Probiotics and prebiotics in pediatrics

Prebiotics in healthy infants and children for prevention of acute infectious diseases: a systematic review and meta-analysis

Prebiotics, defined as nondigestible dietary ingredients resistant to gastric acidity and fermented by the intestinal flora, are used to positively influence the composition of intestinal flora, thereby promoting health benefits. The objective of this systematic review was to assess the efficacy of prebiotics in the prevention of acute infectious diseases in children. A systematic literature search was conducted using the Ovid Medline, Scopus, Web of Science, and Cochrane Library's Central databases. Finally, five randomized controlled trials, all of them investigating infants and children 0-24 months of age, were included in the review. Pooled estimates from three studies revealed a statistically significant decrease in the number of infectious episodes requiring antibiotic therapy in the prebiotic group as compared with the placebo group (rate ratio 0.68; 95% confidence interval 0.61-0.77). Studies available indicate that prebiotics may also be effective in decreasing the rate of overall infections in infants and children 0-24 months of age. Further studies in the age group 3-18 years are required to determine whether prebiotics can be considered for the prevention of acute infectious diseases in the older pediatric population.

A critical appraisal of probiotics (as drugs or food supplements) in gastrointestinal diseases

Probiotics may be registered as food supplements or drugs. This article summarizes differences in European regulations of probiotics registered as food supplements and drugs, as well as issues related to the quality of probiotic products. For registration as a drug, the European Medicines Agency demands extensive and detailed quality, efficacy and safety evidence; whereas compulsory analyses requested for food supplements consist only in a nutritional analysis. As a result, the quality of those probiotics registered as drugs, compared to food supplements, is in general controlled with higher standards. Despite these differences and whatever the status of the probiotic product, its efficacy and safety has to be documented in well conducted randomized controlled trials (RCTs). Furthermore, this paper reviews recent evidence on the use of probiotics for gastrointestinal diseases, evaluating all the existing information up to January 2014. In all eligible published studies in which use of probiotics for gastrointestinal diseases were investigated and reported, no language limitations were applied. Special focus is placed on RCTs (or their meta-analyses) showing positive results, so that the findings may be applicable to everyday clinical practice. Currently, the best documented clinical areas appear to be probiotics efficacy for the treatment of acute gastroenteritis in children and for the prevention of antibiotic-associated diarrhea both in children and in adults. In other gastrointestinal conditions, some promising observations are emerging, but no definitive conclusions can be reached at present.

Probiotics in the treatment of chronic rhinoconjunctivitis and chronic rhinosinusitis

Chronic rhinitis and rhinosinusitis (CRS) are relevant health conditions affecting significant percentages of the western population. They are frequently coexisting and aggravating diseases. Both are chronic, noninfectious, and inflammatory conditions sharing to a certain extent important pathophysiologic similarities. Beneficial effects of probiotics are long known to mankind. Research is beginning to unravel the true nature of the human microbiome and its interaction with the immune system. The growing prevalence of atopic diseases in the developed world led to the proposition of the "hygiene hypothesis." Dysbiosis is linked to atopic diseases; probiotic supplementation is able to alter the microbiome and certain probiotic strains have immunomodulatory effects in favour of a suppression of Th-2 and stimulation of a Th1 profile. This review focuses on randomized, double-blind, placebo-controlled trials investigating clinical parameters in the treatment of chronic rhinitis and CRS. An emerging number of publications demonstrate beneficial effects using probiotics in clinical double-blind placebo-controlled (dbpc) trials in allergic rhinitis (AR). Using probiotics as complementary treatment options in AR seems to be a promising concept although the evidence is of a preliminary nature to date and more convincing trials are needed. There are no current data to support the use of probiotics in non-AR or CRS.

Understanding the role of probiotics and prebiotics in preventing allergic disease: evidence and methodological issues

Research in the area of prevention of allergic disorders through modification of the intestinal microbiota by provision of probiotics and/or prebiotics is relatively new. This paper briefly summarizes evidence regarding the role of probiotics and/or prebiotics in reducing the risk of allergy. There are studies that show a protective effect, no effect or even a predisposing effect of using probiotics and/or prebiotics in preventing allergic disease. A variety of methodological issues are likely to contribute to current uncertainty. These include differences in the study population (high-risk vs unselected population), optimal strain selection (all probiotics are not equal), differences in definitions of outcomes, timing and duration of the interventions, and a lack of repeat studies.

Probiotics tailored to the infant: a window of opportunity

Initial neonatal gut colonization is a crucial stage for developing a healthy physiology, beneficially influenced by breast-feeding. Breast milk has been shown not only to provide nutrients and bioactive immunological compounds, but also commensal bacteria, including gut-associated anaerobic bacteria such as Bifidobacterium species. Infant formulas are increasingly supplemented with probiotic bacteria despite uncertainties regarding their efficacy, and lack of mechanistic understanding. Breast milk may be a valuable source of such bacteria which, upon validation of their mechanism of action, might open a window of opportunity for developing probiotic-supplemented infant formula with proven efficacy.

