Talk:Infant colic/Draft

Nancy Sculerati MD has nominated this version of this article for approval. Other editors may also sign to support approval. The Health Sciences Workgroup is overseeing this approval. Unless this notice is removed, the article will be approved on April 22, 2007.

Article Checklist for "Infant colic/Draft"

Workgroup category or categories	Health Sciences Workgroup [Categories OK]
Article status	Developed article: complete or nearly so
Underlinked article?	No
Basic cleanup done?	Yes
Checklist last edited by	Christo Muller (Talk) 10:31, 11 April 2007 (CDT)

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First posting

An original Citizendium by myself with references. Now to add pictures. Comments, changes, deletions, and additions as always welcome. Links need to be added. Christo Muller (Talk) 09:59, 9 April 2007 (CDT)

Wow, very impressive! Would have been nice to have about eight months ago, although our baby didn't really have colic. What might be nice (I mean, for purely selfish personal reasons) is an article about how babies start to walk, and one on how they start to talk. --Larry Sanger 10:50, 9 April 2007 (CDT)

Another editor asks

Christo, I am working my way through. I think this is just the kind of thing that CZ can offer the world as a real benefit. I do not intend on "authoring" in the sense of adding any new ideas or information. I would like to edit this-which I have begun doing, simply for such things as language and links. Hopefully, we can get this approved. I have a first specific complaint that requires your input. I quote below: "During the attack the babies face is contorted in apparent pain (though the eyes may remain open, and the child appear alert, in contrast to, for instance, needle stick and post-operative pain)." Now that is useful for pediatricians, Recovery room nurses, house staff etc- but what about parents? They are hopefully neither sticking needles in or operating on their children with enough regularity to use these examples pragmatically (that is a joke, coming from a mother- a loving mother I am told- who is also a surgeon, so please -anyone reading this-don't get too upset) - so can you re-state it? Perhaps distinguishing it from cries that parents should worry about- like meningitis or even acute otitis media, rather than dismiss as "just colic", or cries like hunger- dirty diaper that they may be familiar with?. Nancy Sculerati 11:06, 9 April 2007 (CDT)

Well done

Good job Christo. A very thorough, informative, neutral narrative. What more could we ask for. My only 2 cents were from an editing point of view noting that there was some repetition with signs and symptoms that were repeated among at least two of the sections, but it might have been necessary to keep it clear in the readers mind. Other than that, you kept me focused and answered all my questions along the way. --Matt Innis (Talk) 12:26, 9 April 2007 (CDT)

Just a bit more editing

1) the graph would benefit from a bit more of a caption. Additionally, could you actually describe some of the data it is based on? I know you have references, I'm asking you to describe the content of those references in the text, in a paragraph that refers explicitly to the excellent graph you created. 2)"It is equally wise to remember that when the health worker has not identified a definite cause for the crying, this does not exclude more serious problems with anything like 100% certainty, and conversely, where a separate disease has been diagnosed, its treatment will not necessarily solve co-incidental colic."

This sentence (quoted above) is very clear to me, but the article would benefit from its expansion, in my view. Perhaps, bearing in mind that this article is likely to be read by exasperated parents (at midnight) with a certain high pitched cry very audible in the background (as they stare at their computer screens), you could actually give a couple of theoretical cases. Interesting, easy to follow. You know- make it clear that you are making up examples, but a narrative that illustrates those important concepts of sensitivity and specificity. Just like you would probably use in talking to parents you are counseling. That's a hard one (specificity/sensitivity) for even medical students and residents to apply to real cases. Anyway, thanks, the article is really looking good. Nancy Sculerati 14:23, 12 April 2007 (CDT)

