o3104i2023, 22-47 Infante coi: Clinical features and diagnasis - UpTeDate UpToDate’ Reimpressio ofa! do uptopate® www.uptodate.com © 2023 UpToDate, Inc. e/ou suas afiliadas. Todos os direitos reservados. 9. Wolters Kluwer Colica infantil: caracteristicas clinicas e diagnostico ‘Autores: Teri Lee Turner, MD, MPH, MEd, Shea Palamountain, MD Editor de se¢ao: Marilyn Augustyn, MD Editor Adjunto: Diane Blake, MD Todos os tépicos sao atualizados & medida que novas evidéncias se tornam disponiveis e nosso proceso de reviséo por pares é concluido. o da literatura atual até: marco de 2023. | Ultima atualizagdo deste tépi : 08 de marco de 2023. INTRODUGAO O choro persistente ou excessivo (célica) é um dos problemas mais angustiantes da infancia. E angustiante para o bebé, para os pais e para o clinico [ 1 ]. Os pais podem ver o choro como evidéncia de doenga ou como uma acusagao de sua capacidade de cuidar [ 2]. A célica 6 uma condico autolimitada benigna que se resolve com o tempo. No entanto, as crengas da familia sobre a causa do choro e suas interagdes com o sistema de sade relacionadas ao choro podem afetar a maneira como eles veem a crianga e o sistema de satide muito tempo depois de o choro ter sido resolvido. As caracteristicas clinicas, etiologia e diagnéstico de choro prolongado ou excessivo em lactentes sao revistos aqui. A gestao é discutida separadamente. (Consulte "Célica infantil: manejo e resultados" .) DEFINIGOES Padrdes normais de choro - Todos os bebés, tenham ou néo célicas, choram mais durante 0s trés primeiros meses de vida do que em qualquer outro momento. A duragao média do choro durante os trés primeiros meses de vida varia de 68 a 133 minutos por dia. Em uma metanidlise de 28 estudos de diérios documentando a duracao da agitacao e do choro em 8.690 bebés, a duracao média do choro foi de 117 a 133 minutos por dia durante as primeiras seis semanas de vida e diminuiu para 68 minutos por dia em 10 a 12 semanas. semanas, mas variou amplamente de bebé para bebé [3 ]. tps :slwwuptodate.comicontentsinfantile-coliccinicaHfeatures-and-dlagnosis/print?search=Cdlicas no recém nascidoSsource=search_result... 1/31osiain023, 22.47 Infantile cole: Clinical features and diagnosis - UpToDate Poucas pessoas concordam sobre o quanto o choro é considerado excessivo. Na meta- andlise de 28 estudos descritos acima, a duracao aproximada do percentil 95 %° choro diario. variou de [3]: * 225 a 250 minutos durante as primeiras seis semanas de vida * 210 minutos em 8 a 9 semanas * 145 minutos em 10 a 12 semanas Definicdes baseadas na duracéo podem nao ser titeis clinicamente porque o choro “normal” e "anormal" depende do contexto e da qualidade do choro [4]. Além disso, aderir a uma definicao estrita ndo € Util para as familias cuja crianga nao atinge o limiar de choro anormal. Célica - Nao existe uma defini¢ao padrao para o termo "célica". Para propésitos clinicos, nés 0 definimos amplamente como choro sem motivo aparente que dura 23 horas por dia e ocorre em 23 dias por semana em um bebé saudavel <3 meses de idade. A defini¢do ampla considera a variedade de experiéncias dos pais, limites de preocupaco e perspectivas que, em Ultima andlise, moldam o relacionamento entre os pais e a crianga. (Consulte "Célica infantil: manejo e resultados", seco sobre ‘Resultados’ .) Outros termos que podem ser usados de forma intercambidvel com célica incluem "comportamento de choro", "choro excessivo", "comportamento infantil instdvel" e "periodo de choro ROXO" [5,6]. Definigées mais rigidas para célica, frequentemente usadas em pesquisas clinicas, podem incluir critérios de duragao minima (por exemplo, uma semana, trés semanas, etc.) ou caracteristicas clinicas associadas. Como exemplos: * Os critérios de Wessel especificam que os episédios de choro devem durar 23 horas por dia, ocorrer em 23 dias por semana e persistir por 23 semanas ("regra dos trés") [7 ]. Os critérios de Wessel também exigem que a crianca seja "saudavel e bem alimentada". O critério de persisténcia por trés semanas foi descartado pela maioria dos autores porque poucos pais ou médicos conseguem esperar trés semanas antes da avaliacdo ou intervencao [ 8 ]. * Os critérios de Roma IV, que classificam a célica infantil como um distirbio gastrointestinal funcional em bebés desde o nascimento até os cinco meses de idade, exigem todos 0s itens a seguir: 1) idade <5 meses quando os sintomas comecam e param; 2) perfodos recorrentes e prolongados de choro, agitaco ou irritabilidade que comecam e param sem causa ébvia e ndo podem ser evitados ou resolvidos pelos cuidadores; 3) nenhuma evidéncia de baixo ganho de peso, febre ou doenca; 4) 0 cuidador relata choro/agitacao por 23 horas por dia em 23 dias/semana em uma entrevista por telefone ou face a face; e 5) 0 choro diario total é confirmado como 23 hitpsslwwuptodate.comicontentsinfantil-coiccinicaHfeatures-and-dlagnosis/print?search=Cdlicas no recém nascidoSsource=search_result... 2/31osiain023, 22.47 Infantile cole: Clinical features and diagnosis - UpToDate horas quando medido por pelo menos um didrio de 24 horas mantido prospectivamente [ 9]. * Outra definicao exige que os episédios de choro atendam aos critérios de Wessel (incluindo persisténcia por 23 semanas) e pelo menos trés dos seguintes: paroxistico; qualitativamente diferente do choro normal (por exemplo, mais alto, agudo e mais varivel no tom, mais disfénico); associado a caracteristicas de hipertonia; inconsolabilidade [ 10 ]. (Consulte 'Caracteristicas clinicas' abaixo.) EPIDEMIOLOGIA As estimativas da prevaléncia de célica em lactentes variam de 8 a 40 por cento[7,11-16].A ampla variedade se deve a diferengas nos critérios diagnésticos, desenho do estudo, populagdes e percepgdes familiares de choro "excessivo e prolongado" [11,17 ]. Em uma revisdo sistematica e meta-andlise de 28 estudos de didrios parentais, incluindo 8.690 bebés, Célica (definida como choro/agitagao por 23 horas por dia em 23 dias em qualquer semana) foi documentada em 17 a 25 por cento dos bebés de idade < 6 semanas, 11 por cento das criancas de 8 a 9 semanas e 0,6 por cento das criancas de 10 a 12 semanas [3]. Aincidéncia de célica nao parece diferir entre homens e mulheres, bebés alimentados com leite materno e férmula, bebés nascidos a termo e prematuros, ou primogénitos e filhos subseqiientes [ 18-20]. Parece ser mais comum em patses industrializados, bebés brancos e em reas mais distantes do equador [ 19,21 ]. Associacées entre célica e insatisfagao no relacionamento conjugal, percepcao de estresse dos pais, falta de autoconfianca dos pais durante a gravidez, insatisfacdo com o parto e niveis de estresse familiar tém sido relatadas [ 7,22 ] . A relagdo causal entre célica e estresse familiar é dificil de determinar porque ambos os fatores afetam a percepcao dos pais ea resposta ao choro. Existe uma interaco complexa entre a célica e a dindmica familiar, que também sao afetadas por fatores pré e pés-natais. Em um estudo de caso-controle, as familias com bebés com célica tiveram mais problemas na estrutura familiar, funcionamento e estado afetivo durante o periodo de célica e um ano depois do que as familias de controle [ 23]. No entanto, é dificil determinar uma relacao causal entre a dinamica familiar porque ambos os fatores afetam a percepcao e a resposta dos pais ao choro. ETIOLOGIAS PROPOSTAS A etiologia da célica é desconhecida. Provavelmente representa um caminho final comum para numerosos fatores contribuintes [ 19 J. As etiologias propostas devem levar em conta a hitpsslwwuptodate.comicontentsinfantil-coliccinicaHfeatures-and-dlagnosis/print?search=Célicas no recém nascidoSsource=search_result... 