What are the management options for severe infant colic?

Management of Severe Infant Colic

For severe infant colic, start with Lactobacillus reuteri (DSM 17938 or ATCC 55730) in breastfed infants, as it reduces crying time by a median of 65 minutes per day, and switch to an extensively hydrolyzed protein formula in formula-fed infants. 1, 2

First-Line Management by Feeding Type

Breastfed Infants

• Administer Lactobacillus reuteri (DSM 17938 or ATCC 55730) as the primary intervention, which markedly reduces crying time with high-quality evidence 1, 2
• Implement a maternal elimination diet excluding milk and eggs for 2-4 weeks if probiotic therapy is insufficient 3, 4
• The low-allergen maternal diet has demonstrated favorable results in reducing colic symptoms, though evidence quality is moderate 4

Formula-Fed Infants

• Switch to an extensively hydrolyzed protein or amino acid-based formula as the first dietary intervention 3, 2
• Casein hydrolysate formulas have the strongest scientific evidence among formula options for reducing colic symptoms 4
• Consider partially hydrolyzed formulas with prebiotics or probiotics as an alternative, though efficacy requires further documentation 5

Feeding Modifications

• Reduce feeding volume while increasing feeding frequency to prevent overfeeding and gastric distension 3
• Thickening formula may reduce symptoms but carries increased risk of necrotizing enterocolitis in preterm infants and should be avoided in this population 3
• Keep infants upright or prone position only when awake and under direct supervision 3

Pharmacological Agents: What NOT to Use

• Simethicone is ineffective for treating colic despite its widespread use for bloating 2, 6
• Proton pump inhibitors are ineffective and carry risks including increased community-acquired pneumonia, gastroenteritis, and candidemia 3, 2
• Dicyclomine is contraindicated in infants due to serious side effects 2, 6
• Cimetropium bromide may reduce crying in severe cases but has documented side effects and limited testing 5, 4

Parental Support and Reassurance

• Provide explicit reassurance that colic is benign, self-limiting, and typically resolves by 3-6 months of age 2, 6
• Educate parents that colic peaks at 6 weeks and affects 10-40% of infants regardless of sex, feeding type, or socioeconomic status 2
• Counseling about the benign nature is considered first-line management until effective treatment is established 6

Interventions Without Evidence

• Do not recommend chiropractic or osteopathic manipulation, as evidence does not support their use 2
• Infant massage, swaddling, and acupuncture lack supporting evidence 2
• Herbal supplements have insufficient evidence and should not be recommended 2
• Behavioral interventions including increased or decreased stimulation show poor methodological quality in studies 4

Critical Diagnostic Considerations

Rule out alarm symptoms before diagnosing colic: 3

• Bilious or forceful vomiting
• Fever or lethargy
• Poor weight gain or feeding refusal
• Abdominal distension or tenderness
• Bloody stools
• Hepatosplenomegaly or bulging fontanelle

Common Pitfalls to Avoid

• Avoid overprescribing acid suppressants, particularly proton pump inhibitors, which have significant risks without proven benefit in colic 3
• Do not delay switching formulas in formula-fed infants when initial management fails 4
• Ensure proper strain identification when prescribing probiotics—only L. reuteri DSM 17938 or ATCC 55730 has demonstrated efficacy 1, 2
• Do not use anticholinergic, antidiarrheal, or opioid agents as they may mask clinical deterioration 7

Treatment Algorithm Summary

1. Confirm diagnosis by excluding alarm symptoms through detailed history and physical examination 2, 8
2. Breastfed infants: Start L. reuteri (DSM 17938/ATCC 55730), add maternal elimination diet if needed 1, 2
3. Formula-fed infants: Switch to extensively hydrolyzed or amino acid-based formula 3, 2
4. Adjust feeding technique: Reduce volume, increase frequency, maintain upright positioning when awake 3
5. Provide parental education about benign, self-limiting nature with resolution by 3-6 months 2, 6
6. Avoid ineffective medications: No simethicone, proton pump inhibitors, or dicyclomine 2, 6