Probiotics and necrotising enterocolitis in premature infants

Attempts to limit sporulation in the probiotic strain Bacillus subtilis BG01-4TM through mutation accumulation and selection

The use of bacterial spores in probiotics over viable loads of bacteria has many advantages, including the durability of spores, which allows spore-based probiotics to effectively traverse the various biochemical barriers present in the gastrointestinal tract. However, the majority of spore-based probiotics developed currently aim to treat adults, and there is a litany of differences between the adult and infant intestinal systems, including the immaturity and low microbial species diversity observed within the intestines of infants. These differences are only further exacerbated in premature infants with necrotizing enterocolitis (NEC) and indicates that what may be appropriate for an adult or even a healthy full-term infant may not be suited for an unhealthy premature infant. Complications from using spore-based probiotics for premature infants with NEC may involve the spores remaining dormant and adhering to the intestinal epithelia, the out-competing of commensal bacteria by spores, and most importantly the innate antibiotic resistance of spores. Also, the ability of Bacillus subtilis to produce spores under duress may result in less B. subtilis perishing within the intestines and releasing membrane branched-chain fatty acids. The isolate B. subtilis BG01-4^TM is a proprietary strain developed by Vernx Biotechnology through accumulating mutations within the BG01-4^TM genome in a serial batch culture. Strain BG01-4^TM was provided as a non-spore-forming B. subtilis , but a positive sporulation status for BG01-4^TM was confirmed through in vitro testing and suggested that selection for the sporulation defective genes could occur within an environment that would select against sporulation. The durability of key sporulation genes was ratified in this study, as the ability of BG01-4^TM to produce spores was not eliminated by the attempts to select against sporulation genes in BG01-4^TM by the epigenetic factors of high glucose and low pH. However, a variation in the genes in isolate BG01-4-8 involved in the regulation of sporulation is believed to have occurred during the mutation selection from the parent strain BG01-4^TM. An alteration in selected sporulation regulation genes is expected to have occurred from BG01-4^TM to BG01-4-8, with BG01-4-8 producing spores within 24 h, ~48 h quicker than BG01-4^TM.

Bermúdez M, Campoy C. Impact of Total Parenteral Nutrition on Gut Microbiota in Pediatric Population Suffering Intestinal Disorders

Parenteral nutrition (PN) is a life-saving therapy providing nutritional support in patients with digestive tract complications, particularly in preterm neonates due to their gut immaturity during the first postnatal weeks. Despite this, PN can also result in several gastrointestinal complications that are the cause or consequence of gut mucosal atrophy and gut microbiota dysbiosis, which may further aggravate gastrointestinal disorders. Consequently, the use of PN presents many unique challenges, notably in terms of the potential role of the gut microbiota on the functional and clinical outcomes associated with the long-term use of PN. In this review, we synthesize the current evidence on the effects of PN on gut microbiome in infants and children suffering from diverse gastrointestinal diseases, including necrotizing enterocolitis (NEC), short bowel syndrome (SBS) and subsequent intestinal failure, liver disease and inflammatory bowel disease (IBD). Moreover, we discuss the potential use of pre-, pro- and/or synbiotics as promising therapeutic strategies to reduce the risk of severe gastrointestinal disorders and mortality. The findings discussed here highlight the need for more well-designed studies, and harmonize the methods and its interpretation, which are critical to better understand the role of the gut microbiota in PN-related diseases and the development of efficient and personalized approaches based on pro- and/or prebiotics.

Effects of human milk fortifier properties on intrinsic probiotic bacteria

Background To meet the nutritional needs of preterm infants, multicomponent nutrient fortifiers are added to human milk. The fortified human milk (FHM) product changes the physical and biochemical characteristics of the milk. We questioned whether such physical-chemical changes in the milk would alter intrinsic probiotic bacterial activity. The objective of the study was to evaluate the effect of osmolality and pH on the growth of probiotic bacterial species intrinsic to human milk. Methods Human milk samples (n = 26) were collected from mothers in the neonatal intensive care unit (NICU) and stored at -20°C until analyzed. The samples were thawed and divided into three portions. Human milk fortifiers (HMFs) were added to two portions to prepare concentrations of FHM. The remaining portion was the unfortified control sample. Each sample was then divided into two parts. One part (baseline) was used to measure the osmolality and pH and plated on selective agar to enumerate the growth of lactobacilli and bifidobacteria species. The remaining part was incubated at 37°C for 24 h to further test bacterial integrity (post-incubation) and then the same measurements were made (osmolality, pH, bacterial colony counts). Results When compared with unfortified milk at baseline, osmolality increased and pH decreased significantly after the addition of HMFs. Lactobacilli and bifidobacteria colony counts did not differ among the groups pre-incubation. Post-incubation lactobacilli and bifidobacteria increased in all the groups. Conclusion The appropriate addition of HMFs differentially affected the osmolality and pH of the milk. These physical changes did not affect the growth of probiotic bacterial species.