Probiotics for the treatment of Helicobacter pylori infection in children

The combination of a proton pump inhibitor and two antibiotics (clarithromycin plus amoxicillin or metronidazole) has been the recommended first-line therapy since the first guidelines for Helicobacter pylori (H. pylori) infection in children were published. In recent years, the success of eradication therapies has declined, in part due to the development of H. pylori resistant strains. Alternative anti-H. pylori treatments are currently becoming more popular than the traditional eradication methods. Components that may be used either as a monotherapy or, in combination with antimicrobials, resulting in a more effective anti-H. pylori therapy have been investigated in depth by several researchers. One of the potential therapies is probiotic cultures; promising results have been observed in initial studies with numerous probiotic strains. Nevertheless, many questions remain unanswered. In this article, we comprehensively review the possible mechanisms of action of probiotics on H. pylori infection, and present the results of published studies using probiotics as possible agents to control H. pylori infection in children. The effect of the addition of probiotics to the standard H. pylori eradication therapy for the prevention of antibiotic associated side-effects is also discussed.

Three-combination probiotics therapy in children with salmonella and rotavirus gastroenteritis

GOALS

Quantitative Vesikari scales and qualitative severe diarrhea (Vesikari scale ≥11) assessments were used to grade the Salmonella-induced and rotavirus-induced gastroenteritis severity. A significant reduction in severe diarrhea (Vesikari score ≥11) was used to evaluate the efficacy of three-combination probiotics (BIO-THREE).

BACKGROUND

Several studies have shown that rotavirus and Salmonella infections are the leading causes of infectious gastroenteritis. Although probiotics have been effective in some studies, the use of 3-combination formulation probiotics is rare.

STUDY

This single-center, open-label, randomized, controlled trial included 159 patients (age range, 3 mo to 14 y) hospitalized with infectious gastroenteritis between February 2009 and October 2010.

RESULTS

Patients were grouped according to the pathogen identified (48, Salmonella; 42, rotavirus; and 69, unknown origin). The total diarrhea duration was significantly shorter for children who received BIO-THREE (P<0.0001). After BIO-THREE administration, there were significantly less intervention group patients with severe diarrhea at intervention day 3. Vesikari scale or diarrhea frequency results did not reveal significant differences between groups (except for day 5 in patients with rotavirus), and there were no significant changes in other clinical parameters or the length of hospital stay.

CONCLUSIONS

Seven-day BIO-THREE administration demonstrated high efficacy and safety in infants and children with severe gastroenteritis. The incidence of severe gastroenteritis was significantly reduced in the rotavirus origin and BIO-THREE intervention groups.

Atopic dermatitis and the atopic march revisited

Atopic dermatitis (AD) has become a significant public health problem because of increasing prevalence, together with increasing evidence that it may progress to other allergic phenotypes. While it is now acknowledged that AD commonly precedes other allergic diseases, a link termed 'the atopic march', debate continues as to whether this represents a causal relationship. An alternative hypothesis is that this association may be related to confounding by familial factors or phenotypes that comanifest, such as early-life wheeze and sensitization. However, there is increasing evidence from longitudinal studies suggesting that the association between AD and other allergies is independent of confounding by comanifest allergic phenotypes. The hypotheses on plausible biological mechanisms for the atopic march focus on defective skin barrier function and overexpression of inflammatory mediators released by the skin affected by AD (including thymic stromal lymphopoietin). Both human and animal studies have provided evidence supporting these potential biological mechanisms. Evidence from prevention trials is now critical to establishing a causal nature of the atopic march. An emerging area of research is investigation into environmental modifiers of the atopic march. Such information will assist in identifying secondary prevention strategies to arrest the atopic march. Despite much research into the aetiology of allergies, little progress has been made in identifying effective strategies to reduce the burden of allergic conditions. In this context, the atopic march remains a promising area of investigation.

The human microbiome and probiotics: implications for pediatrics

Steady advances in our knowledge of the composition and function of the human microbiome at multiple body sites including the gut, skin and airways will likely contribute to our understanding of mechanisms of probiotic action by beneficial microbes. Microbe:microbe and microbe:human interactions are important considerations as we select probiotics for pediatric patients in the future. Although our knowledge about the composition of the microbiome is progressing rapidly, many gaps exist about the functional capacity and metabolic machinery of the human microbiome. Based on a limited amount of data, probiotics appear capable of altering the composition and function of the microbiome. Probiotics may be part of dietary strategies that combine ways to enhance microbiome function with nutrients that may be converted to active compounds promoting human health. Probiotics have yielded beneficial effects in numerous studies in the context of different diseases in pediatric gastroenterology. These disease states include necrotizing enterocolitis, antibiotic-associated diarrhea and colitis, acute gastroenteritis and irritable bowel syndrome. In the skin and airways, it is unclear if probiotics can affect the function of the microbiome to reduce the impact of diseases such as asthma and atopic dermatitis. An enhanced understanding of the effects of probiotics on the microbiome should facilitate selection of optimal probiotic strains for specific diseases in the future.

Yacon effects in immune response and nutritional status of iron and zinc in preschool children

OBJECTIVE

The aim of this study was to evaluate the effect of yacon flour on iron and zinc nutritional status and immune response biomarkers in preschool children.

