Written by Barry M. Lester, World Association for Infant Mental Health - Signal Newsletter, July-December 2006
“So what is Colic?” and “How many different cries does a baby have?” are the two questions I am most frequently asked. What parents really want to know is: What causes colic, and how is colic defined and diagnosed. How can I make it go away? Underlying all the questions is the biggie: Is it my fault? The answers are more complicated than you might think.
We still don’t know what causes colic. There is no simple cure, no magic bullet, to make the baby stop crying. And despite many heroic attempts by pediatricians and researchers to downplay the condition, the suffering of colicky babies and their parents goes on daily. Colic makes professionals feel incompetent because they can’t treat something that upsets families so much.
Despite what many well-meaning pediatricians tell their patients, colic is not a harmless condition. Our research–as well as plenty of others’– has shown that these babies are more likely to have difficult temperaments and to experience feeding and sleeping problems. Their cries and their heart rates are different. How the family functions can be impaired. Their parents perceive them as more vulnerable. They can go on to have behavior issues in preschool and problems later on in school with attention/hyperactivity, sensory integration, and emotional reactivity.
"You don’t have to know what causes colic to be able to recognize, define, or diagnose it."
You don’t have to know what causes colic to be able to recognize, define, or diagnose it. There is a traditional definition of colic called the Rule of Three that is probably the one pediatricians use most. Developed in 1954 by pediatrician Morris Wessel, it was based on the patients that he was seeing in his practice in New Haven, Connecticut. I don’t like it much, but in all fairness, it has been around for a long time. Here it is: The Rule of Three says that colic exists when an otherwise normal, healthy baby cries for at least 3 hours a day for at least 3 days a week and has been doing this for at least 3 weeks.
One problem with this definition is that it equates colic with excessive crying, and it explains why the literature often uses phrases such as “colic or excessive crying.” Normally developing babies increase the amount they cry over the first 6 weeks. About 20 percent of babies cry for 3 hours a day or more–and that has been fairly well established. Babies who cry 3 hours a day may not have colic but may simply be normal babies with difficult temperaments.
There may indeed be babies who cry excessively because of colic–but there is more to colic than excessive crying. For many colicky babies there is a distinct colic episode. The baby has normal periods of crying during the day, but when he reaches a colicky phase, there is something different going on. Mothers say all the time: “This is not his normal crying, this is colic.”...
Many babies with colic have additional symptoms that occur especially during this distinct colic episode. At the Colic Clinic, we group these symptoms into four areas...
The main source for the symptoms, behaviors, and characteristics on the checklist come from the parents I’ve seen at the clinic and from countless interviews, magazine articles, and desperate calls and e-mails to friends and family. The second source was the scientific literature. What I learned from the research studies was that not all babies show all characteristics and not all babies show the same characteristics. But most show some. The four characteristics are sudden onset, cry quality, physical signs, and inconsolability.
Let’s take a closer look at the four characteristics: Sudden onset means that the colic episode seems to come out of the blue. One mother described it by saying, “It’s as if my baby is possessed.” Another term for this is paroxysmal onset, which suggests the sudden and episodic quality that sets it apart form regular crying. It is as if the baby is separated or insulated from the outside world. The episode takes on a life of its own. You get the feeling that this is something that is going to have to run its course. While you may be able to dampen it or ease it somewhat, you can’t really stop it. What you have to do is ride it out and make the baby–and yourself–as comfortable as possible.
The second characteristic is the cry quality. The cry changes–not in the same way for all babies, but for most babies there is a qualitative change in the cry during an episode. For many babies, the cry takes on the characteristics of pain cry. Mothers say that their babies sound as if they’re in pain.
What mothers mean by this, and what acoustic analysis confirms, is that the cry comes on suddenly and reaches its peak intensity very quickly. We hear that intensity as loudness, a higher pitch, and more noise. In fact, some mothers say it is more like a scream than a cry. One mother said, “He is screaming at the top of his lungs.”...
So what happens when your baby is screaming out of control? You want to help her. She is saying, “Mommy, Daddy, make it stop!” But you can’t. And that can make you feel helpless and inadequate as a parent.
