In a healthy, well‑fed 2‑month‑old infant with normal growth who has frequent, prolonged episodes of intense crying lasting about three hours, during which he lifts his legs and passes gas, what is the most appropriate initial management?

Management of Infantile Colic in a 2-Month-Old

The most appropriate management is to reassure the parents (Option A), as this represents classic infantile colic in a healthy, thriving infant at the peak age of presentation, and parental education with reassurance is the cornerstone of management. 1, 2

Why Reassurance is the Primary Answer

• This 2-month-old infant presents with textbook infantile colic: paroxysms of crying lasting approximately 3 hours, leg raising, and gas passing—all typical behavioral manifestations of the gastrointestinal dysfunction seen in colic. 1
• The infant has normal growth and feeding, which are the key features that allow you to make a positive diagnosis of colic without extensive workup. 2, 3
• Crying peaks between 2-4 months of age, making this infant at the exact peak age for colic symptoms. 1, 4
• Colic affects 10-40% of infants worldwide and is a benign, self-limiting condition that resolves by 3-6 months of age. 2, 3

Why Simethicone (Option C) is Incorrect

Simethicone is ineffective for the treatment of colic and should not be used. 2

• Multiple studies have demonstrated that simethicone provides no benefit over placebo for infantile colic. 2
• The American Academy of Pediatrics guidelines do not recommend simethicone as a treatment option. 1

Essential Clinical Approach

First: Confirm This is Benign Colic

Before reassuring parents, you must exclude concerning organic causes by checking for these alarm features:

• Bilious vomiting, gastrointestinal bleeding, consistently forceful vomiting 1, 4
• Fever, lethargy 1, 4
• Hepatosplenomegaly, abdominal tenderness or distension 1, 4
• Poor weight gain or feeding difficulties 1
• Fractures or signs of trauma (this is peak age for abusive head trauma) 4

Since this infant has normal growth and feeding with no alarm features mentioned, you can proceed with reassurance. 2, 3

Second: Provide Comprehensive Parental Education

Reassurance must include specific education about:

• The natural history: Symptoms will resolve by 3-6 months of age without long-term adverse effects. 2, 5
• Peak timing: Crying peaks at 6 weeks to 2-4 months, so parents should expect this is the worst period. 1, 4
• Safety counseling: This is critical—crying is the most common trigger of abusive head trauma, and almost 6% of parents admit to smothering, slapping, or shaking their infant because of crying. 1, 4
• Explicit permission: Tell parents it is safe to put the baby down in a safe place and take a break if they feel overwhelmed. 1, 4

Third: Offer Practical Soothing Techniques

• Gentle motion, rhythmic movement, and white noise can calm the overstimulated infant. 1
• Avoid overstimulation from excessive tactile, visual, auditory, and kinesthetic stimuli. 1
• Parents should remain calm and serve as an "emotional container" for the infant's strong emotions. 4

If Reassurance and Basic Measures Fail

For Breastfed Infants:

• Consider a 2-4 week trial of maternal dietary allergen elimination (removing milk and eggs). 1
• Lactobacillus reuteri DSM 17938 may reduce crying by approximately 65 minutes per day in breastfed infants, though evidence is insufficient for routine use. 1, 6, 7

For Formula-Fed Infants:

• Switch to extensively hydrolyzed formula if cow's milk protein intolerance is suspected. 1, 2

Critical Pitfalls to Avoid

• Never prescribe proton pump inhibitors—they are ineffective and carry risks including pneumonia and gastroenteritis. 1, 2
• Simethicone is ineffective despite being commonly requested by parents. 2
• Dicyclomine is contraindicated in infants. 2
• Do not order unnecessary laboratory tests or imaging if the infant has normal growth and a normal physical examination. 3