A 6-week-old boy is brought to the office by his parents for evaluation of inconsolable crying. The patient has cried almost continuously up to 4 hours every evening for the past 3 weeks. Pacifiers do not seem to calm him, and he often refuses to feed during this time, making the parents feel overwhelmed and worried. The patient is happy and alert during the rest of the day. He was born full term via uncomplicated spontaneous vaginal delivery and is growing well. He breastfeeds every 2-4 hours and has 2-3 soft stools daily. Temperature is 37.3 C (99.1 F). The anterior fontanel is soft. Otoscopic examination shows erythematous tympanic membranes that are compliant on insufflation bilaterally. Heart and lung examination is unremarkable, and the abdomen is soft. Which of the following is the most appropriate management of this patient?

Question

A 6-week-old boy is brought to the office by his parents for evaluation of inconsolable crying.  The patient has cried almost continuously up to 4 hours every evening for the past 3 weeks.  Pacifiers do not seem to calm him, and he often refuses to feed during this time, making the parents feel overwhelmed and worried.  The patient is happy and alert during the rest of the day.  He was born full term via uncomplicated spontaneous vaginal delivery and is growing well.  He breastfeeds every 2-4 hours and has 2-3 soft stools daily.  Temperature is 37.3 C (99.1 F).  The anterior fontanel is soft.  Otoscopic examination shows erythematous tympanic membranes that are compliant on insufflation bilaterally.  Heart and lung examination is unremarkable, and the abdomen is soft.  Which of the following is the most appropriate management of this patient?

Quizplus · Accepted Answer

11ec25c8_d5f6_2d23_bc81_b9523d4a3a97_MD0003_00 Crying is the primary mode of communication for infants but can cause significant parental frustration and anxiety. The normal duration of crying is highly variable but generally <3 hours a day. Colic is defined as crying for no apparent reason for ≥3 hours a day for ≥3 days a week in an otherwise healthy infant age <3 months. Crying usually occurs around the same time of the day (eg, evening), and parents often have difficulty consoling the infant only during this time. Symptoms peak at age 6 weeks and typically resolve by age 3-4 months. The cause of colic is unknown but may be related to gut immaturity or suboptimal feeding techniques (eg, excessive swallowing of air). A complete history and physical should be performed because colic is a diagnosis of exclusion. Initial management includes providing parents with reassurance and support. Soothing techniques should be reviewed and include using a pacifier; holding, rocking, or swaddling the baby; and minimizing environmental stimuli (eg, dark room). Use of swings, carriers, and strollers can also be calming and allows parents to rest from active soothing. In addition, adjusting feeding techniques (eg, upright feeding position in bottle-fed babies) may help reduce air swallowing and relieve colic. (Choice A) Intussusception (telescoping of one bowel portion into another), most common at age 6-36 months, presents with recurrent episodes of severe abdominal pain. Vomiting and bloody stools may be present. Intussusception is diagnosed with abdominal ultrasound, but this patient's age and crying pattern make it unlikely. (Choice B) Gastroesophageal reflux disease can present with irritability, spitting up, and back-arching after feeds. Severe reflux leading to feeding refusal and poor weight gain may require treatment with an H₂ receptor blocker. This patient is growing well with crying unrelated to feeding. (Choice C) Acute otitis media can present with irritability plus a bulging tympanic membrane (TM) and/or a middle ear effusion with TM inflammation (eg, erythema). TM erythema alone is not diagnostic of this condition and does not warrant oral antibiotics. (Choice D) Lactose intolerance necessitating lactose-free formula is extremely rare in infancy but typically presents with frothy or watery stools. This patient has a normal stooling pattern. Educational objective: Colic is a diagnosis of exclusion characterized by crying for no apparent reason for ≥3 hours a day for ≥3 days a week in an otherwise healthy infant age <3 months. Management includes reassurance and review of soothing techniques. References: Infantile colic: recognition and treatment. (http://www.ncbi.nlm.nih.gov/pubmed/26447441)

A 6-Week-Old Boy Is Brought to the Office by His