing them in a front carrier.
- Rocking the infant.
- Changing the scenery (or minimizing visual stimuli).
- Placing the child in an infant swing.
- Providing a warm bath.
- Rubbing the infant’s abdomen.
- Hip healthy swaddling(ie, with room for hip flexion, knee flexion, and free movement of the legs
- Playing an audiotape of heartbeats.
- Providing “white noise” (eg, vacuum cleaner, clothes drier, dishwasher, commercial white noise generator, etc). Commercial white noise generators (sometimes called infant sleep machines) can produce sound pressure levels greater than the recommended noise threshold for infants in hospital nurseries. To minimize potential adverse effects on hearing or auditory development, white noise generators should be placed as far away from the infant as possible, played at a low volume, and used only for short periods of time.
These interventions are suggested by experts. They have not been proven effective in randomized trials but are inexpensive, unlikely to be harmful, involve the caregivers, and may help to reduce caregiver or infant anxiety. In a large observational study, holding, walking, and rocking were found to be effective in calming breastfed infants (with or without colic) younger than 16 weeks.
Unproven interventions — A number of other interventions for infantile colic have been evaluated in randomized trials with methodologic weaknesses or inconsistent results. Given these limitations, we generally do not suggest these interventions for infantile colic. However, they may be suggested for some patients on a case-by-case basis after a discussion of the potential risks and benefits if first-line interventions have been unsuccessful after several days to weeks. Providing a several week trial of first-line interventions allows time for colic to run its natural course and may avoid unnecessary, costly, or potentially harmful remedies.
Dietary changes — A time-limited trial of dietary interventions may be warranted for infants who do not respond to first-line interventions, particularly if milk protein allergy is suspected. Dietary changes vary depending upon whether the infant is formula-fed or breastfed.