METHODS

Preschool children ages 2 to 5 y were selected from two nurseries and were placed into a control group (n = 58) or a yacon group (n = 59). The yacon group received yacon flour in preparations for 18 wk at a quantity to provide 0.14 g of fructooligosaccharides/kg of body weight daily. Anthropometric parameters were measured before and after the intervention and dietary intake was measured during the intervention. To assess iron and zinc status, erythrograms, serum iron, ferritin, and plasma, and erythrocyte zinc were evaluated. Systemic immune response was assessed by the biomarkers interleukin IL-4, IL-10, IL-6, and tumor necrosis factor-alfa (TNF-α). Intestinal immune response was analyzed by secretory IgA (sIgA) levels before and after the intervention. Statistical significance was evaluated using the paired t test (α = 5%).

RESULTS

Before and after the study, the children presented a high prevalence of overweight and an inadequate dietary intake of zinc and fiber. The yacon group presented with lower hemoglobin, mean corpuscular hemoglobin, and mean corpuscular hemoglobin concentration at the end of the study (P < 0.05). Erythrocyte zinc was reduced in both groups at the end of the study (P < 0.05). Yacon intake increased the serum levels of IL-4 and fecal sIgA (P < 0.05). The control group had lower serum TNF-α after the study period (P < 0.05).

CONCLUSION

Yacon improved intestinal immune response but demonstrated no effect on the nutritional status of iron and zinc in preschool children.

Complicated Clostridium difficile colitis in children with cystic fibrosis: association with gastric acid suppression?

Patients with cystic fibrosis (CF) have several risk factors for Clostridium difficile colonization such as frequent hospitalization and exposure to a broad array of antibiotics utilized for the control, eradication, and prophylaxis of respiratory pathogens. However, despite this high rate of colonization, the occurrence of C. difficile infection (CDI) in CF is rare. We report three children with CF who presented with severe community-associated CDI. All three children had complicated courses and one died. These children were in good health without significant morbidities, and were not frequently hospitalized nor did they receive frequent antibiotic courses. The occurrence of 3 severe cases within a 15-month period prompted us to report these cases and review the literature in regard to CDI. We reviewed the CF GI tract as possible risk factors for a high rate of C. difficile colonization in individuals with CF. Since a high percentage of individuals with CF are on gastric acid blocking agents, we also focused on gastric acid suppression as a potential risk factor for CDI.

Fermentation products: immunological effects on human and animal models

Infant formulas have been shown to influence the development of the gut microbiota. Besides the probiotic- and prebiotic-containing formulas, fermented milk-based infant formulas offer an additional means for modulation of gut immunity and/or gut microbiota. These formulas are produced by the fermentation of cow's milk with specific lactic acid bacteria strains, followed by heat treatment; they do not contain viable bacteria or added prebiotic oligosaccharides but contain specific products resulting from the fermentation process. This review is focused on the effects of fermentation products, distinguishing them from those of living bacteria and prebiotic compounds on the immune system. Besides the possible modulation of gut microbiota composition, in vitro and in vivo studies suggest that specific fermentation products can actively participate in the establishment of immune balance and oral tolerance. Although further research is needed to confirm the clinical benefits observed in infants to better characterize the active fermentation compounds and to delineate the involved pathways, these fermented formulas appear to deserve interest.

A double-blind placebo-controlled randomized trial on probiotics in small bowel bacterial overgrowth in children treated with omeprazole

OBJECTIVE

To evaluate the incidence of small bowel bacterial overgrowth (SBBO) in children treated with omeprazole, and to test whether probiotics influence the incidence.

METHODS

A double-blinded, placebo-controlled trial was performed in 70 children treated orally during four weeks with 20mg omeprazole per day. Lactobacillus rhamnosus R0011 (1.9×10(9) cfu) and Lactobacillus acidophilus R0052 (0.1×10(9) cfu) were simultaneously given daily to 36 subjects (probiotic group), while 34 subjects received placebo (placebo group). The diagnosis of SBBO was based on the development of suggestive symptoms, in combination with a positive glucose breath test.

RESULTS

After one month of proton pump inhibitor (PPI) treatment, 30% (21/70) had a positive breath test suggesting SBBO; of these 62% were symptomatic. Five children developed SBBO-like symptoms, but had a negative breath test; and 44 (63%) were symptom free and had a negative breath test. There was no difference in the incidence of positive breath tests in the probiotic versus the placebo group (33% vs 26.5%; p=0.13).

CONCLUSIONS

Since symptoms suggesting SBBO developed in 26% of PPI-treated children, and since the glucose breath test was abnormal in 72% of these, this side-effect should be more frequently considered. The probiotic tested did not decrease the risk to develop SBBO.

What is health?

Classical medical research is disease focused and still defines health as absence of disease. Languages, however, associate a positive concept of wholeness with health as does the WHO health definition. Newer medical health definitions emphasize the capacity to adapt to changing external and internal circumstances. The results of the 2010 Global Burden of Disease study provides keys for a quantifiable health metrics by developing statistical tools calculating healthy life expectancy. Of central social and economic importance is the question whether healthy ageing can be achieved. This concept hinges on theories on the biological basis of lifespan determination and whether negligible senescence and the compression of morbidity can be achieved in human societies. Since the health impact of the human gut microbiome is currently a topical research area, microbiologists should be aware of the problems in defining health.