The third attribute, physical signs, is actually a group of characteristics that describe changes in the baby’s body during a colic episode. The baby pulls his legs up into his chest. He gets doubled over, which is why mothers often say his stomach hurts and he looks and sounds as if he is in pain. His stomach gets hard and his leg and arm muscles get tight. (The technical term for this is hypertonia, which means increased tone, or tension, in the muscles.) His face gets red; there may be episodes of breath-holding. His fists clench–sometimes squeezed so tight that you can’t open them. It is almost as if the baby is holding on for dear life. The color in the wrists and fingers can get red or white. Sometimes the arms and legs stiffen and stick out straight.
The fourth characteristic is inconsolability. It may sound silly after all this to say that a baby in a colic episode is inconsolable. But the reason we included it is to underline what I said before: You really can’t stop this. You may be able to ease it somewhat, reduce some of the crying, perhaps reduce some of the intensity, and make the baby more comfortable. But you won’t really be able to stop it. Inconsolability happens when a baby is in an insulated cry state. This means there’s a wall between him and you so that you can’t really reach him the way you can when his cry state is normal. You need to know, though, that this thing is going to run its course. If you accept that, it will be easier and less frustrating for you–and for the baby.
You can see that by equating colic with excessive crying we run the risk of calling colic “normal” and missing a lot of other cry characteristics that colicky babies have. If it’s just about excessive crying, it’s easy to conclude that there’s nothing wrong with colicky babies. Babies can be excessive criers but be in a normal, not insulated, cry state. These babies do not show any of the true colic characteristics...
When does crying become a clinical concern? When is it a true syndrome? When is it colic? It has to do with how much the baby is crying, along with the additional symptoms–special episodes with sudden onset, changes in the cry, physical signs, and outright inconsolability. But there is still one critical ingredient missing, and it’s this: The crying has resulted in some problem either in the infant or in the family. In other words, colic is not just the crying. It’s the fact that the crying has caused a problem...
The way I define colic means thinking about it as a behavioral disorder. So if we regard colic as a behavior disorder, infants with excessive crying that causes clinically significant distress in the family or impairment in the infant would be said to have colic. On the other hand, a baby with excessive crying that causes no significant distress in the family or impairment in the infant would not be said to have colic.
Two criteria need to be met in order to diagnose colic: First, there is a significant complaint of a persistent pattern of crying that is more frequent and more severe than is typical for babies at this age. This can be a disturbance in the amount, frequency, or quality of crying. There may be excessive crying (Rule of Three) as well as symptoms such as sudden onset, high pitch, physical signs, and inconsolability. Second, there is clear evidence of impairment in other areas of function. This could mean that the behavior is affecting the baby’s development or other behaviors, the two most common being sleeping or feeding. Or the behavior could be causing stress in the parents, affecting family function and the marital relationship. It could be affecting the parent-infant relationship. There may be attachment or bonding problems. The parents may feel inadequate, suffer loss of self-esteem, and feel ineffective as parents. They may feel angry and disappointed that their baby is acting this way...
Colic is not just in the eye of the beholder. It is not just a mother having a problem with normal crying. Colic is an identifiable cry problem in the infant that is causing some impairment either in the infant or in relationships in the family. Something in the baby is causing a problem for the baby or outside the baby. That’s it. End of diagnosis. Beginning of treatment.
1. Excerpted with permission from:
Lester, B. M. & O’Neill G., C. (2005).
Why is my baby crying? New York, NY: HarperCollins Publishers.
About the Author
Barry earned his doctoral degree with me in 1973. Two years prior to that he packed up and went off to Guatemala to work at the Institute for Nutrition for Central America and Panama, and of course, I just had to go there to observe his research lab and his dissertation work on habituation to auditory signals in very young infants. His interest in infant crying had its origins in this work and it launched what has become an extraordinary career in infancy, developmental psychology, psychophysiology, and developmental and behavioral pediatrics. Barry is Director of the Infant Development Center at Women and Infants’ Hospital in Providence, Rhode Island, and is Professor of Psychiatry and Human Behavior and Professor of Pediatrics at Brown Medical School. We have published 9 books together over the years and I am delighted that he agreed to provide this very appropriate response to Lisa’s essay. HEF