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POSITION STATEMENT

Using probiotics in the paediatric population

Posted: Dec 3 2012

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Principal author(s)

Valérie Marchand; Canadian Paediatric Society, Nutrition and Gastroenterology Committee
Abridged version: Paediatr Child Health 17(10):575

Abstract

As more is learned about the importance of the intestinal microbiome to human health there is increasing interest in the potential benefits of probiotics. Probiotics are live micro-organisms which, when consumed in adequate amounts, confer a health effect on the host by altering its microflora. Probiotics have been administered both prophylactically and therapeutically for various conditions. This statement definines the development and role of intestinal microflora, and examines the evidence supporting the use of different probiotics to treat common paediatric conditions, such as diarrhea, atopy, functional intestinal disorders and necrotizing enterocolitis. Recommendations to guide physicians in the judicious use of these products are offered.

Key Words: Bifidobacteria; Diarrhea; Lactobacilli; Microflora; Probiotics; Saccharomyces 

This statement defines what probiotics and prebiotics are, reviews the development and role of intestinal microflora and examines evidence supporting the use of different probiotics for various childhood conditions. A literature review was conducted in English and French using Medline (1966 to 2011), the Cochrane database and relevant websites. PubMed was used to identify relevant randomized controlled trials (RCTs) and meta-analyses involving the use of probiotics in paediatrics. Physician guidance for the judicious use of these products in paediatric patients is offered.

Probiotics (eg, lactobacilli, bifidobacteria, saccharomyces) are live micro-organisms which can confer a health effect on the host when consumed in adequate amounts. They are nonpathogenic in the normal host, resist processing and are able to survive in the digestive tract. Prebiotics (eg, fructo- and galacto-oligosaccharides) are nonviable food components which can confer a health benefit on the host by modulating intestinal microflora.

Development and composition of gut microflora

Colonization of an infant’s intestine begins immediately after birth. Type of delivery, the infant diet (breast milk versus formula) and other factors, such as environment, gestational age and the presence of antibiotics, influence the composition of gut microflora. Because bifidobacteria and galacto-oligosaccharides are components of breast milk, the flora of breastfed infants contain more lactobacilli and bifidobacteria than the flora of formula-fed infants. Once solid food is introduced into the diet, the composition of a child’s intestinal microflora begins to resemble the adult flora.

The role of gut microflora

The gut microflora is a complex ecosystem supporting the structure and function of the intestinal mucosa. Intestinal bacteria contribute to the gut’s barrier function by competing with pathogenic bacteria, increasing mucin secretion, decreasing gut permeability and modulating the gut’s immune function.[1][3]Colonic bacteria metabolize malabsorbed carbohydrates into short-chain fatty acids (SCFA). SCFA are a preferential fuel for the enterocyte; they also acidify colonic content and increase water absorption.

Using probiotics

Probiotics modify the gut microflora by lowering colonic pH through production of SCFA, by producing antimicrobial compounds and antitoxins, and by competing with other bacteria for nutrients and adhesion receptors. They also enhance gut barrier function and have a role in immunomodulation. Different strains of probiotics have different biological activities.

Preventing antibiotic-associated diarrhea

Antibiotic-associated diarrhea (AAD) is usually defined as ≥3 loose stools/day for ≥2 days occurring up to two weeks after the initiation of antibiotics. AAD occurs in about 30% of patients.

A 2002 meta-analysis which included two paediatric and seven adult studies favoured the use of probiotics, with an OR of 0.37.[4] Several paediatric RCTs using different strains of probiotics were also published [5][12](Table 1), as well as two specifically paediatric meta-analyses, which showed a significant reduction of AAD using various probiotics (RR 0.47 and 0.44). The most consistently effective were Lactobacillus rhamnosus GG (LGG) and Saccharomyces boulardii. However, the number needed to treat to prevent one case of diarrhea was 10 in one meta-analysis and seven in the other.[13][14] Consuming yogurt containing probiotics did not prevent AAD in another study.[15]

While per protocol results seem to indicate that probiotics such as S boulardii and LGG decrease the incidence of AAD, the intention to treat analysis showed less impressive results, suggesting that lack of compliance may be an issue.

