Source: Manual of Ambulatory Pediatrics 2010
SOAP Note – Colic
COLIC
Characterized by periods of unexplained irritability and intense crying in healthy infants, apparently associated with abdominal pain.
I. Etiology
A. Cause is unknown but is probably multifactorial.
B. Precipitating factors include overfeeding, underfeeding, formula intolerance, failure to “burp,” tension, or emotional problems in the family.
C. Food intolerance may be the cause in some infants.
II. Incidence
A. It occurs during the first 1 to 2 weeks of life, most often in a first-born infant.
B. It generally subsides by 3 months of age but may continue for 5 to 6 months.
C. It occurs with equal frequency in males and females in 10% to 20% of infants.
III. Subjective data
A. Episodic, intense, persistent crying for periods up to 4 to 6 hours; most often in the late afternoon and evening
B. Legs drawn up to abdomen
C. Hands tightly clenched
D. Feet may be cold
E. Passes flatus
F. Pertinent subjective data to obtain
1. Detailed dietary history, including amount and type of feeding
2. Detailed history of formula preparation and feeding techniques
3. If mother is nursing, detailed history of her dietary intake
4. Detailed history of elimination pattern and any changes in elimination
5. Length of time colic has been present
6. Duration and pattern of crying spells: How often do they occur? Do they occur at a particular time of day?
7. What parents have done to alleviate symptoms and if anything seem to help
8. How parents are coping
9. What parents think is wrong with the infant
10. Circumstances prevailing at time of conception
11. History of pregnancy, labor, and delivery
12. Family interaction: Is father supportive? Is mother depressed? Are parents having marital difficulties?
13. In addition to being of diagnostic benefit, the history helps the parents unburden and feel supported.
14. History of vomiting; family history of allergic conditions
15. History of atopic dermatitis
IV. Objective data
A. Temperature, weight, height, head circumference, chest circumference
B. Complete physical examination should include neurologic (may be marked response to Moro reflex); abdomen may be distended and tense.
C. Examine for testicular torsion, anal fissure, intestinal obstruction, incarcerated hernia, open safety pin, or hair or thread wrapped around finger, penis, or toe.
D. Observe
1. Maternal-child interaction
2. Infant’s reaction to stimuli (may be marked)
3. Infant’s reaction to cuddling
V. Assessment
A. Diagnosis is usually made by
1. History of repeated episodes
2. Normal physical examination with normal growth and development
3. The rule of “threes”—crying for more than 3 hours, more than 3 times a week, for more than 3 weeks
B. Differential diagnosis
1. Anal fissure: Bright blood in stool; fissure visualized on anus
2. Incarcerated hernia: Sudden onset, swelling in groin and ipsilateral scrotum
3. Testicular torsion: Testis tense and tender; cord thickened and shortened
4. Poor feeding practices (overfeeding or underfeeding): Confirmed by history
5. Incorrect formula preparation: Confirmed by history
6. Family tension: May be confirmed by interview
7. Poor coping ability: May be confirmed by interview
VI. Plan: Management is varied and may not be successful but should include the following:
A. Immediate response to and understanding of parents’ concern. Reassure parents that infant is not ill and that they are not responsible for the colic.
B. Formula
1. Although there is no conclusive evidence that formula intolerance is a cause of colic, consider a formula change. (A slight difference in the fat source—polyunsaturated fats versus saturated fats—may help alleviate symptoms.)
2. Soy formula may be given on trial basis if attacks are prolonged and there is a positive family history of allergies; however, there is a high rate of cross-reactivity to soy protein, and baby may develop soy protein intolerance.
3. Nutramigen, Lactofree, Alimentum, or Pregestimil: Use if question of lactose and milk protein intolerance and infant does not improve with soy.
4. Review amount and frequency of feedings and feeding techniques.
C. Breastfeeding
1. Eliminate possible sources of distress from mother’s diet: Excess tea, coffee, cola, strong-flavored or highly-spiced foods, chocolate, shellfish, excess milk.
