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Infantile Colic Care Pathway Overview

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Usually identified by an infant crying loudly over a period of more than three hours a day for more than three days a week over a period of more than three weeks.

  • Crying is usually between 6pm and midnight
  • Infant may draw legs up to abdomen
  • Infant may pass wind
Red Flags
  • Fever (more than 38 degrees C, 100.4 degrees F, rectal) in an infant less than twelve weeks of age.
  • Paradoxical irritability (infant doesn't want to be held).
  • Premature rupture of membranes (more than 24 hours), perinatal maternal fever/infection, neonatal jaundice.
  • Maternal drug use.
  • Poor in level of activity, cyanotic/apneic "spell", or seizure-like episode.
  • Bilious or projectile vomiting.
  • History not suggestive of classical "infant colic syndrome".
  • History suggestive of physical feeding problem or poor weight gain.
  • History suggestive of possible neglect or abuse
  • Antibiotic pre-treatment ("partially treated" sepsis/meningitis), particularly in the young infant.
  • History of recent head trauma.
Differential Diagnosis

  • otitis media
  • meningitis/sepsis
  • encephalitis
  • urinary tract infection
  • osteomyelitis, septic arthritis
  • pneumonia
  • gingivostomatitis / pharyngitis
  • gastroenteritis
  • Kawasaki Disease

  • child abuse - shaken baby
  • corneal abrasion or foreign body in eye
  • accidental fracture/musculoskeletal injury

  • intussusception
  • reflux esophagitis (GERD)
  • constipation/anal fissure
  • midgut volvulus
  • incarcerated inguinal hernia
  • appendicitis
  • milk protein intolerance and allergy
  • testicular torsion
  • penile tourniquet (from hair)

  • underfeeding

  • hypoxemia/hypercapnia

  • hyponatremia, hypernatremia
  • metabolic acidosis
  • hypocalcemia/hypercalcemia, hypoglycemia, hyperglycemia
  • inborn errors of metabolism

  • nappy dermatitis
  • atopic eczema
  • burns (accidental and non-accidental)
  • foreign body (pin)
  • hair encirclement (strangulation of digit, penis, clitoris, uvula) diagnosed by a thorough physical exam
  • bites and stings

  • neonatal narcotic withdrawal
  • neonatal barbiturate, ethanol, hydantoin withdrawal
  • irritability related to smoking mothers who breastfeed
  • reaction to pertussis immunization
  • theophylline, antihistamine, decongestant, cyclic antidepressant, amphetamine, cocaine toxicity
Initial Primary Care Assessment

History and examination should include the:

  • General health of the baby.
  • Antenatal and perinatal history.
  • Onset and length of crying.
  • Nature of the stools and stool pattern
  • Feeding assessment.
  • Mother's diet if breastfeeding.
  • Family history of allergy.
  • Parent's response to the baby's crying.
  • Factors which lessen or worsen the crying.

Colic is usually indicated, if no red flags by crying bouts that start when a baby is about 3 weeks old (usually late in the day, although they can occur anytime), lasting for more than three hours a day, on more than three days a week, for more than three weeks in a row. It typically peaks at 6 to 8 weeks and subsides by 3 to 4 months.

Initial Primary Care Management

The most useful intervention is advice and support for parents/carers and reassurance that their baby is well, they are not doing something wrong, the baby is not rejecting them, and that colic is a common phase that will pass within a few months. If parents/carers aren't coping refer to the health visitor for support.


  • Gentle motion (for example pushing the pram and rocking the crib).
  • 'White noise' (for example from a vacuum cleaner, hairdryer, or running water).
  • Bathing the baby in a warm bath.

If there are times when the crying feels intolerable, it is best to put the baby down somewhere safe (such as their cot) and take a few minutes 'time out'.

