What are the treatment options for an infant with colic?

Treatment of Infantile Colic

For breastfed infants with colic, implement a 2-4 week maternal elimination diet restricting at least milk and egg as first-line therapy; for formula-fed infants, switch to extensively hydrolyzed protein or amino acid-based formula. 1, 2

First-Line Management: Dietary Interventions

For Breastfed Infants

• Maternal dietary elimination is the primary intervention, restricting at minimum cow's milk and eggs for 2-4 weeks, as cow milk protein expressed in breast milk can trigger colic symptoms 1, 2
• This approach is specifically recommended for infants with complications of gastroesophageal reflux (GER), not just "happy spitters" 1
• Studies demonstrate that breastfed infants benefit from maternal low-allergen diets 1

For Formula-Fed Infants

• Switch to extensively hydrolyzed protein or amino acid-based formula for 2-4 weeks 1, 2
• One study showed 24% of formula-fed infants had complete resolution of symptoms after switching to protein hydrolysate formula thickened with 1 tablespoon rice cereal per ounce 1
• Thickened feedings (up to 1 tablespoon dry rice cereal per 1 oz formula) or commercially thickened formulas are reasonable options for infants without cow milk protein intolerance 1

Critical caveat: Empiric formula switching without evidence of milk protein allergy is not generally recommended 2. The dietary changes above apply specifically to infants with colic symptoms, not routine formula changes.

Additional Feeding Modifications

• Reduce feeding volume while increasing feeding frequency to minimize gastric distension 2
• Implement proper burping techniques after each feeding 2
• Avoid overfeeding, which was part of successful management protocols 1

Positioning and Environmental Modifications

• Keep infant completely upright when awake 2
• Avoid seated and supine positions after feeding 1, 2
• Avoid environmental tobacco smoke exposure 1

Second-Line Management: Probiotics

For breastfed infants who fail first-line dietary measures, Lactobacillus reuteri may reduce crying time by approximately 65 minutes per day at 21 days. 1, 2

• Meta-analysis of 3 trials in breastfed infants with colic demonstrated marked reduction in crying time (median difference -65 minutes/day; 95% CI -86 to -44) 1
• However, all trials had potential biases, and the strength of recommendation is moderate 2
• Evidence for formula-fed infants is weaker, with only one study suggesting possible effectiveness 1
• Prevention trials showed only possible benefits in 2 of 7 studies 1

Important limitation: Considerable variability exists in study populations, delivery methods, and dosing, precluding definitive recommendations 1

What NOT to Use

Simethicone

• Despite FDA approval for gas relief 3, systematic reviews show conflicting results for infantile colic 4
• There is little scientific evidence to support its use for colic specifically 4

Dicyclomine

• While shown to be effective, the manufacturer has contraindicated its use in infants due to significant safety concerns 5
• Should not be used despite historical efficacy data 5

Other Unproven Therapies

• Herbal teas: Not consistently helpful and some may be dangerous 6
• Increased stimulation: Unfavorable results 4
• Lactase supplementation: No proven benefit 4

Monitoring and Red Flags

Essential Follow-Up

• Monitor weight gain closely to ensure thriving despite colic symptoms 2
• If no improvement after 2 weeks of dietary changes, evaluate for other causes or refer to pediatric gastroenterology 2

Warning Signs Requiring Immediate Evaluation

• Bilious vomiting 2
• Gastrointestinal bleeding 2
• Consistently forceful vomiting 2
• Fever 2
• Abdominal tenderness or distension 2
• Poor weight gain, unexplained anemia, fecal occult blood, recurrent pneumonia, or hematemesis 1

Parental Support

The cornerstone of management remains reassurance regarding the benign and self-limiting nature of colic, which typically resolves by 6 months of age 6, 5. Parents should understand that colic affects up to 30% of babies, and underlying organic causes account for less than 5% of cases 6. Laboratory tests and radiological examinations are unnecessary if the infant is gaining weight normally and has a normal physical examination 6.