Conventional medicine: "Since both these medications cause sedation and sleepiness, it is possible that the beneficial effect is on the central nervous system. This raises the question of whether it would be wise to use such treatments indiscriminately." If you agree, I think that pointing out that in infants who at the age during which colic strikes, actual brain meyelination and synaptic connections are being made, and that drugs crossing the blood -brain barrier may have not only immediate, but, at least in theory, lasting effects. Aternative medicine:" Once the reason for their efficacy is determined, these herbals would become part of the armamentarium of scientific medicine." Perhaps a word also that a profile of side effects and safety (therapeutic index) would also be available - and is not now available for these medications. Nancy Sculerati 21:08, 12 April 2007 (CDT)

all babies in distress

Christo. I am going through again, from the beginning. I changed word order and punctuation in some places, and inserted a sentence that explains more about entry criteria in a study (without using that term.) I want to confine my role here strictly to editing, and not authoring, and I believe that I have done so, but please change any of my changes without need for explanation if you would prefer the previous language. I come to the phrase: "all babies in distress". Since it is so important to a mother or father when faced with a colicky infant to know whether the doctors think the baby actually is in distress, and the point of this section seems, to me, partly to reassure parents that the loudness and pitch of the cry of the baby is the same when they get into a crying jag; whether they are in pain, hungry, or irritated by diaper rash, or suffering from catastrophic problems, as when they are not any of those things, but - as far as can be told-are actually just fine (but crying anyway.) So, this "all babies in distress", needs clarification. Do you mean "in distress", or do you mean in an episode of crying? If you mean in distress, could you be more specific. I had 2 babies and I assure you if I thought they were "in distress", neither man nor beast could have stopped me from doing something about it, let alone some doctor's written assurance that it doesn't matter. Are you implying that it's OK for my baby to be in distress? Or are you implying that's it allright for a baby to cry a lot? I'm resorting to the dictionary - give me a moment ;) Nancy Sculerati 09:16, 14 April 2007 (CDT)

For a noun, the Oxford English Dictionary uses this meaning for distress, as applies to the use of the word in the prase "in distress" (e.g. damsel in distress)" 2. a. The sore pressure or strain of adversity, trouble, sickness, pain, or sorrow; anguish or affliction affecting the body, spirit, or community. " Affliction sounds like disease to me. Nancy Sculerati 09:26, 14 April 2007 (CDT)

Thanks Nancy. The closest I have come to defining distress in the medical or physiological sense is that the organism is experiencing stress with which it is not able to cope. In this interpretation, stress is both necessary and valuable, distress has doubtful value and may be harmful. Stress is commonly associated with increased efficiency, distress with a failure of compensatory mechanisms. The issue is important in the US, since your congress has written a law which requires that researchers working with animals have to make sure that the animal does not suffer unnecessary "pain or distress". Since it is law, the responsible government agencies have to be able to apply it, and check that "distress" is not being caused, but no-one has a generally accepted definition of distress, nor has anyone a clue as to how to measure it. (I will have to look up the applicable USC, but I know that there have been whole conferences held just on this issue!) Be that as it may, your point is well made. In the article the word is used in a rather loose way, and I shall review the relevant section to see what I can come up with, to decrease the potential for confusion. Christo Muller (Talk) 16:15, 16 April 2007 (CDT)

some references

Crotteau CA. Wright ST. Eglash A. Clinical inquiries. What is the best treatment for infants with colic?. [Review] [9 refs] [Journal Article. Review] Journal of Family Practice. 55(7):634-6, 2006 Jul. UI: 16822454

EVIDENCE-BASED ANSWER Infantile colic, defined as excessive crying in an otherwise healthy baby, is a distressing phenomenon, but there is little evidence to support the many treatments offered. Several small studies report some benefit from use of a hypoallergenic (protein hydrolysate) formula, maternal diet adjustment (focusing on a low-allergen diet), and reduced stimulation of the infant. While dicyclomine has been shown to be effective for colic, there are significant concerns about its safety, and the manufacturer has contraindicated its use in this population. An herbal tea containing chamomile, vervain, licorice, fennel, and balm-mint was also effective in a small RCT, but the volume necessary for treatment limits its usefulness (strength of recommendation: B, inconsistent or limited-quality patientoriented evidence). The one proven treatment is time, as this behavior tends to dissipate by 6 months of age.

There are myriad strategies-ranging from craniosacral osteopathic manipulation to car ride simulation-offered for dealing with infantile colic. Although none of these treatments has been validated in rigorous studies, the available evidence offers tentative support for 3 strategies: (1) a trial of a hypoallergenic (protein hydrolysate) formula (for formula fed infants), (2) a low-allergen maternal diet (for breastfeeding mothers), and (3) reduced stimulation of the infant.