9/31o3104i2023, 22-47 Infante coi: Clinical features and diagnosis - UpToDate idade de inicio, a variabilidade individual, a tendéncia do choro ocorrer mais comumente a noite e a resolucao espontanea [ 24 ]. Etiologias gastrointestinais, biolégicas e psicossociais tém sido propostas. Gastrointestinal — A célica é comumente considerada um disturbio gastrointestinal; a palavra "célica" deriva do grego "kolikos", 0 adjetivo de "kolon" [ 25]. Fatores gastrointestinais que sdo propostos para contribuir para a célica inclue! * Técnicas de alimentagao defeituosas - Subalimentaco, superalimentacao, arrotos pouco frequentes e engolir ar foram descritos como possiveis etiologias de célica. * Intolerancia a proteina do leite de vaca - Um subgrupo de bebés com célica pode apresentar sintomas causados, pelo menos em parte, pela intolerancia & proteina do leite de vaca. Revisdes sistematicas de pequenos estudos randomizados com limitagdes metodolégicas (por exemplo, cegamento inadequado) sugerem que formulas hidrolisadas ou uma dieta hipoalergénica para maes que amamentam podem reduzir 0 desconforto em bebés com célicas [ 26-29 }. (Consulte "Manifestacdes clinicas da alergia alimentar: uma visdo geral" e "Proctocolite alérgica induzida por proteina alimentar na infancia" .) * Intolerancia & lactose ~ Nao est claro se a intolerancia a lactose desempenha um papel na célica infantil. Estudos randomizados de tratamento com lactase para célica infantil tam resultados conflitantes [ 30-33 ]. + Imaturidade gastrointestinal - é incerto se a célica esta relacionada a imaturidade gastrointestinal e 4 absorcao incompleta de carboidratos no intestino delgado. Esta hipdtese propde que a fermentagao do carboidrato nao absorvido pelas bactérias colénicas produz gas excessivo, No entanto, estudos que medem a excrecao respiratéria de hidrogénio em lactentes com e sem célica apresentam resultados inconsistentes [ 34-36 ]. * Intestinal hypermotility - Evidence supporting an association between intestinal hypermotility due to autonomic imbalance is contradictory [37-39]. In observational studies, motilin concentrations are increased in infants with colic, but vasoactive intestinal peptide and gastrin concentrations are not [40-42]. Motilin stimulates gastric emptying and intestinal peristalsis, reducing transit time in the small intestine. * Alterations in fecal microflora - Alterations in fecal microflora may play a role in infantile colic. Several observational studies have demonstrated differences in intestinal microflora between infants with colic and control infants, particularly Klebsiella species, anaerobic gram-negative bacteria, coliform bacteria, Escherichia coli, and Lactobacillus species (L. brevis and L. lactis) [43-47]. Observational studies have also noted an hitpsslwwuptodate.comicontentsinfantile-coiccinicaHfeatures-and-dlagnosis/print?search=Célicas no recém nascidoSsource=search_result... 4/31osiain023, 22.47 Infantile cole: Clinical features and diagnosis - UpToDate association between colic and gut inflammation (as indicated by increased fecal calprotectin) and altered gut microbiota [43,47]. Others have noted decreased fecal calprotectin levels as colicky symptoms improved over time [48] or in response to Lactobacillus reuteri therapy [49]. The role of fecal microflora is supported by randomized trials in infants with colic in which treatment with L. reuteri reduced crying time and was associated with changes in gut microbiota (eg, increased fecal Lactobacilli, decreased fecal E. coli) [50-54]. (See "Infantile colic: Management and outcome”, section on 'Probiotics’.) Other proposed etiologies * Biologic — Biologic factors that are proposed to contribute to colic include: + Tobacco smoke and nicotine exposure - Maternal smoking during pregnancy or in the postpartum period has been associated with an increased risk of infantile colic in several cohort studies [55-57]. In the largest study, the prevalence of colic (using Wessel criteria) was 9.4 percent among infants of smokers versus 7.3 percent -1,4) [57]. Prenatal exposure to nicotine replacement therapy also was associated with an increased risk among infants of nonsmokers (adjusted odds ratio 1.3, 95% CI 1. of infantile colic. + Immature motor regulation - Many of the mechanisms that regulate motor activity are immature in infants. The immaturity of these mechanisms may result in increased vulnerability to feeding intolerance [58,59]. Thus, colic may be a common clinical manifestation in the subpopulation of infants who have maturational dysfunction in one or more of the aspects of motility regulation [58] + Increased serotonin - The hypothesis that infantile colic is related to increased serotonin is supported by an observational study, in which random urinary concentrations of 5-hydroxy-3-indole acetic acid (a serotonin metabolite) were greater in infants with colic than in control infants [60]. + Early form of migraine - Infantile colic may be an early manifestation of childhood migraine. In a prospective cohort, migraine without aura was more common in adolescents with infantile colic than in those without infantile colic (multivariate risk ratio 2.7, 95% CI 1.5-4.7); colic was not associated with an increased risk of migraine with aura [61]. These findings confirm those of retrospective studies [62-66], although it is not clear whether infantile colic is an early manifestation of childhood migraine or a marker of migraine genetics (67]. * Psychosocial — Colic is a psychosocial phenomenon. It is the caretaker's perception of what is excessive and prolonged and the caretaker's response to crying episodes that hitpsslwwuptodate.comicontentsinfantil-coiccinicaHfeatures-and-dlagnosis/print?search=Cdlicas no recém nascidoSsource=search_result... 5/31osiain023, 22.47 Infantile cole: Clinical features and diagnosis - UpToDate define whether the crying is seen as a problem, Psychosocial theories of colic focus on temperament, overstimulation, and parental variables. + Temperament - Healthy behavior and development are believed to be predicted on the "goodness of fit" between the child's environment and their innate characteristics [68-71]. Evidence supporting this theory is limited. The most direct evidence comes from therapeutic trials aimed at modifying parental behavior [72- 74]. In one controlled clinical trial, when parents of colicky infants were counseled regarding effective responses to crying, the crying decreased from 2.6 to 0.8 hours per day [73]. In another, parental counseling was more effective than dietary changes (crying decreased from 3.2 to 1.1 hours per day in the counseling group and from 3.2 to 2 hours per day in the dietary change group) [74]. + Hypersensitivity - Another proposed hypothesis is that crying at the end of the day represents discharge after a long day of exposure to environmental stimuli and is a means of maintaining homeostasis [75]. + Parental variables - Various parental psychosocial factors, including family stress, maternal anxiety, and transmission of tension from the mother to the infant, have been proposed to be associated with colic [7,76,77]. Associations between maternal