Colic Nursing Care Planning and Management

Colic is intense, prolonged crying in an otherwise healthy infant, usually in the late afternoon or evening, that you cannot console and cannot pin to a clear cause. It typically starts within the first few weeks of life. The infant is fine; the parents are not. Most of your work here is parent-facing: confirm the baby is healthy, rule out the dangerous mimics of crying, and get exhausted caregivers some relief and confidence. The exact cause is still uncertain, with GI discomfort, an immature nervous system, and environmental factors all proposed.

What is colic?

Colic is a behavioral syndrome of excessive, paroxysmal crying in an otherwise healthy neonate or infant aged 2 weeks to 4 months who is difficult to console. It tends to occur in the evenings without an identifiable trigger. The most widely used definition, from Wessel et al, is based on the amount of crying: paroxysms lasting more than 3 hours, occurring more than 3 days in any week, for 3 weeks. It is equally likely in breastfed and formula-fed infants.

Pathophysiology

The term colic comes from the Greek kolikos or kolon, pointing at the GI tract, but the cause is not settled. Researchers have proposed nervous-system, behavioral, and psychologic origins. A meta-analysis suggested colic may be a form of migraine rather than a GI condition. That analysis used 3 studies (891 subjects total): one found colic more likely in infants whose mothers have migraine, and the other two found infants with colic more likely to experience migraine in childhood and adolescence. Using a pooled random-effects model, Gelfand and colleagues found an odds ratio of 5.6 for the migraine-colic association. A secondary analysis adding two studies that addressed a different primary question put the odds ratio at 3.2.

Statistics and Incidences

Colic is one of the common reasons parents seek a pediatrician or family practitioner in the child's first 3 months. It affects 10% to 30% of infants worldwide and occurs equally in males and females, typically at 2 weeks to 4 months. Some infants with colic show increased susceptibility later in childhood to recurrent abdominal pain, allergic disorders, and certain psychological disorders.

Causes

Demonstrated and suggested causes include GI factors (gastroesophageal reflux, overfeeding, underfeeding, milk protein allergy, early introduction of solids); incomplete or absent burping and incorrect positioning after feeding. Note that colic is not limited to firstborn children, which weakens the "inexperienced parents" theory. Other associations include exposure to cigarette smoke and its metabolites (maternal smoking and nicotine replacement therapy in pregnancy), food allergy including cow's milk allergy (CMA), low birth weight, and a characteristic intestinal microflora, with lower counts of intestinal lactobacilli seen in colicky infants.

Clinical Manifestation

The exam is normal, and that is the point. Infants with colic look normal and often have accelerated growth; failure to thrive should make you doubt the diagnosis. Diagnosis rests on excluding serious causes of crying. On acoustic analysis, colicky crying is more variable in pitch, more turbulent or dysphonic, and higher-pitched than regular crying, and mothers rate it as more urgent, discomforting, arousing, aversive, and irritating.

Assessment and Diagnostic Findings

Labs are usually not indicated unless another condition such as reflux is suspected. If stools are excessively watery, a Clinitest for excess reducing substances may be worthwhile; a positive result can point to an underlying GI problem such as acquired (postinfectious) lactose intolerance. Stool may be tested for occult blood to rule out CMA.

Medical Management

Start by ruling out common causes of crying. Tell parents not to exhaust themselves and to leave the baby with other caretakers for short respites. Consistent followup and a sympathetic physician are the cornerstones of management. Dicyclomine hydrochloride is an anticholinergic shown effective in trials, but its use is not recommended because of serious, though rare, adverse effects (apnea, breathing difficulty, seizures, syncope). A maternal low-allergen diet (low in dairy, soy, egg, peanut, wheat, and shellfish) may relieve excessive crying in some infants.

Pharmacologic Management

Drug therapy is still under study. Simethicone is a nonabsorbable agent that changes the surface tension of gas bubbles so they coalesce, disperse, and release gas for easier expulsion. Herbal remedies (chamomilla, bitter apple, fenugreek) are used in many cultures, but only a handful of studies exist and more safety and efficacy data are needed.

Nursing Management

Nursing Assessment

Take a detailed history of the timing and amount of crying and the family's daily routine, and emphasize the benign nature of colic. Rule out dangerous causes of excessive crying: a hair tourniquet in the eye, strangulated hernia, otitis, and sepsis. On exam, confirm normalcy; weight gain is typical, and failure to thrive should raise suspicion against the diagnosis.

Nursing Diagnosis

• Acute pain related to abdominal distention and tenderness.
• Deficient knowledge related to lack of exposure and unfamiliarity with information resources.
• Impaired parenting related to lack of knowledge and confidence in parenting skills.

Nursing Care Planning and Goals

The caregiver describes satisfactory pain control at less than 3 to 4 on a 0 to 10 scale; reports improved wellbeing with baseline pulse, BP, and respirations and relaxed muscle tone or body posture; explains the condition and the need for medications and treatments; and reports improved confidence in parenting.

Nursing Interventions

Relieve pain. Assess pain characteristics, acknowledge reports of pain immediately, provide rest periods for sleep and relaxation, and position the infant for comfort.

Educate caregivers. Assess their ability to learn, set learning priorities, and correct existing misconceptions. Provide a calm, uninterrupted environment, involve caregivers in setting learning objectives up front, give clear explanations and demonstrations, and allow repetition of the information or skill.

Improve parenting. Interview parents about their perception of the situation, teach normal child growth and development against those perceptions, involve them in activities with the infant they can succeed at, and give positive feedback for nurturing, protective behavior.

Evaluation

Goals are met when the caregiver describes satisfactory pain control at less than 3 to 4 on a 0 to 10 face scale, reports improved wellbeing at baseline pulse, BP, and respirations with relaxed tone, explains the condition and treatments, and reports improved parenting confidence.

Documentation Guidelines

Document individual findings (factors affecting the infant, interactions, nature of social exchanges, specifics of behavior); intake and output; cultural and religious beliefs and expectations; the plan of care and teaching plan; responses to interventions and teaching; and progress toward desired outcomes.