TABLE 1
Random controlled trials of probiotic use for preventing AAD

Study

Patient number, age range

Probiotic

Results

Tankanow, 1990[12]

38
(5 mos to 6 yrs)

L acidophilus

L bulgaricus

RR 0.96 (NS)

Arvola, 1999[8]

167 (119)†
(2 wks to 12.8 yrs)

LGG
2x1010 CFU twice daily

Probiotic 5%
Placebo 16%
RR 0.32 (NS)

Vanderhoof, 1999[7]

202 (188)
(6 mos to 10 yrs)

LGG
1 – 2x1010 CFU daily

Probiotic 8%

Placebo 26%

RR 0.29 *

Jirapinyo, 2002[11]

18
(1 to 36 mos)

L acidophilus

B infantis

Probiotic 37%
Placebo 80%
RR 0.47 (NS)

Kotowska, 2004[5]

269 (246)
(6 mos to 14 yrs)

S boulardii
250 mg twice/day

Probiotic 7.5%
Placebo 23%
RR 0.30 *

Erdeve, 2004[6]

466

S boulardii

Probiotics 5.7%
Placebo 18.9%
RR 0.30*

Correa 2005[10]

169 (157)
(6 mos to 36 mos)

B lactis|
1x107 CFU/g of powder

S thermophilus
1x106 CFU/g of powder
(formula)

Probiotics 16%
Placebo 31%
RR 0.52 *

Ruszczynski, 2008[9]

240
(3 mos to 14 yrs)

L rhamnosus (strains E/N, Oxy and Pen)

Probiotic 2.5%
Placebo 7.5%
RR 0.33*

NS: non-significant, * : p < 0.05 CFU Colony forming unit, † Brackets indicate final study population


Clostridium difficile

One adult study showed a 50% decrease in the relapse rate in patients with recurrent C difficile when treated with S boulardii in conjunction with antibiotics, but no benefit for those with an initial episode.[16] An adult meta-analysis found no evidence to support the use of probiotics in the treatment of C difficile.[17] To date there have been no paediatric RCTs.

While there is currently no evidence to support using probiotics either to prevent or treat C difficile in children or adults, there might be a role for probiotics in preventing relapse in patients with recurrent C difficile infection.

Treatment of acute infectious diarrhea in children

Probiotics have been used to treat acute viral diarrhea in children. Five paediatric meta-analyses showed reduced durations of diarrhea, ranging between -16.8 h and -30.0 h.[18][22] The subgroup with rotaviral diarrhea seemed to be more responsive to probiotics[19] and LGG appeared to be the most effective probiotic [5][12](Table 2).

While probiotics are useful in reducing the duration of acute infectious viral diarrhea, efficacy is strain- and dose-dependant. The beneficial effects of probiotics seem to be more evident when treatment is initiated early (<48 h). Probiotics are not useful for treating bacterial diarrhea.

TABLE 2
Meta-analyses: Probiotics for treatment of acute infectious diarrhea

Meta-analysis

Trials (patients)

Probiotics

Results

Szajewska, 2001[26]

8 (731) (incidence)

8 (773) (duration)

LGG (3)
L reuteri (2)
L acidophilus (2)
S boulardii (1)

Diarrhea >3 days
RR 0.43 *

Duration of diarrhea
-18.2 h *

Van Niel, 2002[22]

3 (122) (no. stools)

7 (675) (duration)

LGG (4)
L reuterii (2)
L acidophilus (3)

No. stools on day 2
- 1.6 *

Duration of diarrhea
-16.8 h *

Huang, 2002[21]

18 (1917)

LGG (9)
L rhamnosus + L reuteri (2)
L acidophilus + L bulgaricus (1)
L acidophilus + B infantis (1)
L acidophilus (2)
L rhamnosus (1)
L reuteri (2)

Duration of diarrhea
-19.2 h *

Allen, 2004[19]

15 (1341) (diarrhea >3 day)

12 (duration)
(included adults and children)

LGG (2)
L reuteri (2)
Enterococcus LAB SF68 (5)
L acidophilus + L bifidus (2)
S thermophilus + L bulgaricus (1)
L acidophilus (2)
S boulardii (1)

Diarrhea >3 days
RR 0.66 *

Duration of diarrhea
-30.5 h *

Allen 2010[18]

63 (8014)
adults and children

various

Duration of diarrhea
-24.8 h*

NS: non-significant, * : p < 0.05

Preventing infectious diarrhea

The efficacy of probiotics in preventing infectious diarrhea has been studied in multiple settings (with hospitalized patients, in child care settings and in the community) using various strains of probiotics. LGG reduced the incidence of acute diarrhea, particularly in non-breastfed infants [23]-[26] as did S boulardii, Bifidobacterium bifidum, Lactobacillus casei, Bifidobacterium lactis, and Lactobacillus reuteri in other individual studies.[27]-[31] A combination of Bifidobacterium breve and Streptococcus thermophilus decreased the incidence of dehydration.[32] Other studies did not show a significant decrease in the incidence of acute diarrhea [33]-[34](Table 3).