Robustness of gut microbiota of healthy adults in response to probiotic intervention revealed by high-throughput pyrosequencing

Probiotics are live microorganisms that potentially confer beneficial outcomes to host by modulating gut microbiota in the intestine. The aim of this study was to comprehensively investigate effects of probiotics on human intestinal microbiota using 454 pyrosequencing of bacterial 16S ribosomal RNA genes with an improved quantitative accuracy for evaluation of the bacterial composition. We obtained 158 faecal samples from 18 healthy adult Japanese who were subjected to intervention with 6 commercially available probiotics containing either Bifidobacterium or Lactobacillus strains. We then analysed and compared bacterial composition of the faecal samples collected before, during, and after probiotic intervention by Operational taxonomic units (OTUs) and UniFrac distances. The results showed no significant changes in the overall structure of gut microbiota in the samples with and without probiotic administration regardless of groups and types of the probiotics used. We noticed that 32 OTUs (2.7% of all analysed OTUs) assigned to the indigenous species showed a significant increase or decrease of ≥10-fold or a quantity difference in >150 reads on probiotic administration. Such OTUs were found to be individual specific and tend to be unevenly distributed in the subjects. These data, thus, suggest robustness of the gut microbiota composition in healthy adults on probiotic administration.

Characterization of fecal microbiota of children with diarrhea in 2 locations in Colombia

OBJECTIVES

Diarrhea is a leading cause of mortality and morbidity in children younger than 5 years in impoverished regions of the world. Our aim was to compare the fecal microbiota of healthy children with that of children with clinical diarrhea in a population from a tropical highland in Colombia, South America. Our hypothesis was that a reduced prevalence of inherent Lactobacillus and Bifidobacterium species would be associated with enteric viral and bacterial pathogens.

METHODS

Children between 1 and 5 years of age from 2 different locations were evaluated for presence of clinical diarrhea. Nucleic acid, isolated from fecal samples, was used to determine by molecular protocols the abundance of inherent bacterial species and presence of enteric pathogens compared with clinically healthy children. The effect of host demographic factors on incidence of diarrhea was also analyzed.

RESULTS

: The composition of the fecal microbiota was affected by host demographic factors: age, health status, location, and sex. In partial support of our hypothesis, the relative abundance of commensal Bifidobacterium and Lactobacillus species was inversely correlated with incidence of diarrhea regardless of location.

CONCLUSIONS

Our results suggested that changes in fecal microbiota composition of children with clinical diarrhea are associated with certain demographic factors that should be considered before designing a prophylactic intervention. Delivery of certain Lactobacillus species and Bifidobacterium species or a diet rich in bifidogenic components that promote growth of Bifidobacterium species could provide a prophylactic effect to ameliorate the effect of diarrhea in children at risk.

Pooling expressed breastmilk to provide a consistent feeding composition for premature infants

OBJECTIVE

We hypothesized that pooling a mother's expressed breastmilk for 24 hours compared with individual pump session collection of milk would provide a more consistent caloric product without increasing bacterial contamination.

STUDY DESIGN

We investigated 24-hour pooled breastmilk collection by enrolling 19 mothers who were expressing milk for their infants. Mothers followed a standardized milk collection protocol for 4 study days: daily milk was pooled in a sterile 1-L bottle on Day 1, and on Day 2 milk was aliquoted for each pump session into a sterile 120-mL container. The next week the order of collection was reversed. Milk samples were plated, incubated, and evaluated for bacteria colonization. Milk samples were analyzed for protein, fat, and carbohydrate content.

RESULTS

There was inherently less variability in the caloric and nutrient content of pooled milk compared with individual samples, in which caloric density varied by as much as 29%. Mother's milk had highly variable bacterial counts ranging from 0 to greater than 100,000 colonies/mL. High bacteria counts (>100,000 colonies/mL) occurred in 14.7% (31 of 211) of individual samples compared with 8.6% (three of 35) of pooled samples (p=0.39).

CONCLUSIONS

Twenty-four-hour pooling of human milk reduces nutrient and caloric variability without increasing bacterial counts.

Assessment of bacterial diversity in breast milk using culture-dependent and culture-independent approaches

Initial neonatal gut colonisation is a crucial stage for developing a healthy physiology, beneficially influenced by breast-feeding. Breast milk has been shown not only to provide nutrients and bioactive/immunological compounds, but also commensal bacteria, including gut-associated anaerobic Bifidobacterium spp. The aim of the present study was to investigate bacterial diversity in breast milk, with emphasis on identifying gut-associated obligate anaerobes. Breast milk collected from seven mothers at three sampling points (days 3-6, 9-14 and 25-30 postpartum) was analysed by combined culture-dependent and state-of-the-art, culture-independent methods (Sanger sequencing and 454-pyrosequencing). In addition to the predominance of facultative anaerobes such as Staphylococcus, Streptococcus and Propionibacterium (>90% of isolated strains and 23·7% relative abundance using pyrosequencing), significant populations of obligate anaerobes, including Bifidobacterium and Veillonella, were detected using pyrosequencing and confirmed by the isolation of viable strains (3·4% of isolates and 1·4% relative abundance). Pyrosequencing also revealed the presence of DNA of multiple major gut-associated obligate anaerobes (6·2% relative abundance) such as Bacteroides and, for the first time, several members of the Clostridia, including butyrate producers, such as Faecalibacterium and Roseburia, which are important for colonic health. The present study suggests that breast milk may be a major source of bacterial diversity to the neonatal gut, including gut-associated obligate anaerobes, and may thus significantly influence gut colonisation and maturation of the immune system.

