Definition

The most widely used definition of colic is based on the amount of crying (ie, paroxysms of crying lasting >3 h, occurring >3 d in any week for 3 wk).

Causes

Colic is a poorly understood phenomenon. It is equally likely to occur in both breastfed and formula-fed infants. Although potential adverse sequelae have been described, the disorder is generally believed to be self-limited and benign. Different feeding practices and crying may result in large amounts of air entering the gastric lumen, which suggests that excessive aerophagia may be associated with colic. Colonic fermentation is the second proposed source of excessive intestinal gas in infants. However, no experimental evidence supports either theory.

Epidemiology

Colic affects 10-30% of infants worldwide.

This condition is encountered in male and female infants with equal frequency.

The colic syndrome is commonly observed in neonates and infants aged 2 weeks to 4 months.

Clinical Presentation

Colic remains a diagnosis of exclusion.

Crying by infants with or without colic is mostly observed during evening hours and peaks at the age of 6 weeks. The cause of this diurnal rhythm is not known. The amount of crying is not related to an infant’s sex; the mother’s parity; or the parents’ socioeconomic status, education, or ages.

Obtain a detailed history about the timing, the amount of crying, and the family’s daily routine. The benign nature of colic should be emphasized.

Infants with colic often have accelerated growth. Weight gain is typical, whereas failure to thrive  should make one suspicious about the diagnosis of colic.

Treatment and Management

Rule out common causes of crying is the first step in treating an infant with persistent crying (ie, colic).

Recommend that the parents not exhaust themselves and encourage them to consider leaving their baby with other caretakers for short respites.

Drug treatment generally has no place in the management of colic, unless the history and investigations reveal gastroesophageal reflux.

Consistent follow-up and a sympathetic physician are the cornerstones of management.

Many benign but unproven treatment modalities are available for colic.

Dicyclomine hydrochloride is an anticholinergic drug that has been proven in clinical trials to be effective in the treatment of colic.

Oral hypertonic glucose and sterile water were compared for treatment of colic in infants in a randomized trial. In the group receiving glucose, 30% had significantly less colic than the placebo group.

Remind parents about the importance of feeding a hungry baby, changing wet diapers, and comforting a baby who is cold and crying as a result of these factors. Soothing music accompanied with parental attention (including eye contact, talking, touching, rocking, walking, and playing) may be effective in some infants and is never harmful.

Encourage parents to discuss their feelings and concerns with each other to obtain support. Emphasize the responsibility of the whole family in the care of a baby with colic.

Causes

Precipitating factors include trauma, salivary gland dysfunction, stress, genetic predisposition, local infections, nutritional deficiencies, GI disorders, systemic disorders, food allergy or hypersensitivity, hormonal fluctuations, and chemical exposure.

Clinical Presentation

The diagnosis of aphthous ulcers (canker sores) is primarily clinical. Patients typically describe a prodromal stage of a burning or pricking sensation of the oral mucosa 1-2 days before the ulcer appears.

Aphthous ulcers occur on areas of the mouth in which the mucosa is nonkeratinized and loosely attached, particularly the buccal mucosa, the labial mucosa, the floor of the mouth, the ventral surface of the tongue, and the soft palate. Ulcers may appear as single or multiple lesions, and they are easily distinguished from primary or secondary viral infections, bacterial infections (eg, necrotizing ulcerative gingivitis), dermatologic conditions (lichen planus, cicatricial pemphigoid, pemphigus), and traumatic injuries (contusions, lacerations, burns) by the healthy appearance of adjacent tissues and the lack of distinguishing systemic features.

Diagnosis

The diagnosis of aphthous ulcers (canker sores) is usually based on the history and clinical presentation. No laboratory procedures are available for definitive diagnosis.

• In patients with severe recurrent aphthous ulcers (RAUs), or canker sores, the clinical picture should guide laboratory testing. CBC count, a chemistry panel, and nutritional workup may be necessary.
• Patients with suspected malabsorption or a nutritional deficiency should undergo immediate screening. Consider screening in patients presenting with a history of recurrent aphthous ulcers (canker sores) lasting 6 months or longer.

Treatment and Management

The primary goals of medical therapy in patients with aphthous ulcers (canker sores) are pain relief, maintenance of fluid and nutrition intake, early resolution, and prevention of recurrence. Most patients with minor or herpetiform aphthae should be treated empirically before extensive and costly studies are initiated. Treatment of recurrent aphthous ulcers (canker sores) typically includes anti-inflammatory and/or symptomatic therapy.