There seems to be a modest effect for some probiotic strains in preventing acute diarrhea, particularly in children who are not breastfed. Probiotic use may be considered in long-term facilities or for patients attending child care who have recurrent infections.

TABLE 3
Random controlled trials: Probiotics for prevention of infectious diarrhea

Study

Patients (pts), age, setting, study duration

Probiotic

Results

Saavedra, 1994[28]

55
(5 to 24 mos)
chronic medical care
duration 17 mos

B bifidum

S thermophilus
(formula)

Incidence of diarrhea
Probiotics 7%
Placebo 31% *

Oberhelman, 1999[25]

204
(6 mos to 24 mos)
poor rural area in Peru
duration 15 mos

LGG

3.7x1010 CFU daily,
6 days/wk

Diarrhea episodes (all pts)
Probiotics 5.21/child/yr
Placebo 6.02/child/yr *
Non-breastfed infants
Probiotics 4.69/child/yr
Placebo 5.86/child/yr*
Breastfed infants
Probiotics 6.59/child/yr
Placebo 6.32/child/yr (NS)

Pedone, 2000[29]

928 (779)†
(6 mos to 24 mos)
community
duration 4 mos

L casei

Incidence of diarrhea
Probiotic milk 15.9%
Yogurt 22% *

Hatakka, 2001[23]

571 (513)
(1 yr to 6 yrs)
daycare
duration 7 mos

LGG

5 – 10x105 CFU/mL of formula,
> 200 mL/daily

Days with gastrointestinal symptoms
Probiotics 2.9
Placebo 3.0 (NS)

Szajewska, 2001[26]

81
(1 to 36 mos)
hospitalized (acute care)

LGG

6x109 CFU twice daily

Nosocomial diarrhea
Probiotics 6.7 %
Placebo 33.3% *
RR 0.2
NTT 4

Mastretta, 2002[24]

269 (220)
(1 to 18 mos)
hospitalized (acute care)

LGG

1x1010 CFU daily

Nosocomial rotavirus (27.7%)
Probiotics 25.4%
Placebo 30.2% (NS)
Breastfed 10.6 %
Formula fed 32.4 % *

Chouraqui, 2004[33]

90
(< 8 mos)
residential care setting
duration 4 mos

B lactis (Bb 12)

1x106 CFU/g of powder (formula)

Incidence of diarrhea
Probiotics 28.3%
Placebo 38.7% (NS)
Days with diarrhea
Probiotics 1.15
Placebo 2.3 *

Thibault, 2004[32]

971 (913)
(4 to 6 mos)
community
duration 5 mos

B breve (C50)

S thermophilus 065

Incidence of diarrhea
Probiotics 56.7%
Placebo 55.9% (NS)
Dehydration
Probiotics 2.5 %
Placebo 6.1% *

Weizman, 2005[30]

201 (194)
(4 to 10 mos)
child care centre
duration 12 wks

B lactis (Bb12)

L reuteri
1x107 CFU/g of powder (formula)

Episodes of diarrhea
B lactis 0.13
L reuteri 0.02
Placebo 0.31 *

Billoo, 2006[27]

100
(2 mos to 12 yrs)
community
duration 2 mos

S boulardii
250 mg twice daily

Episodes of diarrhea
Probiotic 0.32
Placebo 0.56*

Binns, 2007[31]

496 (315)
(1 yr to 3 yrs)
child care centre
duration 5 mos

B lactis and prebiotics
(CUPDAY milk)

RR 0.8 *

Chouraqui, 2008[34]

284 (227)
newborns
community
duration 4 mos

B longum (BL999)

L rhamnosus (LPR)

L paracasei (ST11)

BL999 + LPR 6%
BL999 + LPR + ST11 4%
Placebo 5% (NS)

NS: non-significant, * : p < 0.05 CFU Colony forming unit, † Brackets indicate final study population

NTT number needed to treat

Irritable bowel syndrome

Alteration of the gut microflora may be implicated in the pathogenesis of irritable bowel syndrome (IBS). It is a common problem in children and treatment options are limited.