"Several medications have been tested in RCTs; only dicyclomine has shown an effect in a few small RCTs.3,4 However, there have been reports of apnea and other serious, although infrequent, adverse effects. For that reason, the manufacturer has contraindicated the use of this medication in infants aged < 6 months." (Shall we mention apnea? Nancy Sculerati 06:26, 20 April 2007 (CDT))

The American Gastroenterological Association recommends a hypoallergenic, protein hydrolysate formula for formula fed infants or a maternal low-allergen diet as an initial strategy for infant struggling with colic symptoms if the clinician is considering a diagnosis of (cow's milk) allergy.7

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scholarly & readable

What a FINE JOB. I have , as is my wont, been going through a full text search on colic through medline, and all I do is come upon the papers you have so nicely digested and worked into this article. Best of all, I think, the article is not just accurate but is written well and has a doctorly care of the infant with colic incorporated into every line.(see start of sentence) Nancy Sculerati 06:34, 20 April 2007 (CDT)

opening sentences

I think the opening sentences could use a little fine-tuning for a general audience. Below is my suggestion:

Infant colic is a medical term for persistent and inconsolable crying by healthy infants, who are usually between the ages of two and sixteen weeks. It is a syndrome – a defined set of symptoms and signs – and not a specific disease. A common definition is: continuous crying that lasts for a period of more than three hours, occurring more than three days per week, and continuing for longer than three weeks. "Infant colic" (or "colic") applies only to young infants, and does not include older babies and toddlers who may cry excessively.Thomas H. White 09:17, 20 April 2007 (CDT)

incorporated your suggestion, which does improve readability, made minor change in it ("common" to "most generally accepted") . (see article) Thanks for making it! Nancy Sculerati 09:52, 20 April 2007 (CDT)

A suggestion and comments on points mentioned above.

I have corrected two minor typos, see page history.

Rephrase two sentences: The second paragraph has two sentences which sound wrong (I think it was my edit on top of Nancy's ;-(): "... there is some dispute that infant colic even exists as a true medical disorder. The phenomenon that some babies at certain ages cry excessively may be a non-specific response to any number of stimuli, and the crying as such has no significance as indicating a disease, nor is it a disease itself. It is simply something that some babies do very easily and often at that time of their lives." The (my italics) sentences describe the claims of one side of the debate (whether colic is a disease or not), and I suggest we add some "may"s and "may be"s, to show that there is no solid proof one way or the other; as it stands it reads as if these may be facts. I propose: "The phenomenon that some babies at certain ages cry excessively may be a non-specific response to any number of stimuli, and the crying may have no significance as indicating a disease, nor be a disease itself. It may simply be something that some babies do very easily and often at that time of their lives." The next sentence then follows more logically "If that (i.e. all the maybe's) is the case, then...". If others do not disagree, I shall change tomorrow.

Since "may" can be interpreted in so many ways, can you try another change? Could you put in just what you did in the explanation above, that this is one side of the debate? Even use the line that you give us above,in addition, that there is no solid proof one way or another. Nancy Sculerati 17:58, 20 April 2007 (CDT)

To keep it simple, one can write: The "colic is not an illness" view holds that the phenomenon that some babies at certain ages cry excessively may be a non-specific response to any number of stimuli, and the crying as such has no significance as indicating a disease, nor is it a disease itself. Seems ok then? (Not yet changed) --Christo Muller (Talk) 02:00, 21 April 2007 (CDT)

Change it either way, it will work. Nancy Sculerati 10:22, 21 April 2007 (CDT)

Dicyclomine: From the medication (Bentyl in this case) pamphlet: "There are reports that administration of dicyclomine syrup to Infants has been followed by serious respiratory symptoms (dyspnea, shortness of breath, breathlessness, respiratory collapse, apnea. asphyxia), seizures, syncope, pulse rate fluctuations, muscular hypotonia, and coma. Death has been reported. No causal relationship between these effects observed in infants and dicyclomine administration has been established. Dicyclomine is contraindicated in infants less than 6 months of age and in nursing mothers." These side-effects are pretty rare, so that causality is doubtful (Did the infants have colicky symptoms due to another disease?), and I thought one could leave out the horror tale and stick to pointing out the contra-indication. Maybe we could convey the information that the full warning is in the package insert by something like: "The medication package insert also warns nursing mothers against taking this medication for disorders in themselves, since it is excreted in breast milk."