anxiety disorder, maternal history of emotional tension or depression early in the pregnancy, and paternal depressive symptoms during pregnancy are supported by prospective studies [77-80]. CLINICAL FEATURES There are differences of opinion regarding whether what is called "colic" is the upper end of the normal range of crying or a discrete disorder with unique clinical features [81,82] We use the following clinical features to distinguish colic from normal crying [10]: * Paroxysms - The cry/fuss behavior of colic generally is paroxysmal [10,83]. Colicky episodes typically have a clear beginning and end. The onset seems to be unrelated to what the infant was doing just before the "attack." The infant may have been happy, fussy, feeding, or even sleeping. These spells of crying occur suddenly and often cluster during the evening hours. * Qualitative differences - The cry of colic is qualitatively different from normal crying. Itis louder, higher and more variable in pitch, and more turbulent and dysphonic than noncolicky crying [83-85]. Colicky crying may sound as if the infant is in pain or is screaming rather than crying [83]. The mothers of colicky infants describe their infant's hitpsslwwuptodate.comicontentsinfantil-coliccinica-features-and-dlagnosis/print?search=Célicas no recém nascidoSsource=search_result... 6/31osiain023, 22.47 Infantile cole: Clinical features and diagnosis - UpToDate cries as more urgent, piercing, grating, arousing, aversive, distressing, discomforting, and irritating than do the mothers of noncolicky infants [2,85,86]. * Hypertonia — Episodes of colic may be associated with physical characteristics associated with hypertonia [83]. These include facial flushing, circumoral pallor, tense or distended abdomen, drawing up of the legs, clenching of the fingers, stiffening and tightening of the arms, or arching of the back. * Difficulty consoling - Infants with colic can be difficult to console, no matter what the parents do. There may be periods when the crying diminishes, but the infant remains fussy [83]. Relief may be noted after the passage of flatus or feces. Most of the characteristics of crying in infants with colic also occur in normal infants but with less frequency and shorter duration. The early peak and evening clustering, as an example, have been described in widely disparate societies and in normal preterm infants at two months corrected age. EVALUATION FOR IDENTIFIABLE CAUSES OF CRYING The evaluation typically includes a history and examination for identifiable causes of crying/fussiness. Laboratory or imaging studies generally are not necessary. The thoroughness of the history and examination is reassuring to parents and may strengthen the clinician-family relationship [87] Goals — Colic typically is suspected based on the history but confirmed in retrospect after it has run its characteristic course. In the meantime, colic must be differentiated from other conditions that can cause prolonged crying or irritability in infants and may require specific treatment ( table 1). This distinction usually can be made with history and physical examination. (See ‘History’ below and ‘Examination’ below.) Characteristic features of colic include paroxysms of crying that start and stop without obvious cause and normal growth, development, and examination. Thus, it is particularly important to consider other conditions in infants with poor weight gain, abnormal development, or abnormalities on physical examination. Virtually any illness/condition can present with crying [19,20,88]. When to schedule — It can be helpful to schedule the evaluation during the time of day that the infant is fussy (if possible, given that colic often occurs in the evening) [87]. This allows the clinician to observe the crying behavior, the parents' soothing techniques, and the infant's ability to be soothed tps slwwuptodate.comicontentsinfantile-coliccinica-features-and-dlagnosis/print?search=Célicas no recém nascidoSsource=search_result... 7/3103/04/2028, 22:47 Infantie coi: Cinical features and diagnasis - UpTeD: History — The history may provide clues to the etiology of infant's fussiness, It must assess identifiable causes of crying( table 1), as well as psychosocial factors that may be contributing to it. (See ‘Other proposed etiologies’ above.) Important aspects of the history in a child with colic include [5,26]: * The infant's feeding, stooling, urination, and sleeping patterns, including vomiting (helpful in evaluating the possibility of gastrointestinal, cardiovascular, and metabolic conditions)( table 1) + Bloody stool may indicate cow's milk or soy-induced colitis, anal fissure, intussusception (see "Milk allergy: Clinical features and diagnosis", section on ‘Clinical features' and "Food protein-induced allergic proctocolitis of infancy", section on ‘Clinical presentation’ and "Lower gastrointestinal bleeding in children: Causes and diagnostic approach’, section on ‘Infants and toddlers’) * Bilious or projectile vomiting may indicate gastrointestinal obstruction (eg, pyloric stenosis, volvulus) (see "Infantile hypertrophic pyloric stenosis, section on ‘Clinical manifestations' and "Intestinal malrotation in children", section on ‘Clinical presentation’) * Prenatal and perinatal history, including risk factors for sepsis (eg, premature rupture of membranes, maternal fever, maternal colonization with group B Streptococcus) (see “Clinical features, evaluation, and diagnosis of sepsis in term and late preterm neonates", section on ‘Maternal risk factors') * Psychosocial history, including assessment of parent-infant interactions, and the perceptions and interactions of extended family members (eg, grandparents), which may play a role in parenting style and techniques for soothing (see ‘Other proposed etiologies’ above) * Specific questions about the crying or fussiness, including [19]: + When does the crying occur? = Colicky crying typically occurs during the evening. Crying that occurs directly after feeding may be associated with air swallowing or gastroesophageal reflux and may respond to changes in feeding technique (eg, upright positioning, smaller volumes, etc). (See ‘Gastrointestinal’ above and “Infantile colic: Management and outcome’, section on ‘Feeding technique’.) + How long does the crying last? - Duration of crying may help to differentiate normal infant crying from colic. (See ‘Definitions’ above.) + What do you do when the baby cries? - The response to this question may provide information about soothing techniques that are helpful, not helpful, may exacerbate itp tanupiodato.com/conentsntntle-cole-clnicaeatures-and-iagnsisiprntssarch-Calcas no recbm nasido8soUrce-sea sult. 813121042029, 2247 Infantile cole: Clinical features and diagnosis - UpToDate crying, or may be harmful (eg, shaking). (See "Infantile colic, Management and outcome’, section on ‘Soothing techniques'.) + What does the cry sound like to you? - Parents usually can differentiate different types of crying (eg, hunger, pain). The response to this question may indicate how the parents feel about the crying (eg, empathetic, distressed, angry, helpless). Colicky crying is more often described as "screaming," “piercing,” "distressing," or “irritating” than noncolicky crying [2,85,86]. (See ‘Clinical features’ above.) + How and what do you feed the baby? - Underfeeding, overfeeding, and inappropriate feeding