Two adult meta-analyses using various strains of probiotics found a modest improvement in symptoms.[35][36] There have been four published paediatric trials. LGG decreased abdominal distension [37] and was more likely to improve symptoms of patients with IBS than a placebo.[38] Escherichia coli decreased gassiness and bloating, and one product, VSL#3 (Seaford Pharmaceuticals, Ontario), improved IBS scores [39][40](Table 4).

The data on IBS and probiotics are preliminary but there seems to be an effect in improving some symptoms.

TABLE 4
Probiotic use in irritable bowel syndrome (IBS)

Patients, study duration

Probiotic

Results

64 (50)†
Irritable bowel syndrome
Duration 6 wks

LGG

1x1010 CFU twice daily

Improved abdominal pain
Probiotic 44 %
Placebo 40% (NS)

Improved abdominal distension
Probiotic 24%
Placebo 0%*

112 (104)
Irritable bowel syndrome
Functional dyspepsia
Functional abdominal pain
Duration 4 wks

LGG

3x109 CFU twice daily

Treatment success (no pain)
Probiotic 25%
Placebo 9.6%*
NTT 7

203
Irritable bowel syndrome
Duration 43 days

E coli

1.5-4.5 x 107 CFU

Improvement of gassiness and bloating*

59
irritable bowel syndrome
6 wks, crossover

VSL # 3

Improvement of the IBS score (SGAR) at 6 wks
Placebo -0.51
Probiotic -1.7*

NS: non-significant, * : p < 0.05, † Brackets indicate final study population
CFU Colony forming unit; NTT Number needed to treat; SGAR Subject’s global assessment of relief

Infantile colic

The intestinal microflora may play a role in pathogenesis of colic. Lower counts of lactobacilli have been found in the intestinal flora of colicky infants.[41][42] Two trials showed a significant reduction of crying in infants receiving L reuteri [43][44](Table 5).

While there may be a role for probiotics in treating infantile colic, there is insufficient evidence to recommend for or against using probiotics to manage this condition. A recent CPS practice point on infantile colic reached the same conclusion.

TABLE 5
Probiotic use for infantile colic

Study

Patients, age, study duration

Probiotic

Results

Savino, 2010[44]

50 (46)†
(2 wks to 16 wks)
duration 21 d

L reuteri

Daily crying time on day 21

Probiotics 35 min

Placebo 90 min*

Savino, 2007[43]

90 (83)
(21 days to 3 mos)
duration 28 d

L reuteri

1x108 CFU daily

versus simethicone

Daily crying time on day 28

Probiotic 51 min

Simethicone 145 min*

NS: non-significant, * : p < 0.05, † Brackets indicate final study population

Preventing necrotizing enterocolitis

Altered intestinal permeability and intestinal bacteria may be involved in the pathogenesis of necrotizing enterocolitis (NEC). One recent study showed that a bifidobacteria-supplemented formula decreased intestinal permeability in preterm infants.[45] Studies with NEC prevention as their primary outcome are listed in Table 6. In the first published study, LGG did not decrease the incidence of NEC significantly.[46] Subsequent studies showed that infants fed breast milk supplemented with lactobacillus and bifidobacteria had a significantly lower incidence of NEC and deaths than infants receiving unsupplemented breast milk.[47]-[49] The severity and incidence of NEC was lower in infants given a mixture of Bifidobacterium infantis, B bifidus and S thermophilus.[50]

In three recent meta-analyses, enteral probiotic supplementation significantly reduced the incidence of severe NEC (RR 0.32 to 0.36) and mortality (RR 0.40 to 0.47) without systemic infection with the bacteria used as probiotics.[51]-[53]

Probiotics may help to prevent NEC. Administering live microorganisms to preterm newborns should be approached with caution. Along with breastfeeding promotion, probiotics can be considered for the prevention of NEC in preterm infants >1 kg who are at risk for NEC. There is currently no data for infants weighing <1000 g.

