Coping with Colic and Purple Crying: Tips and Strategies for Parents
Colic is the term used to describe excessive crying in infants for no apparent reason during the first three months of life. Starting in the second week of life and peaking at around 6 weeks, it's a challenging problem that can be distressing for both the baby and their parents. While the cause of colic is not clear, most infants will outgrow it by three to four months of age.
Definition:
There is no standard definition for the term "colic”but for practical purposes, we can define it as excessive crying for no apparent reason that lasts for greater than 3 hours per day and occurs more than 3 days per week in an otherwise healthy infant under the age of 3 months[1]. Other terms that may be used interchangeably with colic include “Infantile colic” and "period of PURPLE crying”.
Causes of colic:
Despite extensive research, the cause of colic remains unclear, with multiple theories proposed. Is colic an extreme form of normal infant crying, or does it stem from underlying gastrointestinal, neurological, or psychosocial issues?
Initially, the word “colic”referred to pain in the area of the colon. "Colic" stems from the Greek "kolikos”, meaning belonging to the colon [2]. Thus, identifying a baby as “colicky” meant you believed the baby was in pain, most likely because of an ailment of the gastro-intestinal tract.
Researchers failed to find evidence that colicky babies are crying due to gastrointestinal causes such as: Gastro-oesophageal reflux, Cow’s milk protein allergy, lactose intolerance, gastrointestinal immaturity, Intestinal hypermotility. Some studies found that infants with colic may have differences in their gut normal flora (bacteria living in babies’ intestine) [3,4].
Evidence for a neurological basis for colic is limited, with some studies suggesting it is caused by immature motor regulation of the gut, serotonin levels (It is hypothesized that in the evening, peak serotonin concentration causes intestinal cramps associated with colic because serotonin increases intestinal smooth muscle contractions), and some studies have even suggested that colic may represent a nearly form of migraine [5].
Psychosocial factors such as infant temperament, mother–infant interactions, father-infant interactions, maternal anxiety and depression may also be associated to colic [6, 7].
Clinical features:
- Occurs suddenly without an apparent reason regardless of whether the infant was previously content, irritable, feeding, or sleeping.
- The cry of colic is qualitatively different from normal crying. It is louder, high-pitched and may sound as if the infant is in pain or is screaming rather than crying.
- Infants with colic can be difficult to console, no matter what the parents do.
- Episodes may be associated with a red face, tense or distended abdomen, drawing up of the legs, clenching of the fists, stiffening and tightening of the arms, or arching of the back.
- Can occur any time during the day but is often worse in the afternoons and in the evenings.
It would be remiss of me to discuss baby colic without acknowledging the contribution of Dr. Ronald Barr, a developmental paediatrician, who coined the term "The period of PURPLE crying" [8].
This term has helped parents understand that excessive crying in their baby is a normal part of development and not a medical condition that requires medication. The use of the term "colic" and administering medication can wrongly suggest that something is wrong with the baby. The PURPLE acronym describes the typical characteristics of this phase, which usually starts around two weeks of age and can last until the baby is three or four months old.
The word period means that the crying has a beginning and an end and the letters in PURPLE stand for the common characteristics of the period of PURPLE crying. Here's what they mean:
P - Peak of crying: During this period, your baby may cry more each week, peaking at around two months of age, and then gradually decreasing.
U - Unexpected: Your baby's crying may come and go unexpectedly, without any apparent reason.
R - Resists soothing: Despite your best efforts to soothe your baby, they may continue to cry.
P - Pain-like face: Your baby's face may look like they are in pain, even if they are not.
L - Long-lasting: Your baby may cry for extended periods of time, lasting 5 hours or more per day.
E - Evening: Your baby's crying may be worse in the late afternoons and evenings.
Other Potential Causes of excessive Infant Crying:
Babies cry a lot in their first 3 months especially when they are hungry, tired, gassy or when they have a dirty nappy.
On average, babies cry for almost 2 hours a day, and some babies cry for even longer than that [9].
If you feel that you can’t comfort your baby, you should seek medical advice to make sure there is nothing else going on.
Other causes to consider:
- Gastro-oesophageal reflux disease: usually associated with vomiting during or after feeds, irritability after feeds, back arching, poor weight gain.
