Colic and Breastfeeding

Colic is the name given for unexplained persistent crying in an otherwise healthy baby. Time limits on the crying—such as at least three hours of crying a day for at least three days a week—are sometimes used as a marker for diagnosis.1 Although some people believe it is developmentally normal for babies to cry for hours at a time, babies cry for a reason. Babies cry to attract attention when they are hungry, in pain, too hot or too cold, poorly, scared or need comfort. Extensive crying can be very stressful for a baby with potentially negative consequences for their brain development.23

There are lots of reasons for babies to refuse to breastfeed or seem fussy or unsettled at times and some of these are discussed in The Fussy Breastfed Baby. There can be an overlap between reasons for a baby to be fussy and reasons for a baby to cry much more extensively and inconsolably. This article discusses the definition of colic and shares ten possible explanations for extensive crying due to colic like symptoms.

baby crying held on mother's shoulder
Colic is the name given for unexplained persistent crying in an otherwise healthy baby

What is colic in babies?

Colic, by dictionary definition, refers to acute pain in the abdomen due to spasm, obstruction or twisting.4 However when baby colic is discussed, a specific cause such as abdominal pain is left out and it tends to be described as follows:

  • Unexplained persistent crying of three to four hours per day in an otherwise healthy baby56
  • Crying episodes are often at the same time each day typically between 6 and 10 pm in the first few months of life (Lawrence, 2016)
  • Babies may have clenched fists, go red in the face, and bring their knees up (NHS, 2018; Lawrence, 2016)
  • A baby may breastfeed often but scream and pull away from the breast as if they are in pain and then cry again (Lawrence, 2016)

Rule out illness

When a baby is crying extensively a health professional will carry out an examination to rule out any underlying health issue including injury or illness such as an ear infection, urinary tract infection or hernia.789

Rule out hunger

Crying can be a sign of hunger so it can also be useful to have a feeding assessment with a breastfeeding specialist such as an International Board Certified lactation Consultant (IBCLC). An IBCLC can help rule out any causes of crying related to breastfeeding. An IBCLC will watch baby breastfeed, discuss breastfeeding management, normal baby needs and behaviours, frequency of feeds and study baby’s weight chart to rule out hunger or faltering growth that could cause crying or fussy behaviour.

It’s important to consider all possible causes for unexplained crying as a diagnosis of colic can lead to parents stopping breastfeeding sooner than they wanted to.10

How long does colic last?

Colic is usually said to start after a few weeks of age and stop after a few months. While some sources report that colic usually stops by three months when the baby’s gastrointestinal system matures (Lawrence, 2016) others say six months of age 11.

Can breastfed babies have colic?

Breastfed babies can have unexplained crying episodes. Colic type symptoms may be associated with an allergy to a food in their mother’s diet or with one of the other possible causes for discomfort listed below.

What causes colic in babies?

Historically colic was often assumed to be caused by abdominal pain of some kind (tummy ache). However colic is usually described as “unexplained crying in a healthy baby”. In other words it is not known what causes colic. Gwen Dewar explains:

It’s the catch-all term doctors use to describe intense, inconsolable crying when they aren’t immediately sure what’s going on. So there isn’t any single answer or remedy. Different babies cry for different reasons.

In the next section we consider ten possible causes for unexplained crying once medical reasons and hunger have been ruled out.

Possible causes for unexplained crying

#1 Cows’ milk allergies

One of the first things to consider with a crying baby who cannot be consoled is whether they could have an intolerance to something in their diet causing tummy ache or other symptoms. An allergy could be to one of the ingredients in infant formula or solid food but even an exclusively breastfed baby may sometimes react to an allergen via his mother’s milk. Some babies can be very sensitive to certain food proteins and may even have been sensitised before birth.12 Several studies in the 80s and 90s have linked the transfer of cows’ milk proteins or allergenic proteins into human milk with symptoms of colic 131415 16 and many breastfeeding text books mention the link between a crying baby and a food sensitivity.1718192021

What are the symptoms of a food allergy?

The full range of symptoms of a food allergy are discussed in Milk Allergy in Babies. They might include crying and restless behaviour, stomach or intestinal problems such as tummy ache, an inflamed gullet (oesophagus), reflux, flatulence, copious poop or constipation, and there can also be skin or breathing problems.