Rather than just leave it either so explicit (and overwhelming) with a laundry list, or so vague as to give no real information, how about saying "has been associated with serious side effects like breathing problems, weakness and depressed conciousness in babies, and, since it is excreted in the breast milk, is contraindicated both in infants under 6 months old and in their nursing mothers."Nancy Sculerati 17:58, 20 April 2007 (CDT)

Your phrasing fits in well, and I have changed the sentence. --Christo Muller (Talk) 02:00, 21 April 2007 (CDT)

The Crotteau reference is duplicated by others in the article, so I did not include it. One of my problems with the hydrolysed casein or whey is the prohibitive expense, and if one states it as a "should try" - as Crotteau does by reference to a specialist gastroenterology journal - then one may end up making a number of less affluent mothers feeling unnecessarily guilty about not being able to buy the stuff. As it stands, the section on changing feeds is reasonably non-committal, leaving the decisions to the mother and the health worker. I think the warning signs of vomiting, blood in stool, etc are sufficiently clearly stated for mothers to be able to identify babies who really need a change, for more serious health reasons. Christo Muller (Talk) 17:28, 20 April 2007 (CDT)

As Editor, I had to come up with at least one reference that you didn't include, Christo! Of course, this is a minor and deriverative reference and you need not include it, but at least I have salvaged my pride (over being able to add absolutely nothing from my own review of the literature, even on the talk page) and have demonstrated a proper editorial effort here! ;) Nancy Sculerati 17:58, 20 April 2007 (CDT)

I've reread the article, and it definitely has unique value for the succinct statement of the "Evidence-based Answer", maybe even more for Anne Eglash's "Clinical Commentary". Compared to Lucassen 1998 (our ref 23) and Garrison 2000 (our ref 32) it seems more intelligible for an average layman (and busy general practice). Being a sort of summary, and making the same point, I include it as support for the "Conclusion" section, the second sentence, where it would add value. --Christo Muller (Talk) 02:00, 21 April 2007 (CDT)

PS- head shots of crying babies? any pictures of crying babies? best would be !Kung San baby, I think, but any, (or several) of the correct age, would do. Nancy Sculerati 17:58, 20 April 2007 (CDT) Especially all different babies, so that it is visually obvious that all babies cry. Nancy Sculerati 20:03, 20 April 2007 (CDT)

Infants seem to be sensitive to their public image: the past two days 3 out of 3 wailers stopped crying when the camera was trained on them - and remained shut up for 5 minutes. But I've got nice pics of dragonflies by sitting and waiting; maybe babies need the same patience. We should get something soon. --Christo Muller (Talk) 02:00, 21 April 2007 (CDT)

Who's the intended audience?

A few content comments and then I ask that question below:

• An average English speaker would interpret the term "colic" to refer to a cramp-like pain arising from a hollow organ - That's news to me. I interpret it to mean persistent and inconsolable crying by healthy infants.

Tried to fix it, Stephen. The actual English definition (not medical-just English) is the one I have now quoted in the text. I have tried to find a citation for the OED online, and the site itself does not give one. Do you think it's ok to use it as I have now done so? Anyway, Infant colic takes the "colic" part from that word, and actually isn't colic at all. (have mercy!) Nancy Sculerati 11:29, 21 April 2007 (CDT)

• Self-limited, it begins and ends by itself. Given such vagueness... - this "self-limited" part is itself vague. Moreover, the term seems to imply that colic has agency.

I don't know what you mean by agency? Self-limited is a term commonly used in lay publications about medical conditions, like ordinary sore throats, colds, and such, that run a course and are cured or "ended" by the body without the need for intervention. see, for example, [1]Nancy Sculerati 11:24, 21 April 2007 (CDT) Will immediately incorporate better wording if you can suggest it. Nancy Sculerati 11:29, 21 April 2007 (CDT)

• ...and up to 70% of mothers of colicky babies entertain explicitly aggressive thoughts towards the child, while 26% have fantasies of infanticide. - Can the study cited here really be extrapolated such this can be stated so definitely?

