Subjective:
6 week old M full term w/no birth complications, no medical problems who presents to the
clinic with parental concerns of extreme fussiness. Mother is with infant today. Reports
worsening fussiness started 4 days ago. Describes intractable crying of 2-3 hours a day, worse in
the evening, and during these episodes he’s noted pulling his knees to his chest. In between
these episodes mother reports he is acting normally. Has tried feeding, pacifier, changing
diapers, burping, rocking, and rectal suppository with no relief. Reports passing gas and
stomach gurgling. Eating normally. Mother reports they recently changed to feeding him cow’s
milk with iron. Denies any V/D, apnea, fever, constipation, seizures, trauma, or history of
shaking or abuse. No family hx of allergies or lactose intolerance. No maternal use of illegal
drugs.
Objective:
VS 37.0 P 130 RR 32 BP 80/55 oxygen saturation 100% on RA.
Ht and Wt and HC in 50th percentile.
Allergies: NKA
DIET:
Bottle feeding cows milk with iron. Mother reports he is feeding well with good weight gain.
ELIMINATION:
Doesn’t recall
SLEEP PATTERN: doesn’t recall.
Assessment:
General: healthy appearing infant not currently crying, alert and active.
HEENT: Anterior fontanelle soft, flat. Good eye contact. No evidence of corneal abrasion or
watery eyes. Vigorously feeding during exam.
NECK: Supple. No lymphadenopathy.
CHEST: Clavicle intact
LUNGS: Clear to auscultation with equal breath sounds. No wheezes, rales or rhonchi.
HEART: Regular rate and rhythm; normal S1/S2. No murmur. Femoral pulse 2+ and equal.
ABDOMEN: Soft, non-distended, active bowel sounds x 4. No definite tenderness. No
hepatosplenomegaly. No masses. No inguinal hernias
GENITOURINARY: Normal male. Testes WNL, no tourniquets noted over his penis and digits.
EXTREMITIES: ROM WNL no pain with movement.
NEUROLOGIC: Normal tone. Cranial nerves grossly intact. Motor/sensory grossly normal.
SKIN: normal color for ethnicity. Pink, no pallor or mottling present.
SPINE: Normal curvature with no defects or dimples
ASSESSMENT: Given normal exam and description of patient behavior, likely diagnosis of
infantile colic.
PLAN:
 Stop feeding cows milk as this can be hard on infant stomachs and this could relieve
colic symptoms.
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Recommended switching to a hydrolyzed formula. Partially hydrolyzed formulas to
consider are Enfamile (Gentlease), Gerber (good start gentle or good start soothe,
Similac (Similac Total Comfort).
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Call your child's provider or nurse during the day or night if any of the following occur:
-The baby has cried continuously for more than two hours.
-You are afraid that you or another caretaker may hurt the baby, or if someone has
shaken the baby.
-If crying could be the result of an injury or fall.
-The baby has a fever of ≥100.4°F (38°C). Parents should call their infant's health care
provider or go to an emergency department immediately. This table describes how to
take a child's temperature (table 3). (See "Patient education: Fever in children (Beyond
the Basics)".)
-The infant refuses to eat or drink anything for more than a few hours, vomits
excessively, is not urinating well, has bloody stools, or has a change in behavior,
including lethargy or decreased responsiveness.
Provided mother with educational colic pamphlet that includes:
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Do not overfeed your baby, which could make them uncomfortable. In general, try to
wait at least two to two-and-a-half hours from the start of one feeding to the start of
the next.
Walk your baby in a baby carrier to soothe them. The motion and body contact will
reassure them, even if their discomfort persists.
Rock your baby, run the vacuum in the next room, or place them where they can hear
the clothes dryer, a fan, or a white-noise machine. Steady rhythmic motion and a
calming sound may help them fall asleep. However, never place your child on top of the
washer/dryer.
Introduce a pacifier. While some breastfed babies will actively refuse it, it will provide
instant relief for others.
When they seem uncomfortable, lay your baby tummy-down across your knees and
gently rub their back. The pressure against their belly may help comfort them. If they
fall asleep this way, place them in their crib on their back. Do not do this within 30 min
after eating as it is best to remain upright for 30 min after eating for digestion.
Swaddle them in a large, thin blanket so that they feel secure and warm.
When you're feeling tense and anxious, have a family member or a friend look after
the baby—and get out of the house. Even an hour or two away will help you maintain a
positive attitude. If no other adult is available to help, it's OK to lay the baby on their
back in the crib or another safe place and leave the room for a few minutes.