Infantile Colic vs. PURPLE Crying: Key Differences in Treatment
Infantile colic and PURPLE crying are essentially the same phenomenon described through different frameworks—both represent normal developmental crying patterns that require parental reassurance and support rather than distinct medical treatments. 1, 2
Understanding the Terminology
PURPLE crying is not a separate diagnosis from infantile colic; it is an educational framework developed to help parents understand normal infant crying patterns. 1 The acronym describes characteristics that overlap completely with colic:
- Peak of crying around 6 weeks
- Unpredictable episodes
- Resistant to soothing
- Pain-like facial expressions
- Long crying bouts
- Evening clustering
Both conditions resolve by 3-4 months of age and affect otherwise healthy infants. 2, 3
Management Approach (Identical for Both)
First-Line: Parental Education and Reassurance
The cornerstone of management is educating parents that this is a benign, self-limiting developmental phase, not a disease requiring cure. 1, 2 The Period of PURPLE Crying program specifically improves mothers' knowledge about crying patterns and behavioral responses, though it has not yet demonstrated strong evidence for preventing abusive head trauma. 1
Evidence-Based Treatment Options
For breastfed infants with colic/PURPLE crying:
- Lactobacillus reuteri DSM 17938 is the only intervention with strong evidence, reducing crying time by a median of 65 minutes per day. 4, 2
- Dosing: 5 drops daily for 21 days minimum. 5
- Clinical response (≥50% reduction in crying) occurs in 85% of infants. 5
- Maternal dietary allergen elimination (particularly cow's milk protein) may be considered as a second-line option. 2
For formula-fed infants:
- Switch to extensively hydrolyzed formula if cow's milk protein intolerance is suspected. 2, 3
- L. reuteri DSM 17938 has less robust evidence in formula-fed infants compared to breastfed infants. 4
Ineffective or Contraindicated Treatments
Avoid these interventions regardless of terminology used:
- Simethicone—ineffective. 2
- Proton pump inhibitors—ineffective and not indicated without GI symptoms. 2
- Dicyclomine—contraindicated due to safety concerns. 2
- Chiropractic manipulation, infant massage, swaddling, acupuncture, or herbal supplements—lack evidence. 2
Critical Clinical Pitfalls
Rule out organic causes before diagnosing colic/PURPLE crying (occurs in <5% of cases): 6
- Obtain detailed history focusing on feeding patterns, stool characteristics, and growth parameters
- Perform thorough physical examination looking for fever, poor weight gain, vomiting, bloody stools, or neurological abnormalities
- These "red flags" indicate need for further workup rather than reassurance alone. 2, 7
Address maternal mental health: Excessive infant crying significantly increases maternal depression risk. 5 L. reuteri treatment reduced maternal depression scores by 63% at study end, likely through reducing infant crying time. 5
Practical Implementation
Week 1-3: Provide parental education using PURPLE crying framework, initiate L. reuteri DSM 17938 if breastfed, consider hydrolyzed formula if formula-fed. 4, 2
Week 4: Reassess crying duration and parental coping. If no improvement with L. reuteri in breastfed infants, consider maternal elimination diet. 2
Ongoing: Monitor for parental exhaustion and depression, as these are the primary morbidities associated with this condition. 1, 5 The crying itself causes no harm to the infant but creates significant family stress. 6, 3
By 3-4 months: Symptoms should resolve spontaneously regardless of intervention. 2, 3 Persistence beyond this age warrants reevaluation for alternative diagnoses. 7