Barriers to Knowledge Translation Regarding the Use of Probiotics as a Risk-Reduction Strategy for Necrotizing Enterocolitis

BACKGROUND

Increasingly, evidence supports enteral probiotics are an important risk-reduction strategy for necrotizing enterocolitis (NEC) among very low birth-weight and extremely low birth-weight preterm infants. Yet, the majority of providers remain reluctant to implement practice changes.

PURPOSE

The aim of this study was to better understand the discrepancy between the available evidence and clinical practice regarding the use of probiotics and other NEC prevention strategies in New Jersey.

METHODS

Using an exploratory descriptive design, a multimodal interprofessional survey was developed and executed to elicit intensive care nursery provider knowledge, views, and current practice.

RESULTS

Although the sample size was small (N = 29), approximately one-half of respondents familiar with the literature rated the quality of the evidence regarding probiotics as "above average" to "excellent." These respondents were "very likely" to "extremely likely" to recommend probiotics as an NEC prevention strategy; however, none actually prescribed this intervention. The most important reason respondents did not prescribe probiotics was the focus on providing exclusive maternal and donor breast milk feedings. Other confounding factors included provision of oral colostrum care, standardized feeding protocols, and withholding feedings during blood transfusion.

IMPLICATIONS FOR PRACTICE

Study results suggested that some providers (primarily nurses) were not familiar with probiotic literature, which may contribute to deficits in knowledge translation to practice.

IMPLICATIONS FOR RESEARCH

Areas for future study include identifying improved mechanisms for knowledge dissemination, recognizing and addressing barriers and facilitators to knowledge translation, and understanding how probiotics fit and/or contrast with other NEC risk-reduction strategies in the research and clinical settings.

Role of probiotics VSL#3 in prevention of suspected sepsis in low birthweight infants in India: a randomised controlled trial

OBJECTIVES

To assess the effect of the probiotic VSL#3 in prevention of neonatal sepsis in low birthweight (LBW) infants.

DESIGN

Randomised, double-blind, placebo-controlled trial.

SETTING

Community setting in rural India.

PARTICIPANTS

LBW infants aged 3-7 days.

INTERVENTIONS

Infants were randomised to receive probiotic (VSL#3, 10 billion colony-forming units (cfu)) or placebo for 30 days, and were followed up for 2 months.

MAIN OUTCOME MEASURE

Possible serious bacterial infection (PSBI) as per the Integrated Management of Neonatal Childhood Illnesses algorithm, as diagnosed by fieldworkers/physicians.

RESULTS

668 infants were randomised to VSL#3 and 672 to placebo. By intention-to-treat analysis, the risk of PSBI among infants in the overall population of LBW infants was not statistically significant (RR 0.79 (95% CI 0.56 to 1.03)). Probiotics reduced median days of hospitalisation (6 days vs 3 days in probiotics) (p=0.018) but not the risk of hospitalisation (RR 0.66 (95% CI 0.42 to 1.04). The onset of PSBI in 10% of infants occurred on the 40th day in the probiotics arm versus the 25th day in the control arm (p=0.063).

CONCLUSIONS

Daily supplementation of LBW infants with probiotics VSL#3 (10 billion cfu) for 30 days led to a non-significant 21% reduction in risk of neonatal sepsis. A larger study with sufficient power and a more specific primary end point is warranted to confirm the preventive effect of VSL#3 on neonatal sepsis in LBW infants.

TRIAL REGISTRATION NUMBER

The study is registered at the Clinical Trial Registry of India (CTRI/2008/091/000049).

The use of probiotics in pediatric gastroenterology: a review of the literature and recommendations by Latin-American experts

OBJECTIVE

The stability and composition of intestinal flora plays a vital role in human wellbeing throughout life from as early as birth. Over the past 50 years, several studies have been conducted to evaluate the effect of probiotic administration in pediatric gastroenterology. This document aims to provide a recommendation score on probiotic utilization in pediatric gastroenterology, together with a review of current knowledge concerning its benefits, tolerability, and safety.