TABLE 6
Probiotic use in necrotizing enterocolitis (NEC)

Study

Patients, age / weight,

feeding

Probiotic

Results

Dani, 2002[46]

585
<33 wks and <1500 g
Formula

LGG

6x109 CFU daily

NEC
Probiotics 1.4%
Placebo 2.7% (NS)

Sepsis
Probiotics 4.4%
Placebo 3.8% (NS)

Lin, 2005[47]

367
<1500 g
Breast milk

L acidophilus
B infantis

125 mg/kg twice daily

NEC stage 2 or 3
Probiotics 1.1%
Placebo 5.3% *

Deaths
Probiotics 3.9%
Placebo 10.7% *

Sepsis
Probiotics 12.2%
Placebo 19.3% *

Bin-Nun, 2005[50]

155 (145)
<1500 g
Formula

B infantis
B bifidus
S thermophilus

1x109 CFU daily

NEC
Probiotics 4%
Placebo 16.4%*

Lin, 2008[48]

434
< 1500 g and < 34 wks
Breast milk

B bifidus
L acidophilus

NEC
Probiotics 1.8 %
Placebo 9.2%*

Braga, 2011[49]

258 (231)
< 1500 g
Breast milk or mixed feeds

B breve
L casei

NEC
Probiotics 0%
Placebo 3.6%*

NS: non-significant, * : p < 0.05 CFU Colony forming unit

Traveller’s diarrhea

There are no paediatric studies of probiotics in preventing traveller’s diarrhea. A meta-analysis of adult trials showed a statistically significant protective effect for various probiotics (RR 0.85),[54] but most of these studies had significant limitations. No conclusions can be drawn from the literature at this time and further trials are needed.

Preventing infections

Probiotics may be useful in preventing infections, both by decreasing intestinal permeability and stimulating the immune system. In one Finnish study, children in day care centres who drank milk supplemented with LGG experienced fewer days with respiratory and gastrointestinal symptoms, but the only outcome to reach statistical significance was the number of days of absence due to illness.[23] B lactis and S thermophilus decreased antibiotic use significantly in children attending daycare.[55] Infant formulas supplemented with B lactis and L reuteri reduced the number of episodes of fever and diarrhea, the number of medical visits, the number of days absent from child care and antibiotic use[30] in one Israeli study. Finally, infants in one community who required formula feeding under two months of age were given LGG and B lactis Bb-12. These infants had a lower incidence of otitis media and recurrent respiratory infections, and were prescribed fewer antibiotics than others who received placebo[56](Table 7).

Probiotics might help to reduce childhood respiratory illnesses, antibiotic use and absences from child care due to illness. However, more trials are needed before any definitive conclusions can be made.

TABLE 7
Probiotic use for preventing infections

Study

Patients, setting, duration

Probiotic

Results

Hatakka, 2001[23]

571 (513)†
(1 yr to 6 yrs)
daycare
duration 7 mos

LGG
5 – 10x105 CFU/mL of formula,
>200 mL daily

Days of absence due to illness
Probiotic 4.9 days
Placebo 5.8 days*

Days with respiratory symptoms
Probiotic 21
Placebo 23 (NS)

Antibiotic treatments
Probiotic 119
Placebo 144 (NS)

Saavedra, 2004[55]

131 (118)
(3 mos to 24 mos)
daycare
duration 210±127 days

B lactis
S thermophilus

Low dose (LD):
1x106 CFU of each/g

High dose (HD):
1x107 CFU of each/g
(formula)

Days of absence due to illness
Probiotic LD 2.07 HD 1.86
Placebo 1.89 (NS)

Antibiotic treatments
Probiotics LD 2.47 HD 3.19
Placebo 3.60*

Weizman, 2005[30]

201 (194)
(4 mos to 10 mos)
child care centre
duration 12 wks

B lactis (Bb12)

L reuteri

1x107 CFU/g powder

(formula)

Days of absence from daycare
B lactis 0.41 (NS)
L reuteri 0.14*
Placebo 0.43

Antibiotic treatments
B lactis 0.21 (NS)
L reuteri 0.06*
Placebo 0.19

Days with respiratory illness
B lactis 0.68 (NS)
L reuteri 0.38 (NS)
Placebo 0.60

Rautava, 2009[56]

81(72)
(2 mos)
community
followed until 12 mos

LGG

B lactis (Bb12)