  • Resting when possible.
  • Asking family and friends for support.
  • Meeting other parents/carers with babies of the same age.
  • CRY-SIS is a support group for families with excessively crying, sleepless and demanding children. Their helpline is available everyday from 9am-10pm. Tel: 08451 228 669. The CRY-SIS website also contains useful information.

  • Colic in breast fed infants has been linked to ineffective attachment at the breast, therefore observe a full breast feed and correct attachment as appropriate - please see breastfeeding pathway.
  • Observe for changes in sucking in the feeding cycle
  • Ensure baby finishes feeding from one breast first, and then offer the other.
  • Try feeding infant in a semi reclined position.
  • Ensure Mother is aware of responsive feeding as it has been suggested colic is improved by feeding according to infant’s needs.
  • Mother may wish to consider temporarily cutting out foods known to increase colic symptoms, e.g. cow’s milk, dairy and excessive caffeine. Observe for 2 weeks to see any effect.
  • For formula fed infants, feed as upright as possible keeping the teat full of milk, to reduce air swallowing.
  • Changing to hypoallergenic milk or low or lactose free formula milk may be an option  but is not recommended as first line treatment - please see cow's milk protein allergy pathway and lactose intolerance pathway.

Treatment Options

No treatment has been shown to be of substantial benefit; only consider trying medical treatments if parents/carers feel unable to cope despite advice and reassurance. The preparations below are available to purchase over the counter from supermarkets and pharmacies. If there is no response to the trial of treatment stop it.

A one week trial of is worthwhile as it is easily available to purchase and has no adverse side effects.

  • Advise that 20 mg (0.5 mL) should be given to the child before each feed. If necessary, this may be increased to 40 mg (1 mL).
  • In children with hypothyroidism, advise that simeticone may interact with levothyroxine if given concurrently, leading to possible under-treatment of hypothyroidism. To prevent or minimize this interaction, these medications should be taken at least 4 hours apart.

May also ease symptoms for some babies, consider a one week trial (4 drops with feeds either in formula milk or in a few teaspoons of expressed breastmilk).  If successful try weaning off every 4 weeks.

For breastfed infants, advise the parent/carer to:

  • Express a few tablespoons of breast milk into a sterile container.
  • Add four drops of lactase.
  • Give the breast milk and lactase mixture to the baby using a sterilised plastic teaspoon.
  • Then breastfeed as usual.

For bottle-fed infants, advise the parents or carers to:

  • Make up the feed as usual.
  • Add four drops of lactase to the warm feed.
  • Wait 30 minutes, shaking the formula occasionally.
  • Then feed the baby as normal, checking that the feed is at the correct temperature.
  • Discard any unused formula.

If formula is being made in advance, advice the parents or carers to:

  • Make up the feed as usual.
  • Add two drops of lactase to the warm feed.
  • Store the formula in the refrigerator for a minimum of 4 hours before use, and use within 12 hours.
  • Feed the baby as normal, checking that the feed is at the correct temperature.
  • Discard any unused formula.

A full clinical review by GP should be carried out if persistent and associated with:

  • increased regurgitation,
  • diarrhoea,
  • projectile vomiting,
  • marked distress at feeds,
  • faltering growth,
  • parental concern,
  • associated wheeze/respiratory symptoms,
  • eczema/urticaria or
  • a strong family history of other conditions 
When to Refer

If the family requires emotional support or support with feeding, refer them to the health visitor. If you are concerned about the mothers mental health consider 2gether and call the Contact Centre on 0800 0151 499 (9am-5pm, Monday-Friday) for advice. Please also see perinatal mental health pathway.

Advice from a paediatrician is required if there is diagnostic doubt.

Use Paediatric Advice and Guidance in the first instance if there are no urgent concerns.

If there are urgent concerns contact the Consultant Advice Line on 0300 422 5800.

Ongoing Care

Ongoing care and emotional support is provided by the health visitor.

Stop any treatment for colic after the age of 3-4 months (and by 6 months of age at the latest), weaning the child off treatment over the period of about one week.

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