SECTION 3. MANAGEMENT OF CLINICAL PROBLEMS AND EMOTIONAL CARE Colic and Crying Syndromes in Infants

Colic or excessive crying is one of the most frequent problems presented to pediatricians by new parents. Organic disease accounts for <5% of infants presenting with colic syndrome. Colic may be best viewed as a clinical manifestation of normal emotional development, in which an infant has diminished capacity to regulate crying duration. Pediatrics 1998;102:1282–1286; colic, crying syndromes, excessive crying, regulators of crying, reactivity, regulation, transient responsivity, sucrose. Of all infant behavior, crying is perhaps the one most familiar to clinicians. Colic, or excessive crying, is one of the most frequent complaints brought to physicians in the infant’s first 3 months.1 It is associated with maternal anxiety and emotional lability;2 it often causes premature weaning because mothers think that crying is attributable to insufficient milk3,4; it can be the presenting complaint of almost any disease in infants; and it rarely, but too often, triggers abuse or even death in infants.5 There are four clinical “crying” syndromes in the first year of life: • colic • persistent mother–infant distress syndrome • the temperamentally “difficult” infant • the dysregulated infant These four syndromes are challenging to clinicians for at least two reasons. They are all difficult to define, manage, and treat. There also is surprisingly little guidance in the literature about how they may be related to each other. For researchers studying emotional development, crying also is a central behavior. However, it must be clearly understood that there is a difference between infant emotions (or emotionality) and crying behavior. That is to say we are concerned with the overt, observable behavior of crying rather than with the inferred negative emotion for which crying may be the overt expression. To help bridge the gap between infant emotional research and clinical practice, I propose the following. In general, the crying syndromes most clinicians deal with are best understood as clinical manifestations of normal emotional development rather than of organic pathophysiologic processes. Better understanding of these syndromes will come from both clinical and child development researchers. Clinical research can provide careful, systematic, and controlled descriptions of the clinical syndromes; normative child development research can provide empiric support for the reasons why babies cry. The following article presents these themes with available evidence from clinical, developmental, cross-cultural, and experimental studies regarding the syndrome of colic. Although this may not complete the job of making the transition from the probable knowledge of groups of infants to the complete and certain knowledge of individual infants in the clinical context, it may at least allow us to take the first steps across the bridge. CLINICAL CRYING SYNDROMES Colic is defined by excessive crying. Although there are many hypotheses, there is no established etiology (or set of etiologies) for this syndrome.5 It is usually characterized by the following features. • Timing—It typically begins at approximately 2 weeks of age and resolves by 4 months. Within the day, crying is concentrated in the late afternoon and evening hours. • Associated behaviors—The bouts of crying are prolonged and unsoothable, even by feeding. The infant usually is described as having clenched fists, legs flexed over its abdomen, arching back, flushing, a hard distended abdomen, regurgitation, passing of gas, and an active, grimacing, or “pain” face. • Paroxysmal crying—The word paroxysmal usually describes unpredictability or apparent spontaneity of the crying bouts, unrelated to events in the environment, including soothing attempts by the parents. Persistent mother–infant distress syndrome refers to a clinical situation in which infants present after the early crying peak at 2 months and show no decrement in the amount of crying.6–8 The infants and families typically have a number of additional at-risk characteristics. The infants often have disturbances in feeding and/or sleeping, mild developmental delay, and organic risk factors. The parents may have significant psychosocial risk factors, prenatal emotional distress, maternal psychopathology, and postnatal parental conflicts. Although the exact Received for publication Aug 2, 1998; accepted Sep 29, 1998. Address correspondence to John G. Warhol, PhD, The Warhol Institute, 225 First Ave, Atlantic Highlands, NJ 07716. PEDIATRICS (ISSN 0031 4005). Copyright © 1998 by the American Acad-