- Lactose intolerance or overload: usually associated with a watery, frothy and explosive diarrhoea.
- Allergy to cows’ milk protein or soy that can be found in breast milk or formula: can be associated with feeding difficulties, skin rash, blood in the stool, vomiting, diarrhoea, and poor weight gain.
- Inguinal hernia – lump in the groin that can be associated with crying and vomiting.
- Nappy rash
- Intussusception- form of bowel obstruction in which one segment of the intestine telescopes inside of another. Associated with severe episodes of pain, vomiting and occasional blood in the stool.
- Constipation/Anal fissure: associated with crying while passing hard stool with or without blood.
- Heart dysrhythmia or other congenital heart disease: associated with multiple other symptoms such as poor feeding, vomiting, poor skin perfusion, in an unwell baby.
- Infection such as a urinary tract infection, meningitis, ear infection: can be associated with fever, irritability or lethargy, poor feeding, vomiting.
- “Hair tourniquet Syndrome”- occurs when the caregiver’s hair is twisted around the fingers, toes or genitals of the baby, causing severe pain, irritability as well as redness and swelling of the area involved.
- Increased intracranial pressure - associated with vomiting, large head and irritability or lethargy.
- Foreign body or scratch in the eye- associated with crying and a watery red eye after a possible eye injury.
Management of colic:
Although colic is not a disease that needs treatment, some interventions have shown to relieve the symptoms in some babies.
The first step is to check whether your baby is hungry, tired or uncomfortable. You might be able to respond to your baby’s crying by:
- Feeding your baby.
- Putting your baby down for a sleep.
- Changing your baby’s nappy.
If these measures don’t seem to work, you could try:
Soothing strategies:
You can use the 5 S’s: swaddling, side or stomach position, shushing, swinging, and sucking.
- Gently rock or carry your baby in a baby carrier or sling.
- Swaddle your baby using a blanket or a “hip healthy” swaddle such as “Love to Dream” or “Ergo Pouch”.
- Rock or pat your baby in their cot.
- Take the baby for a ride in a stroller or in a car. Babies love being on the move.
- Give your baby a warm bath.
- Baby massage: Rub your baby's tummy or place your baby on the tummy for a back rub.
- Offer your baby a dummy or the breast.
- Sing or talk to your baby, play calming music or relaxing “white noise”.
- Dim the lights in the room and limit other visual stimulation.
Feeding practices:
- Try burping your baby more often during feedings.
- If your baby is formula fed, try other bottles or teats to see if they help your baby swallow less air.
- Changes to breastfeeding technique may help, so seeing a lactation consultant may be beneficial.
You can access valuable information on feeding your baby, including informative videos, by following the link provided below:
https://raisingchildren.net.au/babies/breastfeeding-bottle-feeding-solids
Diet changes:
Breast fed infants: While the evidence regarding the benefits of dietary changes for colic is limited [10], some nursing mothers have reported symptom improvement by eliminating milk, soy, eggs, nuts, or wheat from their diet. Although a few studies have shown a positive effect [11, 12, 13], it's important to note that these studies have some limitations in their design, and dietary changes are not routinely recommended for colic. However, in cases where there is a suspicion of a food allergy or intolerance, a maternal elimination diet may be considered a reasonable option.
Breastfeeding moms may find that avoiding gassy foods, including broccoli, onions, garlic, brussels sprouts, cauliflower, and cabbage, as well as spicy foods, caffeinated beverages, and chocolate, can also alleviate colic symptoms.
An Australian study in 2018, suggested that a maternal low-FODMAP diet, used for the treatment of irritable bowel syndrome (IBS), which restricts consumption of certain foods, could improve colic symptoms in infants. However, the study had a small sample size of only 13 mothers, and further research is needed to confirm these findings [14].
While eliminating one food at a time can sometimes be a useful strategy, it can also be very stressful for mothers and potentially lead to dietary deficiencies and decreased milk supply. Therefore, it is important to approach any dietary modifications with caution and consult a healthcare professional to ensure that adequate nutrition and milk supply are maintained.
Formula fed infants: In general, switching from one formula to another is not effective in relieving colic symptoms in babies and may even exacerbate the problem. Although some parents have reported improvement in symptoms when using partially hydrolysed formulas marketed as "colic formulas", there is limited scientific evidence to support this claim.