are proposed etiologies of colic and may respond to changes in feeding techniques. (See ‘Gastrointestinal’ above and "Infantile colic: Management and outcome", section on ‘Feeding technique'.) + How do you feel when your baby cries? - Responses may range from feeling inadequate as a parent, to feeling responsible for the crying, to fear of harming the infant if the crying continues. (See ‘Potential sequelae’ below.) + How has the colic affected your family? What is your theory of why the baby cries? - Understanding what the family fears about the crying is helpful in formulating a management plan, particularly with respect to parental support. (See "Infantile colic: Management and outcome", section on 'Caregiver support and education’.) Examination — Important aspects of the examination of the infant with colic include [5]: * Observation of the infant and parent interaction during a bout of crying (provides information about the infant's ability to be soothed and the parents’ soothing techniques; allows the clinician to see what the parents are going through) [87,89] * Assessment of temperament (eg, sensitivity, irritability, soothability, intensity, adaptability [89,90]) and responsiveness to stimuli (ie, does the infant cry in response to touch or movement?) * Plotting of growth parameters to look for deviations from the normal patterns (which generally preclude a diagnosis of colic); poor weight gain may indicate inadequate nutritional intake, absorption, or utilization; increased losses; or increased requirements (table 2) (see "Normal growth patterns in infants and prepubertal children", section on ‘Normal patterns’ and "Poor weight gain in children younger than two years in resource-abundant countries: Etiology and evaluation", section on ‘Growth trajectory and proportionality’) * Assessment for identifiable causes of prolonged crying in infants (__ table 1), including: + Assessment of hydration and subcutaneous fat (to evaluate adequacy of feeding) tp tannupiodato.com/conentsnfantle-cole-clnicaleatures-and-iagnsisiprntsearch-Caleas no recém nascido8soureersearch rest... 9/9403/04/2028, 22:47 Infantie coi: Cinical features and diagnasis - UpTeD: + Assessment for tongue-tie( picture 1), which may be associated with breastfeeding problems (see "Ankyloglossia (tongue-tie) in infants and children", section on ‘Clinical features’) + Eye examination for foreign body, corneal abrasion, infantile glaucoma (eg, corneal enlargement ( _ picture 2) or clouding), retinal hemorrhage (though fundoscopic examination may be difficult) (see "Corneal abrasions and corneal foreign bodies: Clinical manifestations and diagnosis", section on ‘Eye examination’ and "Primary infantile glaucoma’, section on ‘Clinical features' and "Child abuse: children with abusive head trauma (AHT)") rye findings in + Ear examination for otitis media(__ picture 3) (see "Acute otitis media in children: Clinical manifestations and diagnosis", section on ‘Diagnosis’) + Oropharyngeal examination for thrush (__ picture 4) (see "Candida infections in children’, section on ‘Oropharyngeal candidiasis’) + Cardiovascular evaluation for signs of heart failure or supraventricular tachycardia (eg, tachycardia, tachypnea, poor perfusion, $3 gallop, tachypnea) (see "Heart failure in children: Etiology, clinical manifestations, and diagnosis", section on ‘Clinical manifestations' and "Clinical features and diagnosis of supraventricular tachycardia (SVT) in children’, section on ‘Clinical features' and "Suspected heart disease in infants and children: Criteria for referral") + Evaluation of the abdomen for tenseness, tenderness, absence of bowel sounds (possible clues to an acute abdominal process such as intussusception, volvulus) (see "Intussusception in children", section on ‘Clinical manifestations and "Intestinal malrotation in children", section on ‘Clinical presentation’ and "Causes of acute abdominal pain in children and adolescents") + Evaluation of perineum for diaper rash(_ picture 5), testicular torsion, hair tourniquet, meatal ulcer, anal fissure, inguinal hernia (see "Diaper dermatitis" and “Inguinal hernia in children", section on ‘Clinical features and diagnosis’ and “Neonatal testicular torsion", section on ‘Clinical presentation’) + Evaluation of the skin and musculoskeletal system for signs of trauma (including abusive trauma) or infection; examples of relevant findings include hair tourniquet or other narrow constricting band ( picture 6), bruising or petechiae, decreased range of motion, and pain with passive movement (see "Hair tourniquet and other narrow constricting bands: Clinical manifestations, diagnosis, and treatment", section on ‘Clinical manifestations’ and "Physical child abuse: Diagnostic evaluation and management", section on ‘Evaluation’ and "Bacterial arthritis: Clinical features hitpsslwwuptodate.comicontentsinfantil-coliccinicaHfeatures-and-dlagnosis/print?search=Cdlicas no recém nascidoSsource=search_resul.... 10/3121042029, 2247 Infantile cole: Clinical features and diagnosis - UpToDate and diagnosis in infants and children", section on ‘Clinical features’ and “Hematogenous osteomyelitis in children: Clinical features and complications", section on ‘Clinical features’) + Evaluation of the nervous system for abnormalities (eg, bulging anterior fontanelle, asymmetry, increased or decreased tone) that may indicate meningitis or other neurologic condition (see "Bacterial meningitis in the neonate: Clinical features and diagnosis", section on ‘Clinical features’ and "Elevated intracranial pressure (ICP) in children: Clinical manifestations and diagnosis" and "Approach to the infant with hypotonia and weakness") DIAGNOSIS A presumptive diagnosis of infantile colic can be made in an otherwise healthy infant <3 months of age who cries for no apparent reason for 23 hours per day on 23 days per week. Other causes of crying generally are excluded by the history and physical examination. The diagnosis of colic is confirmed in retrospect, after it has run its characteristic course. (See ‘Evaluation for identifiable causes of crying’ above.) POTENTIAL SEQUELAE Colicky crying is not harmful to the infant in the short- or long-term. However, parents of crying infants may resort to hurting the infant to try to stop the crying [91,92]. In addition, observational studies suggest that infantile colic is associated with increased risk of postpartum depression [93-96] and early cessation of breastfeeding [97]. (See "Postpartum unipolar major depression: Epidemiology, clinical features, assessment, and diagnosis", section on ‘Risk factors’) Ina community-based sample, parents of 3259 infants anonymously responded to a questionnaire about their actions to stop their infant from crying [91]. Among parents of one- and three-month-old infants, 2.2 and 3.7 percent, respectively, reported having smothered, slapped, or shaken their baby at least once because of the crying. In multivariate analysis, these behaviors were more likely if the parents were worried about the crying or judged it to be excessive, and were unrelated to the amount of crying (defined by 23 hours per day on 23 days per week in the week before the survey). INFORMATION FOR PATIENTS hitpsslwwuptodate.comicontentsinfantil-coliccinicaHfeatures-and-dlagnosis/print?search=Célcas no recém nascidoSsource=search_resul.... 