When considering food allergy as a cause of colic, Wambach and Spencer (2020) recommend working through the following steps:

  • Rule out hunger and illness as a cause of crying
  • Keep a mother and baby food/behaviour diary for two weeks. Include medications, supplements and drinks and note baby’s behaviour each day. Include mother’s cravings, likes and dislikes, allergens ingested, and maternal symptoms of allergies.
  • Could solid food be the cause? If baby has recently started solids this is the likely culprit of new crying. If possible, exclusively breastfeed for two to three weeks avoiding bottles even for expressed milk to see if this helps.
  • Refer to a professional allergist, paediatric gastroenterologist or other specialist if no pattern emerges.

What foods cause colic in breastfed babies?

Cows’ milk and other dairy produce including beef (bovine protein) or chocolate are very common causes of crying and discomfort but other foods can be involved (Lawrence. 2016, pp274-280). One study indicated colic may be associated with the mother eating green leafy vegetables and onion as well as cows’ milk.22

Elimination diet

If the cause was an allergy or intolerance, a baby’s colic will settle down when the trigger food is eliminated from the mother’s diet. Allergy can be a sign of underlying allergic disease and there are often other symptoms apart from crying and tummy ache in both mother and baby. As a mother removes baby’s triggers from her diet, her own health may also improve (Wambach and Spencer, 2020). For much more information see Milk Allergy in Babies and Elimination Diet.

#2 Reflux

Reflux (spitting up large volumes of milk) has become a popular explanation for unexplained crying. Several authors describe it as the new colic 2324 and there are concerns that reflux is over diagnosed and medications are being over prescribed 25

Spitting up after some feeds is a normal event for a baby and doesn’t usually cause them pain. However reflux can be associated with allergy (#1) and there is said to be a more severe form of reflux called gastroeosophageal reflux disease (GORD or GERD). If there is a diagnosis of GORD then this is not colic as it now has a diagnosis. For much more information about the causes of spitting up in the breastfed baby see Reflux in Newborns.

#3 Parenting style and expectation

Certain parenting styles may cause babies to cry more. Babies have a strong need to stay in close contact with their mother and some may be more sensitive than others if parents try to have a more hands off approach. Colic mainly occurs in industrialised regions but is rarely seen with less westernised customs and diets and more responsive baby care (Palmer, 2015 p14 & p21). Babies who are breastfed on demand and are carried in close physical contact with a parent for many hours day or night rarely cry.2627 One Scandinavian study found parents who think a baby can be spoiled by holding them too much may be more likely to have unsettled babies.28

Baby breastfeeding with eyes closed
Breastfeeding is a great comfort to a crying baby

Contagious stress

Babies are very in tune with their mothers and may sense when she is stressed causing them to fret and cry—this can worsen their mother’s stress causing baby to cry more in a vicious cycle. Gwen Dewar calls this contagious stress.29

In many cases crying due to parenting style will be relieved when parents accept their little ones’ needs and respond quickly if their baby needs comfort and carry their baby more often. However if this does not help a baby’s crying then there is likely to be another problem to solve:

If a crying baby regularly cannot be consoled, outside of heroic jiggling or Oscar-worthy distraction techniques, then there’s a reason why.

#4 Baby’s temperament

A baby’s personality is sometimes thought to be the cause of unexplained crying.

Sensory processing and emotional difficulty

There may be an underlying difficulty with controlling emotions (emotional dysregulation) and sensory processing in children with colic. Some babies may be highly sensitive and reactive to their surroundings and once their senses have been overloaded they may take a long time to calm down (Dewar, 2018; Walker, 2017). According to Breastfeeding Management for the Clinician (p 525), research suggests:

  • Cholecystokinin (a hormone involved with appetite and digestion) may be lower in colicky infants
  • Vagal tone imbalance (an imbalance in the vagus nerve, an important nerve for the heart, lungs and digestive system) may be associated with colic
  • Cortisol and melatonin (important hormones for our sleep/wake cycles) may contribute to colic if there are imbalances. Melatonin is present in breast milk and can reduce muscle contraction in the gut and reduce abdominal pain.

For more information see Sensory Processing Disorder and Breastfeeding.

Babies can get overtired or overstimulated

Some parents have found their babies can seem to cry excessively through being over tired and overstimulated. A long breastfeed will often be perfect to calm an over tired baby and send them to sleep. But sometimes even the breast is refused and a baby may be unable to fall asleep or relax. Carrying a baby in a sling, skin-to-skin contact, or going for a walk or car ride with baby may be helpful and see below for more ideas.