High-potency corticosteroids applied locally 2-4 times daily may be successful in promoting healing and shortening the course of recurrent aphthous ulcers (canker sores), especially if applied early in the development of the lesions.Topical preparations such as mouthwashor gels are preferred because they limit the amount of medication delivered and thus reduce systemic adverse effects. Remember that corticosteroids increase the risk of candidiasis and other secondary infections.

Benzocaine is the most commonly used anesthetic agent, applied for temporary relief with cotton-tipped applicator on an as needed basis (usually before meals).

Lidocaine 2% gel (by prescription only) can also be used, but can also cause toxicity in children.

Pathophysiology

The pathogenesis of Crohn disease is multifactorial. After a triggering event occurs in a genetically susceptible individual, an altered immune response leads to chronic inflammation of the intestine. Although the etiology of the precipitating event is unknown, luminal bacteria or specific antigens are thought to be involved.

The macroscopic findings at the time of endoscopy and colonoscopy or surgery include various degrees of edema, erythema, ulceration, friability, thickening of the bowel wall and mesentery, and extension of fat over the serosal surface of the intestine.

Skipped areas of inflammation anywhere in the upper or lower GI tract are characteristic of Crohn disease, in contrast to the continuous diffuse colonic inflammation found with ulcerative colitis(UC). Microscopic findings on intestinal mucosal biopsy consist of chronic inflammation with architectural distortion. Granulomas  are sometimes noted on biopsy findings in Crohn disease.

Clinical Presentation

Patients with suspected Crohn disease (CD), or Crohn’s disease, should initially be evaluated by their primary care team. The patients’ symptoms should be elicited in detail. A medical history, detailed review of systems, and family history should be obtained, and growth parameters should be documented.

A careful assessment of growth and development is an important part of evaluating the pediatric patient. Growth abnormalities may be detected by evaluating several parameters: height and weight, percentage height and weight for the patient’s age and percentage weight for the patient’s height, growth velocity, body composition on anthropometry, and skeletal bone age.

• Vital signs are usually normal, although tachycardia may be present with anemic patients. Chronic intermittent fever is a common presenting sign.
• Body weight and height may reveal weight loss and growth delay.
• Abdominal findings may vary from normal to those of an acute abdomen. Diffuse abdominal tenderness is often present. Fullness or a discrete mass may be appreciated, typically in the right lower quadrant of the abdomen, which may represent a palpable thickened loop of bowel.
• Perianal disease (eg, skin tags, abscesses, fistulae, fissures) is present in approximately 45% of patients.
• Pubertal delay may precede the onset of intestinal symptoms, and accurate Tanner staging should be a part of routine physical examination.
• The most common cutaneous manifestations of Crohn disease are erythema nodosum and pyoderma gangrenosum. Skin examination may also reveal pallor in patients with anemia or jaundice in those with concomitant liver disease.
• Eye examination may reveal episcleritis. For the diagnosis of uveitis, a slit lamp examination by an experienced physician is necessary.
• The most common extraintestinal manifestations of Crohn disease are arthritis and arthralgia. The large joints (eg, hips, knees, ankles) are typically involved.

Treatment

The general goals of treatment for children with Crohn’s disease, are

(1) to achieve the best possible clinical, laboratory, and histologic control of the inflammatory disease with the least adverse effects from medication;

(2) to promote growth with adequate nutrition; and

(3) to permit the patient to function as normally as possible (eg, in terms of school attendance, participation in activities).

5-ASA preparations

Although commonly used, recent adult meta-analyses have suggested that oral 5-ASA preparations do not demonstrate clinically important treatment effect for active Crohn disease and are not superior to placebo for the maintenance of remission in Crohn disease.

Nutritional therapy

Nutritional therapy is another important modality for the treatment of disease, malnutrition, and growth failure observed in Crohn disease.

Corticosteroids

• These are the mainstay of therapy for acute exacerbations because they suppress acute inflammation, thereby providing rapid symptomatic relief.

Immunomodulators

• Immunomodulators have been used to induce and maintain long-term remission in chronically active, steroid-dependent or steroid-refractory, moderate-to-severe pediatric Crohn disease.

Antibiotics

A few, small studies have shown the usefulness of antibiotic therapy in the treatment of Crohn disease. Metronidazole, as well as the combination of metronidazole and ciprofloxacin, is useful in both the management of perianal disease and small bowel and colonic disease.