Therapeutic use of prebiotics, probiotics, and postbiotics to prevent necrotizing enterocolitis: what is the current evidence?

Necrotizing enterocolitis (NEC) is a leading cause of neonatal morbidity and mortality, and preventive therapies that are both effective and safe are urgently needed. Current evidence from therapeutic trials suggests that probiotics are effective in decreasing NEC in preterm infants, and probiotics are currently the most promising therapy for this devastating disease. However, concerns regarding safety and optimal dosing have limited the widespread adoption of routine clinical use of probiotics in preterm infants. This article summarizes the current evidence regarding the use of probiotics, prebiotics, and postbiotics in the preterm infant, including their therapeutic role in preventing NEC.

Rapid adoption of Lactobacillus rhamnosus GG for acute gastroenteritis

BACKGROUND AND OBJECTIVES

A 2007 meta-analysis showed probiotics, specifically Lactobacillus rhamnosus GG (LGG), shorten diarrhea from acute gastroenteritis (AGE) by 24 hours and decrease risk of progression beyond 7 days. In 2005, our institution published a guideline recommending consideration of probiotics for patients with AGE, but only 1% of inpatients with AGE were prescribed LGG. The objective of this study was to increase inpatient prescribing of LGG at admission to >90%, for children hospitalized with AGE, within 120 days.

METHODS

This quality improvement study included patients aged 2 months to 18 years admitted to general pediatrics with AGE with diarrhea. Diarrhea was defined as looser or ≥ 3 stools in the preceding 24 hours. Patients with complex medical conditions or with presumed bacterial gastroenteritis were excluded. Admitting and supervising clinicians were educated on the evidence. We ensured LGG was adequately stocked in our pharmacies and updated an AGE-specific computerized order set to include a default LGG order. Failure identification and mitigation were conducted via daily electronic chart review and e-mail communication. Primary outcome was the percentage of included patients prescribed LGG within 18 hours of admission. Intervention impact was assessed with run charts tracking our primary outcome over time.

RESULTS

The prescribing rate increased to 100% within 6 weeks and has been sustained for 7 months.

CONCLUSIONS

Keys to success were pharmacy collaboration, use of an electronic medical record for a standardized order set, and rapid identification and mitigation of failures. Rapid implementation of evidence-based practices is possible using improvement science methods.

Probiotics and prebiotics in pediatric diarrheal disorders

INTRODUCTION

In pediatrics, prebiotics and/or probiotics are added to infant formula, mainly to prevent diseases such as diarrheal disorders. Probiotic food supplements and medication are frequently used in the treatment of diarrheal disorders. This paper reviews the recent published evidence on these topics.

AREAS COVERED

Relevant literature published using PubMed and CINAHL was collected and reviewed. Recent review papers were give special attention.

EXPERT OPINION

The addition of pre- and/or probiotics to infant formula seems not harmful, but the evidence for benefit is limited. Most probiotics are commercialized as food supplements, and therefore do not qualify for medication legislation. Worldwide, Saccharomyces boulardii is the only strain which is registered as "medication" in the majority of countries. Efficacy data can only be considered if performed with the commercialized product. Some products reduce the risk for antibiotic-associated diarrhea and reduced the duration of acute infectious diarrhea with about 24 h. Overall, data in the other indications (inflammatory bowel disease, irritable bowel syndrome) are disappointing, although there are some recent promising results. The use of food supplements as medication opens the discussion to create a category of "medical food."

Lactobacillus reuteri DSM 17938 for the management of infantile colic in breastfed infants: a randomized, double-blind, placebo-controlled trial

OBJECTIVE

To determine whether administration of Lactobacillus reuteri (L reuteri) DSM 17938 is beneficial in breastfed infants with infantile colic.

STUDY DESIGN

Eighty infants aged <5 months with infantile colic (defined as crying episodes lasting 3 or more hours per day and occurring at least 3 days per week within 7 days prior to enrollment), who were exclusively or predominantly (>50%) breastfed were randomly assigned to receive L reuteri DSM 17938 (10(8) colony-forming units) (n = 40) or an identically appearing and tasting placebo (n = 40), both orally, in 5 drops, 1 time daily, for 21 days. The primary outcome measures were the treatment success, defined as the percentage of children achieving a reduction in the daily average crying time ≥ 50%, and the duration of crying (minutes per day) at 7, 14, 21, and 28 days after randomization.

RESULTS

The rate of responders to treatment was significantly higher in the probiotic group compared with the placebo group at day 7 (P = .026), at day 14 (relative risk (RR) 4.3, 95% CI 2.3-8.7), at day 21 (RR 2.7, 95% CI 1.85-4.1), and at day 28 (RR 2.5, 95% CI 1.8-3.75). In addition, throughout the study period, the median crying time was significantly reduced in the probiotic group compared with the control group.