11/31osiain023, 22.47 Infante col: Clinical features and diagnosis - UpToDate UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5" to 6" grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10" to 12% grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon. Here are the patient education articles that are relevant to this topic. We encourage you to print or email these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on “patient info" and the keyword{s] of interest.) * Basics topic (see "Patient education: Colic (The Basics)") * Beyond the Basics topic (see "Patient education: Colic (excessive crying) in infants (Beyond the Basics)") SUMMARY * Definitions + Normal crying - The average duration of crying during the first three months of life ranges from 68 to 133 minutes per day. The duration of crying is greatest during the first six weeks of life and declines after eight to nine weeks. (See ‘Normal patterns of crying’ above.) + Colic - There is no standard definition of the term "colic." For clinical purposes, we define it broadly as crying for no apparent reason that lasts for 23 hours per day and occurs on 23 days per week in an otherwise healthy infant <3 months of age. (See ‘Colic’ above.) + Proposed etiologies - The etiology of colic is unknown. It probably represents a final common pathway for numerous contributing factors. Gastrointestinal, biologic, and psychosocial etiologies have been proposed. (See ‘Proposed etiologies’ above.) * Clinical features - Infants with colic have normal growth, development, and examination. Clinical features that are thought to distinguish colic from “normal” crying include paroxysmal episodes; qualitative differences (eg, louder, higher pitched, more dysphonic); hypertonia (eg, facial flushing, clenched fists, etc); and difficulty consoling. (See ‘Clinical features! above.) hitpsslwwuptodate.comicontentsinfantile-coliccinica-features-and:-dlagnosis/print?search=Cdlicas no recém nascidoSsource=search_resul.... 12/3121042029, 2247 Infantile cole: Clinical features and diagnosis - UpToDate * Evaluation - The evaluation of a child with suspected colic typically includes a history and examination for identifiable causes of crying/fussiness(_ table 1). Laboratory or imaging studies generally are not necessary. (See ‘Evaluation for identifiable causes of crying’ above.) * Diagnosis - A presumptive diagnosis of colic can be made in an otherwise healthy infant <3 months of age who cries for no apparent reason for 23 hours per day on 23 days per week. Other causes of crying generally are excluded by the history and physical examination (__ table 1). (See ‘Diagnosis’ above and 'History' above and Examination’ above.) * Potential sequelae - Potential sequelae of colic include physical abuse, increased risk of postpartum depression, and early cessation of breastfeeding. (See ‘Potential sequelae’ above.) + Management - The management of colic is discussed separately. (See "Infantile colic: Management and outcome".) Use of UpToDate is subject to the Terms of Use. REFERENCES 1. Taubman B. A new answer to the old question of colic. Contemp Pediatr 1991; 8:44. 2. Lehtonen LA, Rautava PT. Infantile colic: natural history and treatment. Curr Probl Pediatr 1996; 26:79. 3. Wolke D, Bilgin A, Samara M. Systematic Review and Meta-Analysis: Fussing and Crying Durations and Prevalence of Colic in Infants. J Pediatr 2017; 185:55. 4, Barr RG. Normality: a clinically useless concept. The case of infant crying and colic. J Dev Behav Pediatr 1993; 14:264. 5. Douglas P, Hill P. Managing infants who cry excessively in the first few months of life. BMJ 2011; 343:d7772. 6. The period of PURPLE crying. http://purplecrying.info/ (Accessed on May 04, 2015). 7. WESSEL MA, COBB JC, JACKSON EB, et al. Paroxysmal fussing in infancy, sometimes called colic. Pediatrics 1954; 14:421. 8. Gormally S, Barr RG. Of clinical pies and clinical clues: Proposal for a clinical approach to. complaints of early crying and colic. Ambulatory Child Health 1997; 3:137. 9. Benninga MA, Faure C, Hyman PE, et al. Childhood Functional Gastrointestinal Disorders: Neonate/Toddler. Gastroenterology 2016. hitpsslwwuptodate.comicontentsinfantil-coliccinicaHfeatures-and-dlagnosis/print?search=Célicas no recém nascidoSsource=search_resul.... 19/31spoia023, 2247 Infantile cole: Clinical features and diagnosis - UpToDate 10, Lester BM, Boukydis CF, Garcia-Coll CT, Hole WT. Colic for developmentalists. Infant Ment Health J 1990; 11:320. 11. Lehtonen L, Korvenranta H. Infantile colic. Seasonal incidence and crying profiles. Arch Pediatr Adolesc Med 1995; 149:533. 12. ILLINGWORTH RS. Three-months' colic. Arch Dis Child 1954; 29:165. 13. Hide DW, Guyer BM. Prevalence of infant colic. Arch Dis Child 1982; 57:559. 14, Rubin SP, Prendergast M. Infantile colic: incidence and treatment in a Norfolk community. Child Care Health Dev 1984; 10:219. 15, Stahlberg MR. Infantile colic: occurrence and risk factors. Eur J Pediatr 1984; 143:108. 16, Wake M, Morton-Allen E, Poulakis Z, et al. Prevalence, stability, and outcomes of cry-fuss and sleep problems in the first 2 years of life: prospective community-based study. Pediatrics 2006; 117:836. 17. Reijneveld SA, Brugman E, Hirasing RA. Excessive infant crying: the impact of varying definitions. Pediatrics 2001; 108:893. 18. Clifford TJ, Campbell MK, Speechley KN, Gorodzinsky F. Infant colic: empirical evidence of the absence of an association with source of early infant nutrition. Arch Pediatr Adolesc Med 2002; 156:1123 19, Gray L, Turner A, Magee T, Parker S (deceased). Excessive crying and colic. In: Zuckerma n Parker Handbook of Developmental and Behavioral Pediatrics for Primary Care, 4th e d, Augustyn M, Zuckerman B (Eds), Wolters Kluwer, Philadelphia 2019. p.193. 20. Johnson JD, Cocker K, Chang E. Infantile Colic: Recognition and Treatment. Am Fam Physician 2015; 92:577. 21. Brazelton TB, Robey JS, Collier GA. Infant development in the Zinacanteco Indians of southern Mexico. Pediatrics 1969; 44:274. 22, Rautava P, Helenius H, Lehtonen L. Psychosocial predisposing factors for infantile colic. BM) 1993; 307:600. 23. Raiha H, Lehtonen L, Korvenranta H. Family context in infantile colic. Infant Mental Health 1995; 16:206. 24, Lester BM. Introduction. In: Colic and Excessive Crying: of the 105th Ross Conference on Pediatric Research, Lester BM, Barr RG (Eds), Ross Products Division, Columbus, OH 199 7p. 25. StJames-Roberts I. Distinguishing between infant fussing, crying, and colic: How many p henomenon?. In: Colic and Excessive Crying: Report of the 105th Ross Conference on Pe diatric Research, Lester BM, Barr RG (Eds), Ross Products Division, Columbus, OH 1997. p32. tps slwwuptodate.comicontentsinfantil-coliccinicabfeatures-and-dlagnosis/print?search=Célicas no recém nascidoSsource=search_resul.... 14/3103/04/2028, 22:47 Infante colic: Cinial features and diagnosis - UpToDate 26. Garrison MM, Christakis DA. A systematic review of treatments for infant colic. Pediatrics 2000; 106:184. 27. Lucassen PL, Assendelft WJ, Gubbels JW, et al. Effectiveness of treatments for infantile colic: systematic review. BMJ 1998; 316:1563. 28. lacovou M, Ralston RA, Muir J, et al. Dietary management of infantile colic: a systematic review, Matern Child Health J 2012; 16:1319, 29. Hall B, Chesters J, Robinson A. Infantile colic: a systematic review of medical and conventional therapies. J Paediatr Child Health 2012; 48:128. 