For colicky babies, there is no strong evidence to support the use of soy formula or lactose-free formula.
If an infant on formula is suspected to have a cow's milk allergy or intolerance, a trial of an extensively hydrolysed formula may be helpful [10, 11, 12]. Infants with these conditions typically present with clinical features such as failure to gain weight, vomiting, rashes, or blood in the stool.
Parent self-care
Caring for a baby who has colic can be exhausting, stressful and overwhelming, even for experienced parents. Here are some strategies that can help you take care of yourself and get the support you need:
- Take a break. Remember to take care of yourself and don't hesitate to ask for help from your partner, family, or friends. You deserve some time off to recharge and give yourself an opportunity to get out of the house if possible.
- Use the crib for short breaks. It's OK to put your baby in the crib for a while during a crying episode if you're feeling overwhelmed and need to step back and centre yourself.
- Express your feelings. It's normal for parents in this situation to feel helpless, depressed, guilty or angry. Share your feelings with family members, friends, child and family health nurse, GP or your paediatrician.
- Don't judge yourself. Remember, colic is a normal part of many babies' early months, and it's not caused by anything you've done. When your baby is crying uncontrollably, it's not a reflection of your care or a rejection of you as a parent.
- Take care of your health. As a parent, it's natural to put your baby's needs first, but taking care of yourself is just as important. Make sure you're eating a healthy diet, getting some exercise each day, and resting whenever you can. It's also essential to avoid alcohol and other drugs to keep yourself healthy and focused on your baby's care.
- Remember that it's temporary. Dealing with colic can feel like it's never going to end but remember that it's a temporary phase. Most babies outgrow colic by age 3 to 4 months. So, try to take it one day at a time and remember that things will get easier.
- Have a rescue plan. It's always helpful to have a plan in place for when you're feeling overwhelmed. You can make a plan with a friend or relative to step in when you need some support. If necessary, you can also reach out to your child and family health nurse, GP or your paediatrician.
*Never shake your baby. This can lead to “Shaken Baby Syndrome” and cause permanent damage to their developing brain.
Medications, supplements and herbs
There are many medications, over-the-counter products, supplements, and herbs that can be used to treat infant colic. However, it is challenging to determine which of these treatments are effective due to small sample sizes, conflicts of interest, or other study limitations. While some parents may believe certain treatments work, it is difficult to determine whether the medication truly improved colic symptoms or if the condition simply resolved on its own over time. As a result, there is insufficient evidence to support the use of most of these medications. Below, we have provided a list of available therapies along with their corresponding level of supporting evidence:
Probiotics: Lactobacillus reuteri DSM17938 (Nestle, NAN CARE probiotic drops) was shown to be effective in many small studies in exclusively breastfed infants with colic. There was insufficient evidence to make conclusions for formula-fed infants with colic (15, 16-18).
The largest Meta-analysis demonstrated that Lactobacillus reuteri DSM17938 is effective and can be recommended for breastfed infants with colic. Its role in formula-fed infants with colic needs further research [19].
Anticholinergic drugs, such as Dicyclomine and Cimetropium might reduce crying in colicky babies [11,12], but have potentially dangerous side effects, including drowsiness, breathing difficulty and coma. They are not recommended for infants younger than six months old.
Proton pump inhibitors such as Omeprazole (Losec) are ineffective in relieving colic symptoms. The data from a systematic review of randomized controlled trials do not support the use of proton pump inhibitors to decrease infant crying and irritability (15, 20-21, 33). They should be trialled only when reflux is the suspected cause of your baby’s symptoms.
Acupuncture: The role of acupuncture in the treatment of infantile colic is controversial. Available trials are small and present conflicting results. Some studies indicate that acupuncture induces pain in many of the children. A recent review has shown that acupuncture should not be recommended for treatment of infantile colic on a general basis as there is limited evidence that it works [22].
Lactase is the enzyme that helps to digest lactose, the sugar found in milk. The Lactase supplement is used for the treatment of Lactose Intolerance. The benefits of lactase for colic remain unproven. Randomized trials of lactase treatment for infantile colic have conflicting results [23, 24-25].