Feeding problems

Author Marsha Walker says an association between feeding problems and colic has been noted in some babies. For example babies who have difficulty coordinating suck, swallow, breathe (the sequence needed for comfortable breastfeeding) or who have reflux may have more episodes of feeding related discomfort and be less responsive during feeding. However it isn’t clear whether colic causes the feeding problems or whether the feeding problems are a cause of colic (Walker, 2017, p 525). Bear in mind that crying is also a sign of hunger. Any feeding problems can be discussed with a breastfeeding specialist to ensure they are not preventing a baby getting the milk they need.

#5 Lactose overload

Lactose is the main sugar in breast milk. It is digested (broken down) by an enzyme called lactase that is made in the lining of the baby’s intestine. In general by breastfeeding on demand and offering the first breast until it is finished before offering the second side; there will be the perfect amount of lactose in a breastfeed for optimal digestion. However, if a baby gets too much lactose too quickly or if anything interferes with lactase production, it can prevent lactose being digested properly in the intestines causing a temporary lactose overload. Too much lactose rushing through the bowel may cause colic like symptoms such as fussing at the breast, tummy ache, excess flatulence, and frothy copious green poop. An allergy can cause damage to the lining of the intestine that produces the enzyme lactase so that allergy (#1) and lactose overload may be present together (Minchin, 2015; Noble, 2015).

For much more information about lactose overload, causes and how to avoid it see Lactose Intolerance in Babies and Oversupply of Breast Milk.

#6 Smoking

Research indicates that colic symptoms are more likely when the mother smokes including smoking during pregnancy and after birth.30  One study found that babies are twice as likely to have colic when the mother smokes although there is a protective effect with breastfeeding reducing this effect a little.31 The same effect is seen when mothers use nicotine replacement products suggesting nicotine plays a role in colic.32

#7 Infant migraine

Another theory for unexplained crying is a link between colic and parental migraine meaning baby may have a headache and/or tummy ache (Minchin, 2015 p 579). Dewar explains:

Studies show that babies are more likely to suffer from colic if migraines run in the family (Gelfand et al 2012). In addition, babies are more likely to develop migraines later in life if they experience infantile colic (Romanello et al 2013; Sillanpää and Saarinen 2015).

Certain foods can trigger migraine in some people so this theory may have a connection to diet/allergy (#1). 33

#8 Microbiome

The microbiome is the name used for the community of microorganisms (friendly and beneficial bacteria) living on and within our bodies. The microbiome plays an important role in our health and well being. The balance of bacteria species within an individual baby’s microbiome varies with how that baby is born (vaginal or cesarean), how a baby is fed (breast milk or formula) and their exposure to antibiotics.

Undesirable bacteria and colic

Research has linked higher levels of undesirable bacteria in a baby’s gut and lower levels of friendly bacteria with symptoms of colic.34353637 There are also links between undesirable bacteria and gas/inflammation in the gut.3839 Dewar cites several studies that have looked at whether giving daily probiotics (friendly bacteria Lactobacillus reuteri) to babies could help relieve colic but concludes that more research is needed to justify their use (Dewar, 2018). Not all studies show that Lactobacillus reuteri could help colic40 and industrially produced probiotics can contain unknown allergens 41.

Antibiotics

Colic can be associated with gut infections or antibiotics either via breast milk or given directly to the baby (Noble 2015)

# 9 Physical pain

Sometimes a baby may have a physical pain following their birth making it difficult to be held or feed in certain positions. Physical therapy may be helpful in some cases, however research results vary. One study found chiropractic manual therapy might be helpful for babies with colic42 while another found no direct evidence of benefit of cranial osteopathy or spinal manipulation to help colic symptoms43 For more information see High Muscle Tone and Does Cranial Therapy Work?

#10 Flatulence, wind or gas

Although excess wind or gas is often blamed as causing colic there has not been a proven link between excessive gas and colic.44 Author Robyn Noble says;

  • Excess swallowed air doesn’t usually pass into the intestines but is burped back up the oesophagus just as we burp for relief after taking a fizzy drink (Noble, 2015).
  • Excessive flatulence is a symptom of allergy or intolerance and audible “farts” shouldn’t be heard after a baby is six weeks of age. Colic disappears once the allergy or intolerance is eliminated from mother’s diet (Noble, 2015).