30. Miller J, McVeagh P, Fleet GH, et al. Effect of yeast lactase enzyme on “colic” in infants fed human milk. J Pediatr 1990; 117:261. 31. Stahlberg MR, Savilahti E. Infantile colic and feeding. Arch Dis Child 1986; 61:1232. 32. Kanabar D, Randhawa M, Clayton P. Improvement of symptoms in infant colic following reduction of lactose load with lactase. J Hum Nutr Diet 2001; 14:359. 33. Kearney PJ, Malone AJ, Hayes T, et al. A trial of lactase in the management of infant colic. J Hum Nutr Diet 1998; 11:281. 34, Moore DJ, Robb TA, Davidson GP. Breath hydrogen response to milk containing lactose in colicky and noncolicky infants. J Pediatr 1988; 113:979. 35. Miller JJ, McVeagh P, Fleet GH, et al. Breath hydrogen excretion in infants with colic. Arch Dis Child 1989; 64:725. 36. Hyams JS, Geertsma MA, Etienne NL, Treem WR. Colonic hydrogen production in infants with colic. J Pediatr 1989; 115:592. 37. Miller AR, Barr RG. Infantile colic. Is it a gut issue? Pediatr Clin North Am 1991; 38:1407. 38, STEWART AH, WEILAND IH, LEIDER AR, et al. Excessive infant crying (colic) in relation to parent behavior. Am J Psychiatry 1954; 110:687. 39. FORUP S. Colonic hyperperistalsis in neurolabile infants; studies in so-called dyspepsia in breast-fed infants. Acta Paediatr Suppl 1952; 41:1. 40. Lothe L, Ivarsson SA, Lindberg T. Motilin, vasoactive intestinal peptide and gastrin in infantile colic. Acta Paediatr Scand 1987; 76:316. 41. Savino F, Grassino EC, Guidi C, et al. Ghrelin and motilin concentration in colicky infants. Acta Paediatr 2006; 95:738. 42. Lothe L, Ivarsson SA, Ekman R, Lindberg T. Motilin and infantile colic. A prospective study. Acta Paediatr Scand 1990; 79:410. 43. Rhoads JM, Fatheree NY, NororiJ, et al. Altered fecal microflora and increased fecal calprotectin in infants with colic. | Pediatr 2009; 155:823. hitpsslwwuptodate.comicontentsinfantile-coiccinicaHfeatures-and-dlagnosis/print?search=Cdlicas no recém nascidoSsource=search_resul.... 15/31spoia023, 2247 Infantile ole: Clinical eaures and agnosis - UpToDate 44, Savino F, Cresi F, Pautasso S, et al. Intestinal microflora in breastfed colicky and non- colicky infants. Acta Paediatr 2004; 93:825. 45. Savino F, Cordisco L, Tarasco V, et al. Molecular identification of coliform bacteria from colicky breastfed infants. Acta Paediatr 2009; 98:1582. 46. Savino F, Bailo E, Oggero R, et al. Bacterial counts of intestinal Lactobacillus species in infants with colic, Pediatr Allergy Immunol 2005; 16:72. 47, Rhoads |M, Collins J, Fatheree NY, et al. Infant Colic Represents Gut Inflammation and Dysbiosis. J Pediatr 2018; 203:55. 48. Fatheree NY, Liu Y, Taylor CM, et al. Lactobacillus reuteri for Infants with Colic: A Double- Blind, Placebo-Controlled, Randomized Clinical Trial. | Pediatr 2017; 191:170. 49. Savino F, Garro M, Montanari P, et al. Crying Time and RORy/FOXP3 Expression in Lactobacillus reuteri DSM17938-Treated Infants with Colic: A Randomized Trial. | Pediatr 2018; 192:171. 50. Savino F, Pelle E, Palumeri E, et al. Lactobacillus reuteri (American Type Culture Collection Strain 55730) versus simethicone in the treatment of infantile colic: a prospective randomized study. Pediatrics 2007; 119:e124 51. Savino F, Cordisco L, Tarasco V, et al. Lactobacillus reuteri DSM 17938 in infantile colic: a randomized, double-blind, placebo-controlled trial. Pediatrics 2010; 126:e526. 52. Szajewska H, Gyrczuk E, Horvath A. Lactobacillus reuteri DSM 17938 for the management of infantile colic in breastfed infants: a randomized, double-blind, placebo-controlled trial. J Pediatr 2013; 162:257. 53, Sung V, Cabana MD. Probiotics for Colic-Is the Gut Responsible for Infant Crying After All? J Pediatr 2017; 191:6. 54, Sung V, D'Amico F, Cabana MD, et al. Lactobacillus reuteri to Treat Infant Colic: A Meta- analysis. Pediatrics 2018; 141. 55, Sondergaard C, Henriksen TB, Obel C, Wisborg K. Smoking during pregnancy and infantile colic. Pediatrics 2001; 108:342 56, Rejjneveld SA, Brugman E, Hirasing RA. Infantile colic: maternal smoking as potential risk factor. Arch Dis Child 2000; 83:302. 57. Milidou I, Henriksen TB, Jensen MS, et al. Nicotine replacement therapy during pregnancy and infantile colic in the offspring. Pediatrics 2012; 129:e652. 58, Berseth CL. Immaturity in neonatal regulation of motor activity: Setting the stage for col ic. In: Colic and Excessive Crying: Report of the 105th Ross Conference on Pediatric Rese arch, Lester BM, Barr RG (Eds), Ross Products Division, Columbus, OH 1997. p.77. 59, Baker J, Berseth CL. Postnatal change in inhibitory regulation of intestinal motor activity in human and canine neonates. Pediatr Res 1995; 38:133. hitpsslwwuptodate.comicontentsinfantile-coliccinicaHfeatures-and-dlagnosis/print?search=Cdlicas no recém nascidoSsource=search_resul.... 16/3103/04/2028, 22:47 Infante colic: Cinial features and diagnosis - UpToDate 60. Kurtoglu S, Uzuim K, Hallac IK, Coskum A. 5-Hydroxy-3-indole acetic acid levels in infantile colic: is serotoninergic tonus responsible for this problem? Acta Paediatr 1997; 86.764, 61. Sillanpaa M, Saarinen M. Infantile colic associated with childhood migraine: A prospective cohort study. Cephalalgia 2015; 35:1246. 62. Romanello S, Spiri D, Marcuzzi E, et al. Association between childhood migraine and history of infantile colic. JAMA 2013; 309:1607. 63. Jan MM, Al-Buhairi AR. Is infantile colic a migraine-related phenomenon? Clin Pediatr (Phila) 2001; 40:295, 64. Katerji MA, Painter Mj. Infantile migraine presenting as colic. J Child Neurol 1994; 9:336. 65. Bruni O, Fabrizi P, Ottaviano S, et al. Prevalence of sleep disorders in childhood and adolescence with headache: a case-control study. Cephalalgia 1997; 17:492. 66. Gelfand AA, Goadsby PJ, Allen IE. The relationship between migraine and infant colic: a systematic review and meta-analysis. Cephalalgia 2015; 35:63. 67. Gelfand AA. Infant colic~a baby's migraine? Cephalalgia 2015; 35:1243. 68. Henderson LJ. The Fitness of the Environment: An Inquiry into the Biological Significance of the Properties of Matter, Macmillan Co, New York 1913. 69. Carey WB. Infantile colic: a pediatric practitioner-researcher's point of view. Infant Mental Health J 1990; 11:334, 70. Carey WB. "Colic"--primary excessive crying as an infant-environment interaction. Pediatr Clin North Am 1984; 31:993. 71. Carey WB. Clinical applications of infant temperament measurements. J Pediatr 1972; 81:823. 72, Carey WB, Maternal anxiety and infantile colic, Is there a relationship? Clin Pediatr (Phila) 1968; 7:590. 73. Taubman B. Clinical trial of the treatment of colic by modification of parent-infant interaction. Pediatrics 1984; 74:98, 74, Taubman B. Parental counseling compared with elimination of cow's milk or soy milk protein for the treatment of infant colic syndrome: a randomized trial. Pediatrics 1988; 81:756. 75, BRAZELTON TB. Crying in infancy. Pediatrics 1962; 29:579. 76. Spock B. Etiological factors in the hypertrophic stenosis and infantile colic. Psychosom Med 1944; 6:162. 77. Petzoldt J, Wittchen HU, Wittich J, et al. Maternal anxiety disorders predict excessive infant crying: a prospective longitudinal study. Arch Dis Child 2014; 99:800. hitpsslwwuptodate.comicontentsinfantil-coiccinica-features-and-diagnosis/print?search=Célicas no recém nascidoSsource=search_resul.... 17/31spoia023, 2247 Infantile ole: Clinical eaures and agnosis - UpToDate 78, Paradise JL. Maternal and other factors in the etiology of infantile colic. Report of a prospective study of 146 infants. JAMA 1966; 197:191. 