1x1010 CFU daily

Acute otitis media
Probiotic 22%
Placebo 50% *

Antibiotic treatment
Probiotics 31%
Placebo 60% *

Recurrent infections
Probiotics 28%
Placebo 55% *

NS: non-significant, * : p < 0.05, † Brackets indicate final study population

Preventing atopic and allergic diseases

Atopic diseases are often related to food allergies, which are more likely to develop when intestinal permeability is altered. Probiotics decrease intestinal permeability and the absorption of large molecules. This effect may help to prevent expression of an atopic constitution by diminishing allergen uptake. Lower counts of lactobacilli and bifidobacteria are found in children with atopic dermatitis compared with healthy controls.[57] In studies of children with atopic dermatitis treated with lactobacilli, a significant decrease in measures of intestinal permeability was observed, suggesting that impairments of gut barrier function in these patients can be improved with probiotics.[2] Also, gut microflora interact with gut-associated lymphoid tissue. Probiotics may influence the balance between the TH1 and TH2 responses and prevent the development of allergic disease.

Two RTCs suggested that LGG supplementation before delivery for pregnant mothers with a family history of atopy, and subsequent supplementation while breastfeeding or formula feeding later, reduced the risk of developing atopic dermatitis in their infants.[58]-[60] However, subsequent studies did not show such an effect.[61]-[64] A recent meta-analysis concluded that there was insufficient evidence to recommend adding probiotics to infant feeds to prevent allergic disease or food hypersensitivity [65] (Table 8).

Despite initially encouraging results, recent studies have failed to demonstrate a beneficial effect, and further research is required.

TABLE 8
Probiotic use for preventing atopic disease

Study

Patients

Probiotic

Results

Kalliomaki, 2001[58]

Kalliomaki, 2003[59]

134 mother-infant pairs (at 2 yrs)

107 mother-infant pairs (at 4 yrs)

2 to 4 wks prenatally

24 wks postnatally

LGG

1x1010 twice daily

Atopic dermatitis at 2 yrs
Probiotic 23%
Placebo 46% *
RR 0.51, NTT 4.5

Atopic dermatitis at 4 yrs
Probiotic 26%
Placebo 46% *
RR 0.57

Rautava, 2002[60]

62 mother-infant pairs (57)†

LGG

2x1010 CFU daily

Atopic dermatitis in the first 2 yrs
Probiotic 15%
Placebo 47% *
RR 0.32

Kukkonen, 2007[63]

1223 mother-infant pairs (925)

2 to 4 wks prenatally

Mixture of four strains of probiotics and one prebiotic

No effect on allergic diseases
Reduction of atopic eczema
RR 0.66

Taylor, 2007[61]

231 newborns of mothers with allergies (178)

6 mos postnatally

L acidophilus

3x109 CFU daily

Atopic dermatitis at 6 mos
Probiotic 25.8%
Placebo 22.7% (NS)

Atopic dermatitis at 1 yr
Probiotic 43%
Placebo 39% (NS)

Abrahamsson, 2007[62]

232 mother-infant pairs with history of allergies (188)

4 wks prenatally

1 yr postnatally

L reuteri

1x108 CFU daily

Atopic dermatitis
Probiotic 36%
Placebo 34% (NS)

Positive skin prick test
Probiotic 14%
Placebo 31% *

Kopp, 2008 [64]

105 pregnant mothers with history of atopic disease (94)

4 to 6 wks prenatally

6 mos postnatally

LGG

5x109 CFU twice daily

Atopic dermatitis at 2 yrs
Probiotic 28%
Placebo 27.3% (NS)

NS: non-significant, * : p < 0.05, † Brackets indicate final study population

Treatment of atopic dermatitis

Two early probiotics studies showed promising results for the treatment of atopic dermatitis. LGG and L reuterii were used for six weeks in children with moderate to severe eczema. While there was no significant improvement in objective disease measurements, subjects on probiotics perceived significantly more improvement than those on placebo.[66] L fermentum also diminished atopic dermatitis scores.[67] However, three subsequent meta-analyses concluded that reductions in eczema severity from probiotic treatment were modest and unlikely to be clinically significant.[68]-[70]

Treatment of allergic colitis

Using LGG as an adjunct to maternal hypoallergenic diet in breastfed infants with rectal bleeding caused by allergic colitis did not significantly affect the duration of rectal bleeding.[71] One recent study suggested that there was a greater decrease in fecal calprotectin (a marker of intestinal inflammation) and that rectal bleeding disappeared more quickly in infants treated with extensively hydrolysed formula with probiotics than with extensively hydrolysed formula alone.[72]

Further studies are needed to draw conclusions at this point.