CONCLUSION

Exclusively or predominantly breastfed infants with infantile colic benefit from the administration of L reuteri DSM 17938 compared with placebo.

Clinical effects of probiotics: scientific evidence from a paediatric perspective

Probiotics are live micro-organisms that when given in adequate amounts can cause health benefits. The safety and efficacy of probiotics in the prevention and treatment of various clinical conditions have been evaluated in randomised controlled clinical trials, systematic reviews and meta-analyses. Generally, their safety has been documented. As a supplement to standard rehydration therapy, probiotics have been demonstrated to shorten the duration of diarrhoea resulting from acute viral gastroenteritis and in preventing antibiotic-associated diarrhoea in healthy children. Preliminary evidence suggests that probiotics might prevent necrotising enterocolitis in very-low-birth-weight infants, but further studies are needed before definite conclusions can be drawn. Probiotics have also been assessed in the treatment and prevention of allergic disease but the results, although promising, need further confirmation. Targeting a paediatric population, probiotics have been evaluated in the treatment of irritable bowel syndrome, ulcerative colitis, Helicobacter pylori gastritis and infantile colic, but at this stage, there is no evidence to support their routine use for these indications. There is a great need for studies aiming at disentangling the mechanisms by which probiotics mediate their clinical effects and for comparative studies between various probiotic bacteria. We still need to know which probiotic(s) to use and for which indications. A clearer message on dosages, optimal timing and duration of administration is needed. For this purpose, more carefully designed and sufficiently powered, randomised controlled trials with predefined outcomes are needed.

Cost/benefit of synbiotics in acute infectious gastroenteritis: spend to save

The cost/benefit ratio of probiotics in the ambulatory treatment of acute infectious gastro-enteritis with or without a synbiotic food supplement (containing fructo-oligosaccharides and probiotic strains of Streptoccoccus thermophilus, Lactobacillus rhamnosus, Lactobacillus acidophilus, Bifidobacterium lactis and Bifidobacterium infantis) has been studied. 111 children (median age 37 and 43 months for the synbiotic and placebo group, respectively) with acute infectious gastroenteritis were included in a randomised, prospective placebo-controlled trial performed in primary health care. All children were treated with an oral rehydration solution and with the synbiotic food supplement (n=57) or placebo (n=54). Physicians were allowed to prescribe additional medication according to what they considered as 'necessary'. Cost of add-on medication and total healthcare cost were calculated. Median duration of diarrhoea was 1 day shorter (95% confidence interval -0.6 to -1.9 days) in the symbiotic than in the placebo group (P<0.005). Significantly more concomitant medication (antibiotics, antipyretics, antiemetics) was prescribed in the placebo group (39 prescriptions in 28 patients) compared to the synbiotic group (12 prescriptions in 7 patients) (P<0.001). The difference was most striking for antiemetics: 28 vs. 5 prescriptions. The cost of add-on medication in the placebo group was evaluated at € 4.04/patient (median 4.97 (interquartile (IQ) 25-75: 0-4.97)) vs. € 1.13 /patient in the synbiotic arm (P<0.001). If the cost of the synbiotic is considered, median cost raised to € 7.15/patient (IQ 25-75: 7.15-7.15) (P<0.001). The extra consultations needed to prescribe the concomitant medication resulted in a higher health care cost in the placebo group (€ 14.41 vs. € 10.74/patient, P<0.001). Synbiotic food supplementation resulted in a 24 h earlier normalisation of stool consistency. Although use of the synbiotic supplementation increased cost, add-on medication and extra consultations were reduced, resulting in a reduction of health care cost of 25%.

Probiotics and prebiotics: role in prevention of nosocomial sepsis in preterm infants

Nosocomial sepsis is associated with increased mortality and morbidity including neurodevelopmental impairment and prolonged hospital stay. Prevention of sepsis especially in the preterm infants in the neonatal intensive care unit remains a major challenge. The gastrointestinal tract is an important source of potential pathogens causing nosocomial sepsis as the immature intestinal epithelium can permit translocation of bacteria and yeast. The intestinal tract and its microflora play an important role in the immunity. Altering the gut microflora has been extensively studied for immunomodulation in preterm infants. Probiotics are live microorganisms which when administered in adequate amounts confer a health benefit on the host. Probiotics have been used for prevention and treatment of various medical conditions in children and adults. Studies on probiotics in premature infants have focused on normalizing intestinal flora, improvement in feeding intolerance, prevention of necrotizing enterocolitis and sepsis. In this paper, we discuss the intestinal bacterial colonization pattern; the rational for probiotics and prebiotic therapy with special focus on the prevention of nosocomial sepsis in preterm infants.

Probiotics supplementation increases intestinal blood flow velocity in extremely low birth weight preterm infants

OBJECTIVE

To determine whether probiotics supplementation affects intestinal blood flow velocity in extremely low birth weight neonates.

STUDY DESIGN

In this randomized, double-blind, placebo-controlled study, probiotics were added to the first enteral feeding and continued until discharge or 34 weeks postmenstrual age. Pulsed Doppler was used to measure preprandial and postprandial (at 30 and 60 min) time-averaged mean velocity (TAMV), peak systolic velocity (PSV) and end diastolic velocity (EDV) during the second week of life after ≥ 7 days of probiotics supplementation.