79. Sondergaard C, Olsen J, Friis-Hasche E, et al. Psychosocial distress during pregnancy and the risk of infantile colic: a follow-up study. Acta Paediatr 2003; 92:811 80. van den Berg MP, van der Ende J, Crijnen AA, et al. Paternal depressive symptoms during pregnancy are related to excessive infant crying. Pediatrics 2009; 124:e96. 81, Carey WB. Colic: Prolonged or excessive crying in young infants. In: Developmental-Beh avioral Pediatrics, 4th ed, Carey WB, Crocker AC, Coleman WL, et al (Eds), Saunders Elsev ier, Philadelphia 2009. p.557. 82. Barr RG, Paterson JA, MacMartin LM, et al. Prolonged and unsoothable crying bouts in infants with and without colic. J Dev Behav Pediatr 2005; 26:14. 83, Lester BM. Definition and diagnosis of colic. In: Colic and Excessive Crying: Report of the 105th Ross Conference on Pediatric Research, Lester BM, Barr RG (Eds), Ross Products D ivisions, Columbus, OH 1997. p.8. 84, Fuller BF, Keefe MR, Curtin M. Acoustic analysis of cries from "normal" and “irritable” infants. West J Nurs Res 1994; 16:243. 85. Lester BM, Boukydis CF, Garcia-Coll CT, et al. Infantile colic: Acoustic cry characteristics, maternal perception of cry, and temperament. Infant Behav Dev 1992; 15:15. 86. Pinyerd BJ. Infant colic and maternal mental health: nursing research and practice concerns. Issues Compr Pediatr Nurs 1992; 15:155. 87. Fleisher DR. Coping with colic. Contemp Pediatr 1998; 15:144. 88. Drug and Therapeutics Bulletin. Management of infantile colic. BMJ 2013; 347:f4102. 89. Carey WB. Colic: Prolonged or excessive crying in young infants. In: Developmental-Beh avioral Pediatrics, 4th ed, Carey WB, Crocker AC, Coleman WL, et al (Eds), Saunders Elsev ier, Philadelphia 2009. p.557. 90, Carey WB, The effectiveness of parent counseling in managing colic, Pediatrics 1994; 94:333, 91. Reijneveld SA, van der Wal MF, Brugman E, et al. Infant crying and abuse. Lancet 2004; 364:1340. 92. Levitzky 5, Cooper R. Infant colic syndrome-maternal fantasies of aggression and infanticide. Clin Pediatr (Phila) 2000; 39:395, 93. Vik T, Grote V, Escribano J, et al. Infantile colic, prolonged crying and maternal postnatal depression. Acta Paediatr 2009; 98:1344, 94, Radesky JS, Zuckerman B, Silverstein M, et al. Inconsolable infant crying and maternal postpartum depressive symptoms. Pediatrics 2013; 131:e1857. hitpsslwwuptodate.comicontentsinfantil-coliccinicaHfeatures-and-dlagnosis/print?search=Cdlicas no recém nascidoSsource=search_resul.... 18/3103/04/2028, 22:47 Infante colic: Cinial features and diagnosis - UpToDate 95, Akman I, Kuscu K, Ozdemir N, et al. Mothers’ postpartum psychological adjustment and infantile colic. Arch Dis Child 2006; 91:417. 96. Howell EA, Mora P, Leventhal H. Correlates of early postpartum depressive symptoms. Matern Child Health J 2006; 10:149. 97. Howard CR, Lanphear N, Lanphear BP, et al. Parental responses to infant crying and colic: the effect on breastfeeding duration. Breastfeed Med 2006; 1:146. Topic 609 Version 26.0 hitpsslwwuptodate.comicontentsinfantile-coliccinicaHfeatures-and-dlagnosis/print?search=Cdlicas no recém nascidoSsource=search_resul.... 19/31o3104i2023, 22-47 GRAPHICS Infante colic: Clinical features and diagnasis - UpToDate Causas identificaveis selecionadas de choro prolongado/excessivo em uma crianga com menos de quatro meses de idade Doenca Em geral Ingestao ou superdosagem de drogas (por exemplo, pseudoefedrina) Fome/alimentacao inadequada Sindrome de abstinéncia neonatal Skin Hair tourniquet of digit or penis Open diaper pin poking the skin, diaper rash ‘Trauma (abusive or nonabusive) Eyes Corneal abrasion or foreign body Glaucoma Ears, nose, oropharynx Otitis media Thrush Cardiovascular Anomalous origin of the left coronary artery Heart failure Supraventricular tachycardia Histérico de administracaio de medicamentos Sinais de hipovolemia ou desnutrigao (por exemplo, fontanela afundada, membranas mucosas secas, diminuigéo da gordura subcutnea, etc.) Maternal history of prenatal substance use or positive urine screen {maternal or infant) Apparent on physical examination Apparent on physical examination Bruising, laceration May have photophobia, positive fluorescein examination Chronic or intermittent tearing, photophobia, corneal enlargement, corneal clouding, optic nerve cupping, ocular enlargement Bulging tympanic membrane White plaques on the buccal mucosa, tongue, or palate Cardiomegaly, heart failure Feeding intolerance, tachycardia, poor perfusion, tachypnea Pallor, irritability, poor feeding, cyanosis, restlessness hitpsslwwuptodate.comicontentsinfantile-coliccinica-features-and-diagnosis/print?search=Cdlicas no recém nascidoSsource=search_resul.... 20/3131042023, 22:47 Gastrointestinal Anal fissures Constipation Gastroenteritis Gastroesophageal reflux Gastrointestinal obstruction (eg, pyloric stenosis, intussusception, volvulus) Inguinal hernia Genitourinary Meatal ulcer Ovarian torsion Testicular torsion Urinary tract infection Urinary tract obstruction Skeletal Fracture Osteomyelitis or septic arthritis Neurolo: Abusive head trauma Meningitis Neuromuscular disease, CNS disorder, metabolic disease CNS: central nervous system. Data from: Infantile colic: Clinical features and diagnasis - UpToDate Apparent on physical examination Passage of hard stools Vomiting, diarrhea Vomiting, poor weight gain, feeding refusal, gross or occult blood in the stool Vomiting (may or may not be bilious or forceful), gastrointestinal bleeding, forceful vomiting, abdominal tenderness, distension, right-sided sausage-shaped abdominal mass (intussusception), palpable "olive" (pyloric stenosis) Bulge in the groin area (may be intermittent), vorniting and abdominal distension may indicate incarceration Apparent on examination Feeding intolerance, vomiting, abdominal distension, fussiness/irritability Acute testicular swelling and tenderness Fever, suprapubic tenderness, poor feeding, poor weight gain Abdominal distension (due to enlarged bladder), difficulty voiding, poor urinary stream, straining or grunting during voiding Decreased movement of extremity, asymmetric Moro reflex, localized swelling and crepitation, increased pain response with movement of the extremity Fever, decreased movement of extremity, asymmetric Moro reflex, increased pain response with movement of the extremity Seizures, respiratory difficulty or apnea, retinal hemorrhages, cutaneous bruising, associated injuries Fever, bulging fontanelle, lethargy, irritability, meningismus (often not present in infants) Abnormal tone, muscular weakness 1. Drug and Therapeutics Bulletin. Management of infantile colic. BM 2013; 347;f4102 hitpsslwwuptodate.comicontentsinfantile-coliccinicaHfeatures-and-dlagnosis/print?search=Célicas no recém nascidoSsource=search_resul.... 24/3103/04/2028, 22:47 Infante colic: Cinial features and diagnosis - UpToDate 2. Parker 5, Magee T. Colic. In: The Zuckerman Parker Handbook of Developmental and Behavioral Pediatrics for Primary Care, 3rd ed, Augustyn M, Zuckerman 8, Coronna EB (Eds), Lippincott Williams & Wilkins, Philadelphia 2011. p.182. 3, Roberts DM, Ostapchuk M, O'Brien JG. Infantile colic. Am Fam Physician 2004; 70:735, Graphic 79185 Version 8.0 hitpsslwwuptodate.comicontentsinfantile-colccinicabfeatures-and- iagnosisiprint?search=Calicas no recém nascido8source=search_resul... 