Baby Colic and Breath Holding Spells

by Brian Alverson, MD

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    00:01 Let’s review infant colic.

    00:04 Infant colic happens in the first six months of life.

    00:08 And it’s a period when a child has extreme crying.

    00:12 This can be remarkably frustrating for parents.

    00:17 These infants may be complete inconsolable with their normal interventions such as rocking or bouncing them or taking them for a stroll.

    00:25 It can be very frustrating because parents may think that something’s wrong and yet they take their child to the doctor and there’s nothing going on.

    00:32 It typically happens at the same time of day.

    00:35 And usually around two to six weeks of age.

    00:39 It may start and stop quickly.

    00:41 They may have a three-week period when they’re screaming and crying and then it just goes away.

    00:46 And it’s not attributable to any other cause.

    00:49 We should examine these children and make sure there’s nothing going on like, classically, a scratched cornea or they may present with crying very severely and it turns out they have a hair tourniquet around their finger.

    01:02 So what are some things that could cause excessive crying in children that are not colic that we have to rule out.

    01:10 There’s a mnemonic, ITCRIESS, with two S’s.

    01:13 We can go through that.

    01:15 I is infections such as urinary tract infection, meningitis or osteomyelitis.

    01:20 These infants typically will have fevers.

    01:24 Trauma, which may be non-accidental.

    01:27 When you examine these patients, you want to gently squeeze every bone in their body to make sure there’s not a broken bone.

    01:34 Parents who have committed trauma don’t usually immediately fess up to it.

    01:39 They may have inconsistent stories.

    01:41 There are some way you can figure that out and you can listen to that more in my child abuse lecture.

    01:47 Patients may have cardiac issues.

    01:50 They may be in congenital heart failure.

    01:52 So that’s something you want to watch for.

    01:55 Children very rarely can have reflux or allergy to formula, which causes crying.

    02:01 They may have immunization reactions or insect bites.

    02:06 They may have corneal abrasions.

    02:08 In any child who presents with excessive crying, it’s very reasonable to do a fluorescein exam of the eye to look for a corneal abrasion.

    02:15 That will heal up in a day or two.

    02:17 Rarely, patients have a surgical issue.

    02:20 Examples would be malrotation, which is sort of like volvulus, or intussusception or an inguinal hernia.

    02:27 Or they may have a strangulation from a hair tourniquet like you can see here.

    02:31 It’s where a hair accidentally gets wrapped around fingers, toes, the penis, or the clitoris.

    02:37 All those things can happen.

    02:40 So how do we define infant colic? We have a rule of threes.

    02:44 A child should have crying for at least three hours a day.

    02:48 It should occur three days a week.

    02:50 And it should be present for at least three weeks.

    02:53 If it satisfies these criteria, we typically say, “Yes, your infant has infant colic.” There aren’t a lot of things unfortunately we can do for infant colic that are hugely effective except assuring families that eventually their child will outgrow it.

    03:08 Changing formula is common, but it very rarely helps.

    03:12 What usually happens is they change their formula to something else, the colic goes away, and the parent becomes insistent that that formula change was the key thing.

    03:21 So if they do change the formula, when the child gets better, it’s reasonable to go back to the old formula if it’s more expensive.

    03:29 So if they, for some reason, ended up on for example Alimentum, which is very costly, it might be reasonable to go back to a cow’s milk based formula to give it a try so you might save that family some substantial money.

    03:42 It’s important to acknowledge the parent’s frustration and screen for abuse.

    03:47 A really good question is how is your child to get along with? If the parent describes complete exacerbation, you need to screen for abuse in that circumstance.

    03:59 It’s important that patients feed their babies upright with frequent burping.

    04:05 Babies who lie down or don’t get burped may have reflux that may be exacerbating the problem.

    04:10 Smaller amounts more frequent are better than the larger amounts less frequently.

    04:16 It’s important to reduce extra stimulation in these infants.

    04:19 If they’re sleeping, let them lie.

    04:22 Also, soothing music, swaddling is key, massaging or rocking are all options.

    04:29 And a pacifier use may help.

    04:31 Although sometimes, it’s hard to get the child off the pacifier later in life.

    04:38 Let’s briefly discuss breath holding spells to end this lecture.

    04:42 Breath holding spells are a common phenomenon in children and can be completely terrifying to parents.

    04:48 They’re normal and they don’t cause problems.

    04:51 Basically, when a child experiences something that they don’t like, it can be a frustration, it can be something that frightens them or it can be almost random, they start with crying, and then they just hold their breath.

    05:05 It’s almost like they’re opposition to the world is “I’m going to hold my breath and show you.” Then, they can develop color change.

    05:13 They may develop cyanosis, like this boy is pictured having.

    05:18 This may result in a loss of tone or even frank loss of consciousness.

    05:24 Children can hold their breath until they pass out.

    05:28 This can start as early as six months and generally go for several years.

    05:34 The way to avoid these and the way to treat these is to encourage the parents to use distraction therapy and not to give them too much attention when they do it, once it’s established that this in fact what’s going on and it’s not a seizure or something more significant.

    05:50 Generally, six months to eighteen months of age is the typical age.

    05:55 And for this, really no testing is needed.

    05:57 If it fits the general criteria of having a stimulation and following through those steps that I’ve described.

    06:05 Generally, care is largely supportive.

    06:07 We have to help the parents learn to manage their children’s tantrums.

    06:12 Emphasize the benign nature of the event and encourage distraction techniques.

    06:18 Rarely iron supplements may reduce the frequency even in patients who don’t have anemia.

    06:24 Nobody’s really sure why that works, but sometimes it does, and in severe cases, you can certainly try it.

    06:30 So that’s my review of these general behavioral problems in kids.

    06:35 Thanks for your time.

    About the Lecture

    The lecture Baby Colic and Breath Holding Spells by Brian Alverson, MD is from the course Child Development and Behavior. It contains the following chapters:

    • Infant Colic
    • Breath Holding Spells

    Included Quiz Questions

    1. Infant colic
    2. Gastroesophageal reflux disease
    3. Intussusception
    4. Corneal abrasion
    5. Hair tourniquet
    1. It can start soon after birth
    2. There is intense crying at 1–6 months
    3. It occurs at the same time of the day
    4. It can be due to corneal irritation
    5. It cannot be due to any underlying gastrointestinal pathology
    1. Anemia
    2. UTI
    3. Non-accidental trauma
    4. Corneal abrasion
    5. Insect bites
    1. Crying for at least 3 hours per day > 3 days per week for at least 3 weeks
    2. Crying for at least 4 hours per day > 2 days per week for at least 4 weeks
    3. Crying for at least 2 hours per day > 4 days per week for at least 2 weeks
    4. Crying for at least 3 hours per day > 2 days per week for at least 3 weeks
    5. Crying for at least 3 hours per day > 4 days per week for at least 1 weeks
    1. Tachypnea
    2. Crying
    3. Cyanosis
    4. Loss of tone
    5. Loss of consciousness
    1. Never use a pacifier
    2. Feed baby upright with frequent burping
    3. Reduce extra stimulation
    4. Massaging or rocking
    5. Look for child abuse

    Author of lecture Baby Colic and Breath Holding Spells

     Brian Alverson, MD

    Brian Alverson, MD

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