What are the treatment options for colic in breastfed babies?

Treatment of Colic in Breastfed Babies

For breastfed infants with colic, start with a 2-4 week maternal elimination diet that restricts at least milk and egg, as this addresses the most common underlying cause—cow's milk protein allergy that mimics or exacerbates colic symptoms. 1, 2, 3

First-Line Approach: Maternal Dietary Modification

• Implement a strict maternal elimination diet removing all dairy products and eggs for 2-4 weeks in breastfeeding mothers, as cow's milk protein can be expressed in breast milk and trigger colic symptoms 1, 2, 3
• This approach is supported by the American Academy of Pediatrics as the primary intervention for breastfed infants with colic 2, 3
• Monitor the infant's response closely during this trial period, looking for reduction in crying duration and frequency 1, 3

Second-Line: Probiotic Supplementation

If maternal dietary elimination fails or provides insufficient relief, add Lactobacillus reuteri (strain DSM 17938) to the infant's regimen. 4, 5, 6

• Meta-analysis demonstrates that L. reuteri reduces crying time by approximately 65 minutes per day at 21 days in exclusively breastfed infants with colic 1, 5
• This is the only probiotic strain with consistent evidence specifically in breastfed babies 5, 6
• The evidence is strongest for breastfed infants; effectiveness in formula-fed infants remains uncertain 1, 5

Supportive Measures (Implement Concurrently)

• Reduce feeding volume while increasing feeding frequency to minimize gastric distension 2, 3
• Use proper burping techniques after each feeding, employing patting or gentle tapping rather than rubbing 1, 2, 3
• Keep the infant completely upright when awake and for 10-20 minutes after feeding before placing in the back-to-sleep position 1, 2, 3
• Avoid seated positions (car seats, infant carriers) after feeding, as these exacerbate reflux and may worsen colic 1, 3

What NOT to Do: Common Pitfalls

• Do not use simethicone—it is ineffective for colic treatment 4, 7
• Do not prescribe proton pump inhibitors—they are ineffective for colic and represent overtreatment 4
• Dicyclomine is contraindicated in infants due to serious side effects 4, 8
• Avoid empiric formula switching without evidence of milk protein allergy, as this is not recommended 2
• Do not recommend chiropractic manipulation, infant massage, swaddling, or acupuncture—evidence does not support these interventions 4

Monitoring and Red Flags

• Monitor weight gain closely to ensure the infant is thriving despite colic symptoms 2, 3
• Reassess at 2 weeks—if no improvement occurs with maternal dietary elimination, consider other diagnoses or refer to pediatric gastroenterology 2, 3
• Immediate evaluation is required for bilious vomiting, gastrointestinal bleeding, consistently forceful vomiting, fever, or abdominal tenderness/distension 2, 3

Evidence Considerations

The evidence for maternal dietary modification comes from multiple guideline sources including the American Academy of Pediatrics 1, 2, 3, while the probiotic evidence is based on meta-analyses showing marked benefit specifically in breastfed infants 1, 5, 6. However, all probiotic trials had potential biases 5, so this remains a second-line option after dietary intervention. The combination of dietary modification with supportive feeding techniques provides the most comprehensive approach with the lowest risk profile 2, 3, 7.