Question: What is colic caused by?

Baby colic




Baby colic, also known as infantile colic, is defined as episodes of crying for more than three hours a day, for more than three days a week, for three weeks in an otherwise healthy child.[1] Often crying occurs in the evening.[1] It typically does not result in long term problems.[4] The crying can cause frustration for the parents, depression following delivery, excess visits to the doctor, and child abuse.[1]

The cause of colic is unknown.[1] Some believe it is due to gastrointestinal discomfort like intestinal cramping.[5] Diagnosis requires ruling out other possible causes.[1] Concerning findings include a fever, poor activity, or a swollen abdomen.[1] Fewer than 5% of infants with excess crying have an underlying organic disease.[1]

Treatment is generally conservative, with little to no role for either medications or alternative therapies.[3] Extra support for the parents may be useful.[1] Tentative evidence supports certain probiotics for the baby and a low-allergen diet by the mother in those who are breastfed.[1] Hydrolyzed formula may be useful in those who are bottlefed.[1]

Colic affects 10–40% of children.[1] It is most common at six weeks of age and typically goes away by six months of age.[1] It rarely lasts up to one year of age.[6] It occurs at the same rate in boys and in girls.[1] The first detailed medical description of the problem occurred in 1954.[7]
Signs and symptoms
Colic is defined as episodes of crying for more than three hours a day, for more than three days a week for a three-week duration in an otherwise healthy child between the ages of two weeks and four months.[8] By contrast, infants normally cry an average of just over two hours a day, with the duration peaking at six weeks.[9] With colic, periods of crying most commonly happen in the evening and for no obvious reason.[1] Associated symptoms may include legs pulled up to the stomach, a flushed face, clenched hands, and a wrinkled brow.[9] The cry is often high pitched (piercing).[9]
Effect on the family
An infant with colic may affect family stability and be a cause of short-term anxiety or depression in the father and mother.[9] It may also contribute to exhaustion and stress in the parents.[10]
Persistent infant crying has been associated with severe marital discord, postpartum depression, early termination of breastfeeding, frequent visits to doctors, and a quadrupling of excessive laboratory tests and prescription of medication for acid reflux. Babies with colic may be exposed to abuse, especially shaken baby syndrome.[9]
Causes
The cause of colic is generally unknown. Fewer than 5% of infants who cry excessively turn out to have an underlying organic disease, such as constipation, gastroesophageal reflux disease, lactose intolerance, anal fissures, subdural hematomas, or infantile migraine.[9] Babies fed cow's milk have been shown to develop antibody responses to the bovine protein, causing colic.[11][12] Studies performed showed conflicting evidence about the role of cow's milk allergy.[9] While previously believed to be related to gas pains, this does not appear to be the case.[9] Another theory holds that colic is related to hyperperistalsis of the digestive tube (increased level of activity of contraction and relaxation). The evidence that the use of anticholinergic agents improve colic symptoms supports this hypothesis.[9]
Psychological and social factors have been proposed as a cause, but there is no evidence. Studies performed don't support the theory that maternal (or paternal) personality or anxiety causes colic, nor that it is a consequence of a difficult temperament of the baby, but families with colicky children may eventually develop anxiety, fatigue and problems with family functioning as a result.[9] There is some evidence that cigarette smoke may increase the risk.[8] It seems unrelated to breast or bottle feeding with rates similar in both groups.[13] Reflux does not appear to be related to colic.[14]
Diagnosis
Colic is diagnosed after other potential causes of crying are excluded.[9] This can typically be done via a history and physical exam, and in most cases tests such as X-rays or blood tests are not needed.[9] Babies who cry may simply be hungry, uncomfortable, or ill.[15] Less than 10% of babies who would meet the definition of colic based on the amount they cry have an identifiable underlying disease.[16]
Cause for concern include: an elevated temperature, a history of breathing problems or a child who is not appropriately gaining weight.[9]
"Red flag" indicating that further investigations may be needed include:[17]