• The amount of crying time per day increases up to a maximum at about six weeks of age... - Up to a maximum what? No need to make the reader dig and figure. "...up to a maximum of 300 minutes per day..."

There is no fixed maximum- that's the idea of a curve, in other words the amount of time spent crying increases for each baby a little differently, but overall- they follow the same tine course in amount of crying / age, and the ones that cry most tend to peak highest. That's why I think the graph needs explaining- wordy or not. Better wordy if it's said well. I leave it up to you and Christo to see how it can be best said, or better said. We are not looking for perfection.Nancy Sculerati 11:41, 21 April 2007 (CDT)

• The accompanying figure of the normal crying curve has been created to illustrate some of the most salient points about the phenomenon of crying, as it pertains to infant colic. The graph has been designed as a didactic figure, illustrating the shape of crying curves which might be found in different babies, and is not a report of a clinical investigation. - Ooo-wee! This is the kind of stuff us writing instructors like to put on the board as an example of Wordiness. How about this: "The figure on the right illustrates crying curves of different babies." :-)

we need to explain what a curve is for the smart parent that is not educated in reading curves. Nancy Sculerati 12:07, 21 April 2007 (CDT)

• "Missing" values have been interpolated, and the graph smoothed, so that the fact that an infant may show a temporary decrease in crying, with the line of the graph making a temporary downward curve before increasing again is not shown here. - Footnote it.

I don't think footnoting it is wise-it needs to be expalined better, and again, perhaps you can help us. You see, the graph was "smoothed" in the sense that the data was averaged out. It looks very smooth, like every baby reaches this peak in crying and then arcs down. Well, thats' a little artificial, actually there are jagged points. What Christo is trying to say here is that although all babies generally follow these curves (the shape) individual babies might go up and down a bit. So- if you looked at the curves as drawn, as a parent, and had a colicky baby who seemed to peak in crying two weeks ago, and then crying time went down-but last night IT WENT UP again, you wouldn't panic if we explained this correctly-you would understand that the jagged points have been "smoothed". It's not that your baby is not following the normal pattern. Parents of colicky parents are often desperate, and the last thing they need is to get the idea that if their baby is crying more tonight that means the peak is still to come in the future, or- if its been up and down a bit in crying tinme, that the baby does not have infant colic after all because she doesn't "fit the curve".

I need to stop before going on and say I am really unclear about who is the intended audience for this article.

see below Nancy Sculerati 11:47, 21 April 2007 (CDT)

Stephen Ewen 10:39, 21 April 2007 (CDT)

Will try to address your comments with suitable edits. More about audience in a moment. Nancy Sculerati 10:54, 21 April 2007 (CDT)

have tried to address your comments, and looking forward to more of them from you, thanks Stephen. Now as to audience. This is what I wrote on the talk page of another article I am involved in currently, Infant growth and development (perhaps you'll look and comment?) "This is aimed to be a guide for parents that is accurate enough for a pediatrician to use as a reference.". When I practiced, my routine, everyday clients (I saw children as patients so the "clients", if you will, were the parents) included malpractice lawyers, Hassidic rabbis, major diamond dealers, lawyers who specialized in arbitrage, UN ambassadors, Television executives, and other local (Manhattan) physicians, as well as many other people, but generally, not people who were satisfied with an answer like "oh, because that's the standard treatment" in answer to "why are you recommending that my baby has surgery,doctor?".(especially since each of the two parents was likely to be one of the preceeding). I talked to all these people pretty much the same, laying it out straight but trying to do so in language that could be followed by intelligent lay people.That's who this article is for, and they may not be every parent but, unlike the "average parent" they have no good resources. That's who this article is for, the parent who wants to really understand, as well as the medical student or health science professional, or healing arts professional who want a quick review. Now, I realize you are implying we have failed here, Stephen, but that is what this article is about- it is absolutely on a level that should satisfy a pediatrician (or a malpractice lawyer) as well as a parent, or either one of them as a parent. So we do not want to dumb it down - there's plenty of that stuff available in the brochures and websites that don't really tell the story of infant colic, but are designed for average public consumption. Can you help us make the language easier to understand? In my experience that means more of it- not less, because we do not want to lose a single idea. Nancy Sculerati 11:57, 21 April 2007 (CDT)