RESULT

A total of 31 infants were studied, 15 were randomized to the probiotic and 16 to the placebo groups. There was a significant postprandial increase in TAMV for the probiotic vs the placebo group (P=0.035), with PSV and EDV showing a trend. Demographic and clinical variables were similar between the groups.

CONCLUSION

Probiotics administration significantly increases postprandial intestinal blood flow in extremely low birth weight preterm neonates when compared with the placebo group.

Pro- und Präbiotika

Die rasante Entwicklung der Molekularbiologie und eine inzwischen beachtliche Fülle an Daten aus klinischen Studien haben in der vergangenen Dekade eine neue solide wissenschaftliche Basis für den Einsatz probiotischer Bakterien, speziell von Laktobazillen und Bifidobakterien ergeben. Entgegen manchen Postulierungen existiert jedoch ganz offenkundig sowohl in experimentellen als auch in klinischen Studien eine strenge Stammspezifik von Funktionen und Wirkungen dieser Spezies probiotischer Bakterien. Eine wissenschaftliche Rationale für die Nutzung von Laktobazillen und Bifidobakterien als Probiotika ist bisher nur für vergleichsweise wenige Stämme nachgewiesen worden. Dies gilt für lebende und hitzebehandelte Bakterien gleichermaßen, ob mit oder ohne Mitverwendung ihres Kulturüberstands in den Studienansätzen.

Treatment of necrotizing enterocolitis with probiotics

Necrotizing enterocolitis (NEC) is a devastating condition characterized by diffuse intestinal inflammation and necrosis in preterm infants. It is the most common gastrointestinal emergency in the neonatal intensive care unit and is associated with significant morbidity and mortality. Primary risk factors include prematurity and low birth weight. Although the pathogenesis of NEC is complex and not entirely understood, it is known that an interplay between immature intestinal immune responses and the process of bacterial colonization is required for the development of this disease.

Sun protection, probiotics and parental smoking cessation

PURPOSE OF REVIEW

This article addresses three areas where new research demonstrates the potential to impact the health of children and adolescents: sun protection, probiotic use, and parental smoking cessation.

RECENT FINDINGS

Skin cancer rates are rising, and sun exposure in childhood and exposure to tanning beds are important preventable risk factors. Research on the use of probiotics to treat a variety of intestinal and nonintestinal diseases is expanding. By counseling parents about smoking cessation, pediatricians can assist in decreasing childhood exposure to harmful second-hand and third-hand smoke.

SUMMARY

New research on probiotic use in children shows its potential in prevention and treatment of common childhood illnesses. By finding ways to educate patients and parents on the dangers of ultraviolet radiation and smoke exposure, pediatricians can improve both short-term and long-term health of their patients.

Hirschsprung-associated enterocolitis: prevention and therapy

Hirschsprung-associated enterocolitis remains the greatest cause of morbidity and mortality in children with Hirschsprung disease. This chapter details the various approaches used to treat and prevent this disease process. This includes prevention of complications, such as stricture formation, prophylaxis with rectal washouts, and identification of high-risk individuals. The chapter also details approaches to diagnose Hirschsprung-associated enterocolitis as well as to exclude other etiologies.

Summary of the 24(th) Marabou Symposium: Nutrition and the human microbiome

This summary covers the articles and attributed discussion in the present supplement, which resulted from the 24(th) Marabou Symposium titled "Nutrition and the Human Microbiome", which was held in Stockholm in 2011 with the participation of about 40 global experts in microbiology, physiology, biology, and medicine. The individual articles address a number of topics related to the human microbiome; the attributed discussion, however, offers much more on the nature of the current scientific debate and provides insight into new opportunities for research as well as possible effects of the gut microbes, ranging from possible prenatal epigenetic effects to brain function and behavior.

Microbiota-targeted therapies: an ecological perspective

The connection between disease and the disruption of homeostatic interactions between the host and its microbiota is now well established. Drug developers and clinicians are starting to rely more heavily on therapies that directly target the microbiota and on the ecology of the microbiota to understand the outcomes of these treatments. The effects of those microbiota-targeted therapies that alter community composition range in scale from eliminating individual strains of a single species (for example, with antibacterial conjugate vaccines) to replacing the entire community with a new intact microbiota (for example, by fecal transplantation). Secondary infections linked to antibiotic use provide a cautionary tale of the unintended consequences of perturbing a microbial species network and highlight the need for new narrow-spectrum antibiotics with rapid companion diagnostics. Insights into microbial ecology will also benefit the development of probiotics, whose therapeutic prospects will depend on rigorous clinical testing. Future probiotics may take the form of a consortium of long-term community residents: "a fecal transplant in a capsule." The efficacy of microbiota-targeted therapies will need to be assessed using new diagnostic tools that measure community function rather than composition, including the temporal response of a microbial community to a defined perturbation such as an antibiotic or probiotic.