How to help a baby with colic

Keep breastfeeding

  • Breastfeeding is a great comfort to a crying baby as it provides close contact wth mother, food, warmth and immune protection (Wambach and Spencer, 2020, p 265-266 )
  • Breastfeeding provides pain relief45
  • Breastfeeding is the biologically normal food for a baby and most easily digested
  • Switching to infant formula is likely to make a baby’s symptoms even worse (Wambach and Spencer, 2020, p 265-266; Lawrence, 2016, p 274-280)
  • Specialist formulas have not been shown to improve comfort levels4647
  • Breast milk contains hormones. Melatonin is a hormone that regulates the sleep cycle and relaxes the muscles in the baby’s stomach and intestines meaning breastfeeding is more likely to be protective against colic type symptoms.48 Colic has been associated with the withdrawal of maternal hormones after birth but this is a less likely cause of symptoms in a breastfed baby due to the continued presence of hormones in breast milk (Lawrence, 2016)

It can be helpful to check with an IBCLC lactation consultant to rule out any breastfeeding related causes of crying.

A colicky baby may favour upright positions

Try an elimination diet

If allergy is suspected it makes more sense to remove the allergens via modifying the nursing mother’s diet through an elimination diet rather than remove breast milk altogether. See Elimination Diet and Milk Allergy in Babies for more information. Once the offending allergen in breast milk is removed from a mother’s diet, breast milk is thought to be allergen free within a day or so.49 However any damage to the baby’s gut in terms of inflammation causing tummy ache or discomfort or damage to the intestinal lining affecting lactase production may take a couple of weeks to completely settle down.

Hold and comfort your baby

It is very comforting for a baby who is in pain if they are held and cuddled by a loving parent or carer. Even if the comforting doesn’t eliminate their discomfort at least they can sense they are not alone (Wambach and Spencer, 2020).

Ideas to help a crying baby include:

  • Respond to baby’s cries as quickly as possible
  • Carry baby as much as possible, baby carriers such as slings or wraps can help with this
  • Breastfeed frequently for food, comfort and pain relief
  • Holding baby on their tummy (in a prone position) can help some babies—see photo (Walker, 2017; Wambach and Spencer, 2020). This is sometimes called the magic baby hold, colic hold, or forearm hold.
  • Carrying baby in an upright position against your shoulder can help a baby burp more easily if that is a cause of fussing and many babies like this position
  • Try movement; rocking baby, dancing with baby in arms, or walking around with baby can relax them (a baby carrier can be useful)
  • A change of scenery may distract a crying baby—try a walk in fresh air around the garden, street or park
  • Massage may help some babies
  • Adjust sound levels; music or singing may calm some babies, while others might prefer a dark quiet room
  • Some babies may like to be swaddled so they feel contained even when they can’t be held, others may not like to feel restrained
  • Ideas in high muscle tone may be helpful for some babies
Holding baby on their tummy across a forearm is called the colic hold

No evidence for medications

Where the definition of colic is unexplained crying, it is unlikely that any over the counter remedy will be of much help;

  • Herbs are not recommended for infants.50 Gripe water is a type of herbal remedy which is not evidence based (Lucassen, 2015).
  • Colic drops containing simethicone have not been shown to work515253 Noble explains that commercial products claiming to “bring up wind” reinforce beliefs that air swallowing is the cause but excess swallowed air is simply burped up with generally only a minimum of temporary fussing (Noble, 2015. p 27)

Get support

Caring for a crying baby that cannot be consoled is extremely worrying and stressful for parents. Try to get as much support for yourselves as you can from family and friends to help you cope. Breastfeeding peer support groups can be very helpful, for example La Leche League has support groups all over the world.

Summary

A baby may be said to be suffering from colic when they have have lengthy and repeated daily crying episodes. It is not known exactly what causes colic because by definition it is unexplained crying in an otherwise healthy baby. There are a number of theories to explain this phenomenon for example; cows’ milk allergy, reflux, parenting style, baby’s temperament, parental smoking, baby’s microbiome, infant migraine or if baby has a physical pain resulting from the birth process. Ideas to help a baby with colic include to keep breastfeeding and seek help for any breastfeeding difficulties, comfort your baby when they are upset, and for the nursing mother to try an elimination diet. Always seek help from a medical professional if your baby is constantly crying.