22/31o3104i2023, 22-47 Infante colic: Clinical features and diagnasis - UpToDate Causes of poor weight gain, according to pathophysiologic mechanism Inadequate nutrient intake Inappropriate feeding technique Disturbed caregiver/child relationship Economic deprivation Inappropriate nutrient intake (eg, excess fruit juice consumption, factitious food allergy, inappropriate preparation of formula, inadequate quantity of food, inappropriate food for age, neglect, food fads) Inappropriate parental knowledge of appropriate diet for infants and toddlers Insufficient lactation in mother Picky eater Gastroesophageal reflux Psychosocial problems Maternal/infant dysfunction Mechanical problems (cleft palate, nasal obstruction, adenoidal hypertrophy, dental lesions) Sucking or swallowing dysfunction (CNS, neuromuscular, esophageal motility problems) or chewing difficulty Inadequate appetite or inability to eat large amounts Oral aversion/problem with certain textures Psychosocial problems - apathy or rumination Cardiopulmonary disease Hypotonia, muscle weakness, or hypertonia Anorexia of chronic infection or immune deficiency Cerebral palsy CNS pathology (eg, tumor, hydrocephalus) Genetic syndromes Anemia (eg, iron deficiency) Inadequate nutrient absorption or increased losses Malabsorption (lactose intolerance, cystic fibrosis, cardiac disease, malrotation, IBD, milk allergy, parasites, celiac disease) Biliary atresia, cirrhosis, Vomiting or "spitting up" (related to infectious gastroenteritis, increased intracranial pressure, adrenal insufficiency, or drugs [eg, purposeful administration of syrup of ipecac}) Intestinal tract obstruction (pyloric stenosis, hernia, malrotation, intussusception) Infectious diarrhea Necrotizing enterocolitis or short bowel syndrome Increased nutrient requirements or ineffective metabolic utilization Hyperthyroidism Malignancy (including brain tumors such as diencephalic syndrome) Chronic IBD Chronic systemic disease (juvenile idiopathic arthritis) Chronic or recurrent systemic infection (urinary tract infection, tuberculosis, toxoplasmosis) Chronic metabolic problems (hypercalcemia, storage diseases, and inborn errors of metabolism, such as galactosemia, methylmalonic acidemia, diabetes mellitus, adrenal insufficiency) Chronic respiratory insufficiency (bronchopulmonary dysplasia, cystic fibrosis) Congenital or acquired heart disease hitpsslwwnuptodate.comicontentsinfantile-coliccinica-features-and-diagnosis/print?search=Célicas no recém nascidoSsource=search_resul.... 29/31o3104i2023, 22:47 Infantie colic: Clinical features and diagnasis - UpTeDate Chronic constipation Gastrointestinal disorder (eg, pain from gastroesophageal reflux, intestinal tract obstruction) Craniofacial anomalies (eg, cleft lip and palate, micrognathia) CNS: central nervous system; [BI inflammatory bowel disease Graphic 69846 Version 9.0 hitpsslwwuptodate.comicontentsinfantil-coliccinicabfeatures-and-dlagnosis/print?search=Cdlicas no recém nascidoSsource=search_resul.... 24/3103/04/2028, 22:47 Infante colic: Cinial features and diagnosis - UpToDate Ankyloglossia in a newborn ‘Abnormally short frenulum, inserting at the tip of the tongue in a neonate. Courtesy of Glenn Isaacson, MD, FAAP. Graphic 60685 Version 2.0 hitpsslwwuptodate.comicontentsinfantile-coliccinica-features-and-dlagnosis/print?search=Célicas no recém nascidoSsource=search_resul.... 25/31o3104i2023, 22-47 Infante coi: Clinical features and diagnasis - UpTeDate Corneal enlargement in congenital glaucoma The right cornea is larger than the left. Reproduced with permission from: Tasman W, Jaeger E. The Wills Eye Hospital Atlas of Clinical Ophthalmology, 2e. Lippincott Williams & Wilkins, 2007, Copyright © 2001 Lippincott Williams & Wilkins. Graphic 50389 Version 2.0 hitpsslwwuptodate.comicontentsinfantil-coiccinica-features-and-dlagnosis/print?search=Cdlicas no recém nascidoSsource=search_resul.... 26/31o3104i2023, 22-47 Infante coi: Clinical features and diagnasis - UpTeDate membrane in acute otitis media Bulging tympai whitsh Sg] discoloration “ Examples of the white, bulging tympanic membrane seen in acute otitis media. (A) A bulging tympanic membrane with minimal erythema. (8) Tympanic membrane bulging, marked erythema along the handle of the malleus, and an air-fluid level in the anterosuperior portion of the tympanic membrane, Courtesy of Alejandro Hoberman, MD. Graphic 63268 Version 6.0 tps :slwwuptodate.comicontentsinfantil-coiccinicabfeatures-and-dlagnosis/print?search=Cdlicas no recém nascidoSsource=search_resul.... 27/3103/04/2028, 22:47 Infante colic: Cnial features and diagnosis - UpToDate Three examples of thrush (oral candidiasis) in an infant Note the white plaques on the inner lip and tongue (A) and on the buccal mucosa (B and ©). Reproduced with permission from: www.visualdx.com. Copyright VisualDx. All rights reserved. Graphic 69465 Version 7.0 hitpsslwwuptodate.comicontentsinfantile-coliccinicabfeatures-and-dlagnosis/print?search=Cdlicas no recém nascidoSsource=search_resul.... 26/3103/04/2028, 22:47 Infante colic: Cnial features and diagnosis - UpToDate Irritant Intense erythema and scaling with sparing of the skin fold are characteristic of irritant diaper dermatitis. Reproduced with permission from: wwww.visualdx.com, Copyright VisualDx. All rights reserved. Graphic 90046 Version 2.0 hitpsslwwuptodate.comicontentsinfantile-coiccinica-features-and-dlagnosis/print?search=Cdlicas no recém nascidoSsource=search_resul.... 28/3103/04/2028, 22:47 Infante colic: Cinial features and diagnosis - UpToDate Superficial hair tourniquet Infant brought in by mother who noticed toe was red and swollen while bathing child, Note the grossly visible hair tourniquet at the base of the fourth toe. It was removed using fine forceps without difficulty and with return of normal appearance of the toe within 24 hours. Reproduzido com permissdo de: William € Franklin, DO, FACEP. Copyright ©2003 William E Franklin, DO, FACEP. Grafico 50150 Versdo 3.0 hitpsslwwuptodate.comicontentsinfantil-coiccinica-features-and-dlagnosis/print?search=Célicas no recém nascidoSsource=search_resul.... 30/3103/04/2028, 22:47 Infante colic: Cinial features and diagnosis - UpToDate Contributor Disclosures Teri Lee Turner, MD, MPH, MEd No relevant financial relationship(s) with ineligible companies to disclose. Shea Palamountain, MD No relevant financial relationship(s) with ineligible companies to disclose. Marilyn Augustyn, MD Grant/Research/Clinical Trial Support: Health Resources and Services Administration [Fellowship training]; Irving Harris Network [Fellowship training]. All of the relevant financial relationships listed have been mitigated. Diane Blake, MD No relevant financial relationship(s) with ineligible companies to disclose. As divulgagdes dos colaboradores so analisadas quanto a conflitos de interesse pelo grupo editorial. Quando encontrados, eles so tratados por meio de verificacao por meio de um processo de revisdo em varios niveis e por meio de requisitos para refer€ncias a serem fornecidas para apoiar o contetido. O contetido devidamente referenciado é exigido de todos os autores e deve estar em conformidade com os padrées de evidéncia do UpToDate. Politica de conflito de interesses > tps slwwuptodate.comicontentsinfantile-coliccinicaHfeatures-and-dlagnosis/print?search=Cdlicas no recém nascidoSsource=search_resul.... 31/31