Clinical Report: Probiotics and Prebiotics in Pediatrics

An Expert Interview With Dan W. Thomas, MD

Dan W. Thomas, MD

Disclosures

January 31, 2011

In This Article

Role of Probiotics in Disease

Common Gastrointestinal Conditions

Medscape: Dr. Thomas, can you summarize some of the major findings in the report in each of the therapeutic areas discussed? First, what is the role of these agents in prevention and treatment of acute gastroenteritis (AGE)?

Dr. Thomas: A number of randomized controlled trials (RCT) of probiotics in AGE have been conducted. Rotavirus was the most common cause of acute diarrhea in these studies. While the results indicate that there is modest benefit with use of probiotics to prevent AGE in infants and children, the available data do not support routine use to prevent nosocomial rotavirus diarrhea in children attending daycare. Rotavirus vaccine is likely to be a much more effective agent in preventing rotavirus infection although there may be special circumstances, such as long-term care facilities, where use of probiotics may be useful in prevention. In the treatment of AGE, however, the data are positive. There is evidence from well-conducted RCTs to support the use of probiotics, specifically LGG, in the management of acute infectious diarrhea. Probiotics have been found to shorten the duration of diarrhea by about 1 day and to decrease the number of diarrheal stools. They also shorten the time necessary for intravenous hydration when this is required. Probiotics seem to be more effective when given early in the course of diarrhea and are most effective in healthy infants and young children with watery diarrhea due to viral gastroenteritis, such as rotavirus, but not invasive bacterial infections.

Medscape: Another common cause of diarrhea in young children is the use of antibiotics. What does the report say about use of probiotics in the prevention and treatment of antibiotic-associated diarrhea?

Dr. Thomas: Prevention of diarrhea due to antibiotic use is another area where a meta-analysis of RCTs indicates a benefit from probiotics.[1] In most of the studies, a probiotic was initiated at the same time as the antibiotic, resulting in a substantial reduction in development of diarrhea. Approximately 1 in 7 cases of antibiotic-associated diarrhea was prevented by the use of a probiotic. However, there have been no published RCTs examining probiotics for the treatment of antibiotic-associated diarrhea in children, including Clostridium difficile antibiotic-associated diarrhea, and therefore their use presently cannot be recommended for pediatric patients.

Medscape: Can you discuss the report's recommendations regarding use of probiotics in other GI conditions such as infantile colic and irritable bowel syndrome?

Dr. Thomas: Colic is a common yet incompletely understood condition primarily affecting babies younger than 4 months of age. No studies have examined the use of probiotics in prevention of this condition and only 1 RCT has looked at the potential use these agents in treatment of colic, and that study included only breast-fed infants. While the results were encouraging, finding less crying within 1 week of initiation of Lactobacillus reuteri when compared with simethicone, probiotics cannot yet be routinely recommended.[2] There are also limited data examining use of probiotics in irritable bowel syndrome. One study did find that LGG reduced abdominal discomfort and distention in a group of 50 children. Studies of efficacy in treating constipation have been less positive, however, and they are not recommended at this time for treatment of this condition in children.

Serious Gastrointestinal Disease

Medscape: What about use in more serious GI conditions such as inflammatory bowel disease (IBD) or necrotizing enterocolitis (NEC)?

Dr. Thomas: This is an important issue because it is recognized that as many as half of all children with IBD routinely use alternative medicines, including probiotics. Data from RCTs of adults with chronic ulcerative colitis (CUC) are encouraging. A recent Cochrane review reported that adults with mild-to-moderate CUC received comparable benefit from probiotics as compared with anti-inflammatory drugs such as mesalamine.[3]While there has been a single RCT in children with newly diagnosed CUC that had promising results, more research is needed and probiotics cannot be routinely recommend at this time. Another recent Cochrane review examining the potential role of probiotics in maintaining remission in adults with Crohn disease concluded there was, as yet, no proven benefit.[4] At this time, their use cannot be recommended for children with Crohn disease.

There is evidence to support the use of probiotics to prevent NEC in preterm infants weighing more than 1000 g at birth.[5] However, there remain many unanswered questions over the use of probiotics for prevention of NEC, including overall safety. Further study is recommended before routine utilization of probiotics for this purpose can be recommended.

Use in Non-Gastrointestinal Disease

Medscape: The clinical report also discussed use of probiotics for non-gastrointestinal conditions, particularly atopic disease. Can you share some of these recommendations?

Dr. Thomas: A Cochrane review in 2007 concluded that there was insufficient evidence to warrant routine supplementation of probiotics to either pregnant women or infants for prevention of allergic disorders in infants.[6]That position was reiterated in a 2010 review that concluded that there was not enough evidence to support the use of probiotics, prebiotics, or synbiotics in the prevention or treatment of allergic dermatitis in children.[7]A 2007 large RCT in Finland treated pregnant women with atopic disease with a combination of probiotics and prebiotics during pregnancy that was continued in their infants after delivery.[8] The study did not document a reduction in the cumulative incidence of allergic disease in these infants, although they did find a lower incidence of IgE-mediated allergic disease, including eczema. While interesting, this study requires confirmation.

Medscape: The clinical report also discussed use of these agents in prevention and management of extraintestinal, primarily respiratory, infection. Can you describe these results?

Dr. Thomas: A few studies have examined the potential for these agents to reduce respiratory symptoms in children, particularly those attending daycare. A study in 2001 conducted in daycare centers in Finland compared children randomly assigned children to receive milk with and without LGG.[9] While there were trends favoring fewer days of absence from child care as well as fewer diagnoses of infection or use of antibiotics in children fed milk with LGG, the differences were not significant. No studies have found a benefit from administration of probiotics to treat these infections.

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