2. Review frequency of feedings and feeding techniques.
3. Recommend supplementary feedings if weight gain is poor.
D. Abdominal warmth: Place warm water bottle wrapped in a soft cloth on infant’s abdomen.
E. Rhythmic movement and singing: This helps eliminate tension in mother as well.
1. Rocking chair
2. Carriage
F. Feed 1 to 2 oz of warm water during attack.
G. Counsel parents regarding
1. Feelings of inadequacy and guilt
2. Tension or stress in family or parent
3. Feelings of inability to cope
4. Changes in lifestyle with birth of infant
5. Lack of rest and relaxation
H. Environmental factors
1. Avoid overstimulation.
2. Prevent chilling.
3. Provide soft background noise (e.g., music).
4. Avoid sudden stimulation or startling of infant; approach infant slowly.
I. Pharmacologic management may be tried if other measures are not successful and mother is having a difficult time coping.
1. Mylicon drops: 0.3 mL qid
2. Occasionally abdominal distention and gas can occur secondary to excessive crying and air swallowing.
VII. Education
A. Explain the natural course of colic and that it generally subsides at
3 months of age; occasionally it lasts until 4 months, rarely until 5 to 6 months of age.
B. Explain that colic will not harm the baby physically or psychologically.
C. No specific treatment is guaranteed to produce an immediate cure.
D. Feeding
1. Do not change formulas without consultation.
2. Do not discontinue breastfeeding; symptoms may become worse.
3. The addition of solid foods will not generally improve symptoms; it may exacerbate them.
4. Burp infant frequently during feeding and feed in an upright position.
5. Try to maintain a modified demand schedule for the benefit of both mother and infant. Stress consistency in routine, and do not let infant sleep beyond usual feedings during the day.
6. Be very cautious about overfeeding. Attempts to comfort infant by too frequent feedings will cause overdistention of the bowel, resulting in more discomfort.
7. Nipple holes should allow a slow, steady stream of liquid.
E. Give medication only as directed. Call back immediately if vomiting occurs.
F. Mylicon drops relieve symptoms of excess gas in gastrointestinal tract by freeing it so that it can be eliminated more easily. Therefore, it may appear that the infant is “gassier.”
G. Try a warm bath at the time baby is usually fussy rather than at the scheduled bath time.
H. Encourage parents to go out on occasion. A reliable caretaker can cope with a crying baby for a few hours.
I. Encourage father to participate in care of infant and to relieve mother of some responsibilities.
J. Try gentle massage at each diaper change.
K. The infant should not be left in his or her crib to “cry it out.” He or she will become even more inconsolable.
L. Stress that it is not necessary to rush in and pick up the infant the moment he or she cries out, however. Give the infant an opportunity to go back to sleep. It may be helpful to sit by the crib and pat or rub the infant’s back. However, it will not spoil an infant to be given love and attention when distressed.
M. Reassure parents that a variety of emotions are within a normal range when they are unable to comfort an infant during repeated, prolonged crying episodes. Frustration, guilt, inadequacy, irritability, and even anger or hostility are emotions expressed by the most loving of parents.
N. Use of a pacifier, environmental stimuli such as white noise, and car rides may be suggested.
VIII. Follow-up
A. Frequent follow-up is necessary to provide support and encouragement to the parents and to assess results. Formula changes, elimination diet in mother, and medication should be given an adequate trial and reassessed by telephone or return visit.
B. Daily telephone follow-up may be necessary for the first week if parents are tense and anxious; thereafter, weekly telephone follow-up is sufficient.
C. Request a return visit in 2 weeks; include detailed interval history, physical examination, assessment of growth and development.
D. If parents have adjusted well and infant is thriving, further return visits are at usual intervals. Weekly or biweekly telephone contact continues to be indicated.
IX. Complications: The most important complication is disruption of the mother–infant relationship.
X. Consultation/referral
A. Inadequate weight gain
B. Maternal depression
C. Abnormalities in physical examination
D. Prolonged episodes; little response to treatment