What is the best treatment for a 2-month-old infant with frequent episodes of excessive crying, drawing up legs and passing gas?

Treatment of Infantile Colic in a 2-Month-Old

For this 2-month-old infant with classic colic symptoms (excessive crying >3 hours, leg drawing, gas), start with conservative measures including soothing techniques (motion, white noise) and parental reassurance—simethicone drops are NOT recommended as they are ineffective for infantile colic. 1, 2, 3

First-Line Management: Conservative Approach

Parental Education and Reassurance

• Parental support and reassurance are key components of colic management, as this is a benign, self-limiting condition that resolves by 3-6 months of age 1
• Explain that colic affects 10-40% of infants worldwide and peaks around 6 weeks, with symptoms typically resolving by 3-6 months 1
• Reassure parents this is not due to poor parenting and the infant is otherwise healthy 4

Soothing Techniques (As Parent Mentioned)

• Motion (rocking, car rides, stroller walks) and white noise are reasonable comfort measures, though evidence for their effectiveness is limited 1
• These techniques cause no harm and may provide some relief for both infant and parents 1

Why Simethicone Should NOT Be Used

Despite being commonly recommended, simethicone is ineffective for infantile colic and should not be prescribed. 1, 2, 3

• A rigorous randomized, placebo-controlled multicenter trial of 83 infants found simethicone was no more effective than placebo for colic treatment 2
• A Cochrane systematic review of three studies (110 infants) confirmed no difference between simethicone and placebo in reducing crying or number of responders (RR 0.95% CI 0.73 to 1.23) 3
• While simethicone is FDA-approved as an antigas agent for bloating 5, this does not translate to efficacy for infantile colic 1, 2
• The American Family Physician guidelines explicitly state that simethicone is ineffective for colic treatment 1

Evidence-Based Treatment Options

For Breastfed Infants

• Consider a 2-4 week maternal elimination diet removing cow's milk and eggs, as milk protein intolerance can mimic colic 6, 4, 7
• Lactobacillus reuteri (strain DSM 17938) is the only probiotic with evidence for breastfed infants with colic 1

For Formula-Fed Infants

• Trial of extensively hydrolyzed protein formula for 2-4 weeks if cow's milk protein intolerance is suspected 6, 4, 1
• Consider thickened formula with rice cereal (up to 1 tablespoon per ounce), though this primarily reduces visible regurgitation rather than crying episodes 6

Feeding Modifications

• Avoid overfeeding by reducing volume and increasing frequency of feeds 6
• Ensure adequate burping during and after feeds 6
• Hold infant upright on caregiver's shoulders for 10-20 minutes after feeding before placing supine 6

What NOT to Do

Avoid These Medications

• Do NOT use proton pump inhibitors (PPIs)—they are ineffective for colic and increase risk of pneumonia and gastroenteritis 6, 4, 7, 1
• Do NOT use dicyclomine—it is contraindicated in infants due to serious adverse effects (drowsiness 13%, wide-eyed state 4%) 1, 3
• Do NOT prescribe antibiotics—there is no role for antibiotics in infantile colic 1

Unproven Therapies

• Herbal teas have inconsistent evidence and cannot be recommended 1, 3
• Chiropractic manipulation, acupuncture, and massage lack supporting evidence 1

When to Reassess

Red Flags Requiring Further Evaluation

• Weight loss or poor weight gain (crucial warning sign) 6, 4
• Fever, bloody stools, or bilious vomiting 4
• Symptoms persisting beyond 4-6 months of age 1
• Symptoms worsening rather than improving 4

If Symptoms Persist After 2-4 Weeks

• Reconsider the diagnosis—many conditions mimic colic including gastroesophageal reflux disease (GERD), milk protein allergy, or anatomic abnormalities 6, 4, 7
• Consider referral to pediatric gastroenterology if conservative measures and dietary modifications fail 4, 7

Common Pitfalls to Avoid

• Overtreatment with medications (especially simethicone and PPIs) in the "happy spitter" with uncomplicated regurgitation 6, 4
• Failing to distinguish benign physiologic reflux from pathologic GERD requiring intervention 6, 7
• Not providing adequate parental education, leading to unnecessary medication use and healthcare costs 6, 4
• Placing infant in car seats or semi-supine positions after feeding, which worsens reflux 6