STUDY DESIGN

Published literature was selected without study design restriction: clinical guidelines, meta-analyses, randomized controlled trials (RCTs), cohort studies, outcomes research and case-controlled studies were selected using the following MESH-validated terms: probiotics, diarrhea, acute diarrhea, antibiotic-associated diarrhea, traveler's diarrhea, bacterial diarrhea, nosocomial diarrhea, prophylactic diarrhea, Helicobacter pylori infection, colic, infantile colic, necrotizing enterocolitis (NEC), inflammatory bowel disease, constipation, and allergy. Once the validity and the quality of results were evaluated, a recommendation score and level of evidence were assigned for pediatric gastrointestinal-related conditions, according to the updated Evidence-Based Medicine guidelines: 1a for systematic review (SR) of RCTs, 1b for individual RCT, 1c for SR and individual RCT, 2a for SR of cohort studies, 2b for individual cohort studies, 2c for outcomes research, and 3a for SR of case-control studies.

RESULTS AND CONCLUSIONS

The Latin American Expert group consensus recommends the use of the following probiotics for pediatric gastrointestinal conditions: prevention of acute infectious diarrhea (AID): 1b for Bifidobacterium lactis, Lactobacillus rhamnosus GG (LGG), and L. reuteri; prevention of nosocomial diarrhea: 1 b for B. lactis Bb12, B. bifidum, LGG and Streptococcus thermophiles; treatment of AID: 1a for LGG and S. boulardii, 1b for L. reuteri; prevention of antibiotic-associated diarrhea: 1b for LGG and S. boulardii; prevention of traveler's diarrhea: 1b for S. boulardii; prevention of infantile colic: 1a for L. reuteri DSM 17938; treatment of infantile colic: 1b for L. reuteri DSM 17938; prevention of NEC: 1a for B. breve, mixtures of Bifidobacterium and Streptococcus, LGG, L. acidophilus and L. reuteri DSM 17938; induction and maintenance of remission in ulcerative colitis: 1b for VSL#3; improving symptoms of irritable bowel syndrome: 2c for LGG and VSL#3.

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.

Necrotizing enterocolitis: have we made any progress in reducing the risk?

Necrotizing enterocolitis (NEC) is a disease affecting premature infants with potentially devastating complications in the neonatal intensive care unit (NICU). Inadequate knowledge regarding the underlying pathophysiology of this disease has contributed to the minimal progress made in decreasing the incidence and severity of NEC. Because of an improved survival rate of the most immature infants, the number of diagnosed cases of NEC is anticipated to increase. Unfortunately, decades of research have failed to reduce the risk or improve the prognosis of NEC, magnifying the need for risk-reduction strategies for decreasing significant NEC-related morbidity and mortality. Advancements in our understanding of this disease process have facilitated the development of several strategies that have been investigated in the risk reduction of NEC. This article discusses the pathophysiology and causes of NEC and presents strategies investigated regarding risk reduction of this devastating disease.

[Probiotics and pregnancy]

Prenatal care is one of the great challenges in medicine. Aims of therapies and protocols may influence the life of mothers and babies. Diseases occurring during pregnancy are even more dangerous, because of the difficulties in their treatment strategy. Prevention must be emphasized using safe and natural drugs. Pre- and probiotics are in focus of the medical sciences. Various publications and studies emphasize the importance of these drugs in evidence-based medicine. Safe methods are essential in prenatal care. Authors review published data on the effect and potential use of pre- and probiotics during pregnancy.

Oral probiotics: Lactobacillus sporogenes for prevention of necrotizing enterocolitis in very low-birth weight infants: a randomized, controlled trial

BACKGROUND/OBJECTIVE

The identification of probiotic species involved in gut homeostasis and their potential therapeutic benefits have led to an interest in their use for preventing necrotizing enterocolitis (NEC). Although bifidobacterium and lactobacilli sp. have been used to reduce the incidence of NEC in clinical trials. Lactobacillus sporogenes has not been used in the prevention of NEC in very low-birth weight infants yet. The objective of this study was to evaluate the efficacy of orally administered L sporogenes in reducing the incidence and severity of NEC in very low-birth weight (VLBW) infants.

SUBJECTS/METHODS

A prospective, blinded, randomized controlled trial was conducted in preterm infants with a gestational age of <33 weeks or birth weight of <1500 g. VLBW infants who survived to start enteral feeding were randomized into two groups The infants in the study group were given L. sporogenes with a dose of 350,000,000 c.f.u. added to breast milk or formula, once a day, starting with the first feed until discharged. The infants in the control group were fed without L. sporogenes supplementation. The primary outcome measurement was death or NEC (Bell's stage ≥2).