Probiotics and necrotizing enterocolitis: finding the missing pieces of the probiotic puzzle

Necrotizing enterocolitis (NEC) is one of the leading causes of death in the neonatal intensive care unit. Morbidity and mortality rates significantly increase with decreases in gestational age and birth weight. Strong evidence suggests probiotic prophylaxis may significantly decrease the incidence of NEC and should therefore be incorporated into the standard of care for preterm infants. However, debate still remains because of limitations of completed studies. The purpose of this review was to provide an overview of the controversies regarding probiotic use in preterm infants and to shed light on the practical considerations for implementation of probiotic supplementation.

Effect of Bifidobacterium administration on very-low-birthweight infants

BACKGROUND

The aim of this study was to evaluate the efficacy and safety of early administration of Bifidobacterium bifidum OLB6378 (B. bifidum) on accelerating enteral feeding and bacterial colonization in very-low-birthweight (VLBW) infants.

METHODS

We conducted a single-center prospective pilot study. Thirty-six VLBW infants were randomly divided into two groups: group E, wherein B. bifidum was supplemented within 48 h of birth, and group L, wherein it was supplemented more than 48 h after birth.

RESULTS

Group E and group L reached a total feeding volume of 100 mL/(kg/day) after 10 [7-13] days and 11 [10-15] days, respectively (median [quartile]). The daily bodyweight gain in group E was significantly higher (21.4 ± 3.2 g/day vs 18.3 ± 4.0 g/day, P < 0.02; 11.1 ± 1.5 g/kg/day vs 10.4 ± 1.2 g/kg/day, P < 0.04). No significant differences were found in the fecal Bifidobacterium level between the groups quantitated with a real-time polymerase chain reaction assay at 1 and 4 weeks of age. However, the highest colonization rate of Bifidobacterium was observed when the supplementation started between 24 and 48 h after birth. The incidence of morbidities between the groups was similar.

CONCLUSION

The early administration of B. bifidum to VLBW infants seems effective in promoting growth during the stay in the neonatal intensive care unit without increasing the incidence of morbidity. Furthermore, the preferable timing of starting the probiotic supplementation for VLBW infants is at latest less than 48 h after birth.

Probiotic supplement use among young children in Taiwan: a prospective cohort study

OBJECTIVES

The objective of this study is to provide details on probiotic supplement use among young children in Taiwan.

PARTICIPANTS AND METHODS

This study is based on the Taiwan Birth Cohort Study database. We used questionnaires to collect information on probiotic supplement use among young children from birth to 18 months of age, while also considering their demographic characteristics and other covariates. Low-birth-weight infants, preterm infants, those with birth defects, and those with caregivers who returned incomplete questionnaires were excluded. The final valid sample comprised 16,991 cases.

RESULTS

Approximately half the children received probiotic supplements before the age of 18 months. Only 6.3% of the children received probiotic supplements during the two periods of birth to 6 months and 7 to 18 months. Firstborn children, native mothers, mothers with higher educational levels, higher family income, and parents who lead healthy lifestyles were positively related to probiotic supplement use among children. Young children who were breastfed, with eczema, or with gastrointestinal tract problems were significantly positively associated with probiotic supplement use.

CONCLUSION

The findings show that probiotic supplement usage among young children is associated with a more socially advantaged circumstance and certain child health factors, such as eczema, diarrhea, and constipation. Parents might use probiotic supplements for prevention or treatment of child diseases. The findings of this research could serve as a baseline for future studies, and provide insight into probiotic supplement use behavior for health professionals caring for infants and young children.

The prebiotic effect of Anoectochilus formosanus and its consequences on bone health

The present study evaluated the prebiotic effect of a standardised aqueous extract of Anoectochilus formosanus (SAEAF) and its effects on osteoporosis in ovariectomised (OVX) rats. The OVX rats were randomly divided into five groups and orally treated with water, SAEAF (200 and 400 mg/kg daily) and inulin (400 mg/kg daily) for 12 weeks. The sham group was orally treated with water. The SAEAF treatment enhanced the number of faecal bifidobacteria in OVX rats. The results of a Ca-balance experiment showed that SAEAF increased apparent Ca absorption and retention. The OVX rats were killed after SAEAF treatment lasting 12 weeks. The SAEAF decreased the caecal pH values and increased the caecal wall weight, caecal mucosa calbindin-D9k mRNA expression, free-Ca concentration and levels of SCFA in the caecum. The mineral content, density and biomechanical strength of bones were lower in OVX rats than the sham group, but these bone losses were prevented by SAEAF administration. Microtomography scanning showed that the SAEAF-treated rats had higher trabecular bone volume than the OVX rats. These results suggest that SAEAF prevented bone loss associated with ovarian hormone deficiency in the rats.

Probiotics in neonatology

Probiotics are micro-organisms that confer health benefits on the host. Postulated mechanisms include: increasing resistance of the mucosal barrier to migration of bacteria and their toxins by strengthening intestinal cell junctions, modification of host response to microbial products, augmentation of immunoglobulin A mucosal responses, enhancement of enteral nutrition to inhibit the growth of pathogens; production of antimicrobial proteins; and competitive exclusion of potential pathogens. Published meta-analyses and systematic reviews report the effects of probiotics on important clinical outcomes in neonates. This paper will review the evidence for probiotic supplementation in neonatology, with a focus on preterm infants.