Colic and Unsettled Infants

It’s 9 o’clock at night and your baby has been crying for the last three hours straight. You have checked out the basics – they’re not hungry, the nappy is clean, and you’ve done what feels like 50,000 squats while holding your baby in your arms but to no avail.

What could be going on?

Is this a case of that dreaded colic that everyone talks about?

Colic. Irritable infant. Unsettled babies. These all try to describe the same thing – an inconsolable baby. And as a father of two and a chiropractor that looks after babies, I can assure you that a lot of other parents have gone through similar experiences. This can be a very challenging period as you start to question what is that you are doing; is there a problem with your milk or formula choice? Is the room too cold? Is the room too hot? Could there actually be a serious problem going on?

Well, let’s break it down first. The definition of colic itself has changed over the past few years – a recent review found that there were over 20 different definitions used across 39 studies,1 but the generally accepted definition is defined using what is called a modified Wessel’s criteria and involves looking at a baby who has had periods of inconsolable crying for a duration of greater than three hours for at least three days.2 However, this has limitations – what if your baby is only crying for 2 hours and 50 minutes? The new definition put forward by the Rome IV criteria states “Infant colic is characterized as recurrent and prolonged periods of crying, fussing, or irritability, without obvious cause and not resolvable or preventable by caregivers, without evidence of failure to thrive, fever, or illness in an infant under 5 months at the onset and resolution of symptoms.”2,3 And you know what – it’s quite common at up to 73% prevalence.4

Now here’s the hard part. That definition states “without obvious cause”. How can we find out what is actually causing your baby’s discomfort? And what if there is no discomfort – what if your baby is just one of these babies that like to cry? This is an aspect that researchers have looked at, and they have found that crying does peak at around 8 to 10 weeks of age before declining significantly by the time they are six months of age. As a result, a lot of this crying behaviour is often just listed as normal physiological crying behaviour or PURPLE crying.5 But that’s a topic for another day.

Before I come to a diagnosis of “physiological normal crying”, I always want to make sure that there is nothing else that could be triggering this response first. As always, rule out the serious.6 Talk to your paediatrician. Talk to your GP. Talk to your child’s health nurse. These are health professionals there to help look after your child. Once the serious has been ruled out, what could be left? Well, let’s think about what a baby does. They eat, sleep, and poop. Well…they do other things as well, but these are the ones that I often find tied in with unsettled presentations.

In regard to their eating, what are we feeding them? Breast milk is a dynamic nutritional source; it can change its constitution depending on what you are eating and your baby’s demands. Unfortunately, that also means what you eat can influence what goes in it. Guess what? There’s a chance that your baby may be sensitive to some of the foods that you may eat and this, in turn, may cause tummy upsets which may present as unsettled behaviour. The same goes for formula – what if there is a substance or component within the formula that your baby is sensitive to as well? Once again, we will see unsettled behaviour coming through. Ingestion of a substance that your baby is sensitive to may lead to inflammation within the gut. Do you know what happens to a gut that becomes inflamed? We find that baby will develop constipation or start to have a hard time passing bowel movements, strain or pass out bits of mucous.

But then what about the sleeping side of things? Surely sleeping doesn’t cause pain or create crying issues? Well no, but we may have issues that can disrupt our ability to sleep and one of these ones is musculoskeletal pain or discomfort. In a study my colleague and I had published, we found that in babies with unsettled behaviour over 90% of them presented with musculoskeletal dysfunctions occurring.7 What if your baby has a musculoskeletal dysfunction occurring? How else are they going to tell you that they are sore aside from crying? This actually fits in with what we see with the “Wonder Weeks”. If you’re familiar with the Wonder Weeks there is a stage that occurs at around six weeks of age. At six weeks, we start to break down one particular hormone called relaxin – this hormone is involved in promoting flexibility when you birth out your baby. Now, if you have a region in your body that is not moving properly, which could happen with something as “easy” as giving birth (lemons vs watermelons, need I say more), you won’t know until that relaxin hormone breaks down. This may make regions start to become sore at five to six weeks of age.

Could your baby’s crying behaviour be due to restrictions in normal motion creating discomfort? There are many studies, albeit at a lower level of evidence, that demonstrate improvements in crying behaviour after manual therapy.8–11 This suggests improvement in musculoskeletal function has calmed down any discomfort they may have been experiencing.