Simethicone (Infacol): In theory, colic may be caused by small gas bubbles trapped in the baby's tummy, leading to discomfort. Simethicone’s active ingredient works by helping the small, trapped gas (air) bubbles join into bigger bubbles, which your baby can easily expel as wind. However, most studies and systematic reviews have found little evidence to support its use in the treatment of infantile colic [11, 12, 15, 26, 27, 28, 29].
Herbal preparations: Although a few trials suggest that specific herbal remedies (such as chamomile, lemon balm, fennel seed) may be beneficial in reducing crying in colicky babies [24, 28, 30, 31-32], the benefits are largely unproven [29]. Given the lack of standardization and regulation of herbal products, the potential benefits should be weighed against the potential risks (eg, contamination with bacteria, toxins, and unlabelled ingredients).
Some of the common Australian herbal preparations are:
Gripe water (Hartley's Natural Gripe Water, Corams Baby Gripe Water): contains different concentration of some of the following ingredients depending on the brand: fennel & ginger extracts, dill seed oil, cinnamon bark oil, peppermint oil, coriander oil, Caraway Oil, Cardamom oil, sodium bicarbonate and other ingredients. They are presumed to ease the griping pains associated with abdominal discomfort in babies.
Infants’ Friend: containing chamomile, lemon balm and dill seed oil.
Brauer baby & child colic: containing dill seed oil and chamomile.
Willby's Wind and Colic: containing sodium citrate, dill oil and belladonna tincture (when used correctly in appropriate doses set bypharmacists, belladona tincture may be effective and safe).
Homeopathic preparations have not been proven to be effective. Homeopathic remedies often are considered non toxic because of the low concentrations of active ingredients. However, the labels of homeopathic products may not report all the ingredients, some of which may be harmful.
My experience:
Based on my experience as both a parent and a paediatrician, and taking into account feedback from hundreds of parents, there are a variety of remedies that may be useful in managing colic symptoms in your baby.
- NAN-CARE probiotic drops (Lactobacillus Reuteri) are especially beneficial for exclusively breastfed infants.
- Infants’ Friend.
- Gripe water.
- Willby's Wind and Colic (To ensure safety, it is essential to consult with a pharmacist and adhere to the recommended dosage).
Colic Myths and Facts
- Babies do not cry to manipulate you.
- It is not possible to spoil a baby by holding or comforting them.
- Breast milk is best - you should not stop breast feeding because of colic.
- Rice cereal does not improve colic. Infants should be given only breast milk or formula until they are four to six months old.
When should you see a medical provider urgently?
- Your baby has a temperature greater than 38 degrees.
- If crying could be the result of an injury or fall.
- Your baby refuses to feed for more than a few hours, vomits excessively, is not urinating well, has bloody stools, lethargic or decreased responsiveness.
- You are afraid that you or another caretaker may hurt the baby, or if someone has shaken the baby.
When should you speak to a medical provider?
- You cannot soothe your baby's crying, or you have questions or concerns about how to manage your crying baby.
- Excessive crying continues after your baby is older than four months.
- Your baby fails to gain weight.
Summary:
Infantile colic can be challenging for both babies, parents and medical providers. While there's no one-size-fits-all solution to alleviate colic and crying, there are strategies that can help manage symptoms and provide comfort for your baby, as well as over-the-counter remedies that may also be effective. As a parent, it is important to take care of yourself too, and seek support when needed. If you are worried about your baby, you should seek help from a medical provider.
Remember, this phase will eventually pass, and with patience and understanding, you and your baby will get through it together.
Bibliography:
https://www.nps.org.au/australian-prescriber/articles/infantile-colic
https://www.uptodate.com/contents/infantile-colic-management-and-outcome
https://www.rch.org.au/kidsinfo/fact_sheets/Crying_and_unsettled_babies/
https://www.mayoclinic.org/diseases-conditions/colic/diagnosis-treatment/drc-20371081
1)https://www.uptodate.com/contents/infantile-colic-clinical-features-and-diagnosis
2) https://www.etymonline.com/word/colic
7) Hiscock H, Jordan B. 1. Problem crying in infancy. Med JAust. 2004 Nov 1;181(9):507-12.
8) http://www.purplecrying.info/
Written by Dr Samuel Heitner