Side effects of probiotics

Some probiotics may cause systemic or local infections. LGG and saccharomyces sepsis have been described in critically ill or immunocompromised patients, in some immunocompetent patients, and in patients with a central venous catheter.[73]-[79] There have been no reports of bifidobacterial systemic infection, and there was no increase in the incidence of lactobacilli sepsis in Finland following their introduction of lactobacilli in dairy products. [80]

Conclusion

The literature suggests there are benefits to using probiotics for treating some diseases, such as AAD and acute infectious viral diarrhea, and to help prevent NEC. There might also be a beneficial effect in patients with colic and IBS. The role of probiotics remains unproven in preventing or treating atopic diseases. Caution should be exercised in giving probiotics to patients with an immunodeficiency. The efficacy of probiotics is both strain- and disease-specific, and any probiotic must be provided in adequate amount. Physicians need to be more aware of the differences among probiotic preparations, and government agencies should be involved in regulating the viability and composition of probiotic products.

Table 9 lists some probiotic products. No preparation of LGG is currently available in this country. A list of products licensed in Canada is available at: www.hc-sc.gc.ca/dhp-mps/prodnatur/applications/licen-prod/lnhpd-bdpsnh-eng.php

TABLE 9
Some probiotic products

Name

Probiotics

Concentration

Bio K + milk-based

L acidophilus
L casei

50 billion/container

Bio K + capsules

L acidophilus
L casei

50 billion/capsule

Probaclac children

B bifidum, B longum,
L acidophilus, L casei,
L bulgaricus, L rhamnosus
S thermophilus

3 billion/capsule

Florastor Kids

S boulardi

250 mg/packet

VSL # 3

B breve, B longum, B infantis,
L acidophilus, L plantarum,
L paracasei, L bulgaricus,
S thermophilus

450 billion/packet

Lactibiane Kids

(not available in Canada)

LGG

4 billion/packet

Culturelle Kids

(not available in Canada)

LGG

I billion/packet

BioGaia

L reuteri

Drops, straw, lozenge, ORS, chewable tablets, lifetop cap

ORS Oral rehydration solution

Recommendations

For physicians

1. Keeping in mind that the effect of probiotics is both strain- and disease-specific, physicians should consider recommending probiotics to:

  • prevent antibiotic-associated diarrhea.
  • shorten the duration of acute infectious viral diarrhea.
  • prevent necrotizing enterocolitis in preterm infants who are at risk of necrotizing enterocolitis.
  • decrease the symptoms of colic.
  • decrease some symptoms of irritable bowel syndrome.

2. Based on current evidence, the use of probiotics cannot yet be recommended for the treatment or prevention of atopic diseases.

3. Physicians should be aware of the small risks of invasive infections with using some strains of probiotics in immunocompromised patients, and more rarely in the healthy child.

4. Physicians should advocate for further research to define which strains and dose of probiotics should be used in specific conditions.

For government

The federal government should require manufacturers of probiotics and products containing probiotics to provide high quality products with precise and informative labelling.

Acknowledgements

This statement was reviewed by the Fetus and Newborn, and Infectious Diseases and Immunization Committees of the Canadian Paediatric Society.

CPS NUTRITION AND GASTROENTEROLOGY COMMITTEE


Members: Dana L Boctor MD; Jeffrey N Critch MD(Chair); Manjula Gowrishankar MD; Daniel Roth MD; Sharon L Unger MD; Robin C Williams MD (Board Representative)
Liaisons: Jatinder Bhatia MD, American Academy of Pediatrics; Genevieve Courant NP, MSc, Breastfeeding Committee for Canada; A George F Davidson MD, Human Milk Banking Association; Tanis Fenton, Dietitians of Canada; Jennifer McCrea, Health Canada; Jae Hong Kim MD (Past member); Lynne Underhill MSc, Bureau of Nutritional Sciences, Health Canada
Principal author: Valérie Marchand MD (past Chair)

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Disclaimer: The recommendations in this position statement do not indicate an exclusive course of treatment or procedure to be followed. Variations, taking into account individual circumstances, may be appropriate. Internet addresses are current at time of publication.