Now, this doesn’t mean that a musculoskeletal dysfunction is the only cause of your baby’s discomfort. Not at all. But it may be an aspect. There are several studies that look at the long-term effects of prolonged crying in infants,6,12,13 and well, I would love to go through this with you now – as well as some more of the reasons behind colicky behaviour – but you will just have to wait until a future blog post to read all about them. In the meantime, if you do have an unsettled baby, please get them assessed. Rule out the serious with your medical professionals, but then consider other aspects: could it be the gut or their musculoskeletal system? In which case, your manual therapist trained in assessing and treating infants and young children, such as physiotherapists, osteopaths and chiropractors, may be of benefit.

I hope you enjoyed this read and, as always, if you have any questions please feel free to contact me for more information or discussion.

If you would like to learn a little more I have created some short videos on YouTube that discuss topics we have touched on including pain, purple crying, and the early stages of the wonder weeks.

Thanks very much,

Christian Fludder
Chiropractor for Children

Why PURPLE crying may be misleading
Could this be why your child is screaming in the car
Why is my baby crying
Why is my baby unsettled at Wonder Week 5?

REFERENCES

1. Steutel NF, Benninga MA, Langendam MW, de Kruijff I, Tabbers MM. Reporting outcome measures in trials of infant colic. J Pediatr Gastroenterol Nutr. 2014;59(3):341-346. doi:10.1097/MPG.0000000000000412
2. Zeevenhooven J, Koppen IJN, Benninga MA. The new Rome IV criteria for functional gastrointestinal disorders in infants and toddlers. Pediatric Gastroenterology, Hepatology and Nutrition. 2017;20(1):1-13. doi:10.5223/pghn.2017.20.1.1
3. Baaleman DF, di Lorenzo C, Benninga MA, Saps M. The Effects of the Rome IV Criteria on Pediatric Gastrointestinal Practice. Current Gastroenterology Reports. 2020;22(5):1-7. doi:10.1007/s11894-020-00760-8
4. Vandenplas Y, Abkari A, Bellaiche M, et al. Prevalence and Health Outcomes of Functional Gastrointestinal Symptoms in Infants From Birth to 12 Months of Age. J Pediatr Gastroenterol Nutr. 2015;61(5):531-537. doi:10.1097/MPG.0000000000000949
5. Groisberg S, Hashmi SS, Girardet R. Evaluation of the Period of PURPLE Crying: An Abusive Head Trauma Prevention Programme. Child Abuse Review. 2020;29(3):291-300. doi:10.1002/car.2625
6. Sung V. Infantile colic. Australian Prescriber. 2018;41(4):105-110. doi:10.18773/AUSTPRESCR.2018.033
7. Fludder CJ, Keil BG. Presentation of Neonates and Infants with Spinal vs Extremity Joint Dysfunction. Chiropractic Journal of Australia. 2018;46:79-91.
8. Ellwood J, Draper-Rodi J, Carnes D. Comparison of common interventions for the treatment of infantile colic: A systematic review of reviews and guidelines. BMJ Open. 2020;10(2):e035405. doi:10.1136/bmjopen-2019-035405
9. Carnes D, Plunkett A, Ellwood J, Miles C. Manual therapy for unsettled, distressed and excessively crying infants: A systematic review and meta-analyses. BMJ Open. 2018;8(1):e019040. doi:10.1136/bmjopen-2017-019040
10. Prevost CP, Gleberzon B, Carleo B, Anderson K, Cark M, Pohlman KA. Manual therapy for the pediatric population: A systematic review. BMC Complementary and Alternative Medicine. 2019;19(1). doi:10.1186/s12906-019-2447-2
11. Castejón-Castejón M, Murcia-González MA, Martínez Gil JL, et al. Effectiveness of craniosacral therapy in the treatment of infantile colic. A randomized controlled trial. Complementary Therapies in Medicine. 2019;47:102164. doi:10.1016/j.ctim.2019.07.023
12. Romanello S, Spiri D, Marcuzzi E, et al. Association between Childhood Migraine and History of Infantile Colic. JAMA Pediatr. 2013;309(15):1607-1612.
13. Halpern R, Coelho R. Excessive crying in infants. Jornal de Pediatria. 2016;92(3):S40-S45. doi:10.1016/j.jped.2016.01.004