Vomiting (vomit that is green or yellow, bloody or occurring more than 5/day)
Change in stool (constipation or diarrhea, especially with blood or mucous)
Abnormal temperature (a rectal temperature less than 97.0°F (36.1°C) or over 100.4°F (38.0°C)
Irritability (crying all day with few calm periods in between)
Lethargy (excess sleepiness, lack of smiles or interested gaze, weak sucking lasting over 6 hours)
Poor weight gain (gaining less than  15grams a day)
Problems to consider when the above are present include:[17]
Infections (e.g. ear infection, urine infection, meningitis, appendicitis)
Intestinal pain (e.g. food allergy, acid reflux, constipation, intestinal blockage)
Trouble breathing (e.g. from a cold, excessive dust, congenital nasal blockage, oversized tongue)
Increased brain pressure (e.g., hematoma, hydrocephalus)
Skin pain  (e.g. a loose diaper pin, irritated rash, a hair wrapped around a toe)
Mouth pain  (e.g. yeast infection)
Kidney pain  (e.g. blockage of the urinary system)
Eye pain (e.g. scratched cornea, glaucoma)
Overdose  (e.g. excessive Vitamin D, excessive sodium)
Others (e.g. migraine headache, heart failure, hyperthyroidism)
Persistently fussy babies with poor weight gain, vomiting more than 5 times a day, or other significant feeding problems should be evaluated for other illnesses (e.g. urinary infection, intestinal obstruction, acid reflux).[18]
Treatment
Management of colic is generally conservative and involves the reassurance of parents.[9] Calming measures may be used and include: swaddling with the legs flexed, holding the baby on its side or stomach, swinging the baby side to side or back and forth while supporting the head, making a shushing sound, and breast feeding or the use of a pacifier.[8]  Eye contact, talking, and holding the infant are also reasonable measures,[8] although it is not entirely clear if these actions have any effect beyond placebo.[9][19]
Medication
No medications have been found to be both safe and effective.[8] Simethicone is safe but does not work, while dicyclomine works but is not safe.[9] Evidence does not support the use of cimetropium bromide,[19] and there is little evidence for alternative medications or techniques.[20] While medications to treat reflux are common, there is no evidence that they are useful.[14]
Diet
Dietary changes by infants are generally not needed.[9] In mothers who are breastfeeding, a hypoallergenic diet by the mother—not eating milk and dairy products, eggs, wheat, and nuts—may improve matters,[9][10][21] while elimination of only cow's milk does not seem to produce any improvement.[21] In formula-fed infants, switching to a soy-based or hydrolyzed protein formula may help.[10] Evidence of benefit is greater for hydrolyzed protein formula with the benefit from soy based formula being disputed.[22][23] Both these formulas have greater cost and are not as palatable.[23] Supplementation with fiber has not been shown to have any benefit.[10]
Alternative medicine
No clear beneficial effect from spinal manipulation[24][25] or massage has been shown.[9] Further, as there is no evidence of safety for cervical manipulation for baby colic, it is not advised.[26] There is a case of a three-month-old dying following manipulation of the neck area.[26]
Little clinical evidence supports the efficacy of "gripe water" and caution in use is needed, especially in formulations that include alcohol or sugar.[9] Evidence does not support lactase supplementation.[19] The use of the probiotic Lactobacillus reuteri in babies who are breastfed has tentative evidence of value.[1][27]
Prognosis
Infants who are colicky do just as well as their non colicky peers with respect to temperament at one year of age.[9]
Epidemiology
Colic affects 10–40% of children.[1] occurring at the same rate in boys and in girls.[13]
History
The word "colic" is derived from the ancient Greek word for intestine (sharing the same root as the word "colon").[28]
It has been an age-old practice to drug crying infants. During the second century AD, the Greek physician Galen prescribed opium to calm fussy babies, and during the Middle Ages in Europe, mothers and wet nurses smeared their nipples with opium lotions before each feeding. Alcohol was also commonly given to infants.[29]
In past decades, doctors recommended treating colicky babies with sedative medications (e.g. phenobarbital, Valium, alcohol), analgesics (e.g. opium) or anti-spasm drugs (e.g. scopolamine, Donnatal, dicyclomine), but all of these are no longer recommended because of potential serious side-effects, including death.





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