RESULTS

A total of 221 infants were studied: 110 in the study group and 111 in the control group. There was no significant difference in the incidence of death or NEC between the groups. Feeding intolerance was significantly lower in the probiotics group than in the control group (44.5% (n: 49) vs 63.1% (n: 70), respectively; P=0.006).

CONCLUSIONS

L. sporogenes supplementation at the dose of 350,000,000 c.f.u/day is not effective in reducing the incidence of death or NEC in VLBW infants, however, it could improve the feeding tolerance.

Updated meta-analysis of probiotics for preventing necrotizing enterocolitis in preterm neonates

OBJECTIVE

Systematic reviews of randomized, controlled trials (RCTs) indicate lower mortality and necrotizing enterocolitis (NEC) and shorter time to full feeds after probiotic supplementation in preterm (<34 weeks' gestation) very low birth weight (VLBW; birth weight <1500 g) neonates. The objective of this study was to update our 2007 systematic review of RCTs of probiotic supplementation for preventing NEC in preterm VLBW neonates.

METHODS

We searched in March 2009 the Cochrane Central register; Medline, Embase, and Cinahl databases; and proceedings of the Pediatric Academic Society meetings and gastroenterology conferences. Cochrane Neonatal Review Group search strategy was followed. Selection criteria were RCTs of any enteral probiotic supplementation that started within first 10 days and continued for > or =7 days in preterm VLBW neonates and reported on stage 2 NEC or higher (Modified Bell Staging).

RESULTS

A total of 11 (N = 2176), including 4 new (n = 783), trials were eligible for inclusion in the meta-analysis by using a fixed-effects model. The risk for NEC and death was significantly lower. Risk for sepsis did not differ significantly. No significant adverse effects were reported. Trial sequential analysis) showed 30% reduction in the incidence of NEC (alpha = .05 and .01; power: 80%).

CONCLUSIONS

The results confirm the significant benefits of probiotic supplements in reducing death and disease in preterm neonates. The dramatic effect sizes, tight confidence intervals, extremely low P values, and overall evidence indicate that additional placebo-controlled trials are unnecessary if a suitable probiotic product is available.

Lack of effects of oral probiotics on growth and neurodevelopmental outcomes in preterm very low birth weight infants

OBJECTIVE

To evaluate growth and neurodevelopmental outcomes in preterm very low birth weight (PVLBW) infants treated with oral probiotics for the prevention of necrotizing enterocolitis (NEC).

STUDY DESIGN

A prospective follow-up study was performed in a cohort of PVLBW infants enrolled in a single center with a masked randomized control trial to evaluate the efficacy of oral probiotics in preventing NEC. Growth measures included weight, length, and head circumference. Neurologic and sensory performance was evaluated with standard techniques. Psychometric parameters were measured used the Bayley Scales of Infant Development II (BSID-II). The studies were performed at 3 years corrected age. The primary outcome was death or neurodevelopmental impairment.

RESULTS

Of the 367 subjects enrolled in trial, 301 (89.9%) were evaluated (153 in the probiotics group and 148 in the control group). There were no significant differences in growth or in any of the neurodevelopmental and sensory outcomes between the 2 groups.

CONCLUSIONS

Oral probiotics given to PVLBW infants at 1 week after birth to reduce the incidence of NEC did not affect growth and neurodevelopmental and sensory outcomes at 3 years corrected age.

Necrotizing enterocolitis: etiology, presentation, management, and outcomes

Necrotizing enterocolitis is one of the most common gastrointestinal disease processes affecting infants in the neonatal intensive care unit. Its morbidity and mortality are substantial. This devastating and challenging process results in immediate and long-term morbidities for the affected infant and frustrates the clinician who struggles to prevent the process, recognize it when it does develop, and provide management techniques to enhance the outcome.

Oral probiotics prevent necrotizing enterocolitis in very low birth weight preterm infants: a multicenter, randomized, controlled trial

OBJECTIVE

The goal was to investigate the efficacy of orally administered probiotics in preventing necrotizing enterocolitis for very low birth weight preterm infants.

METHODS

A prospective, blinded, randomized, multicenter controlled trial was conducted at 7 NICUs in Taiwan, to evaluate the beneficial effects of probiotics in necrotizing enterocolitis among very low birth weight infants (birth weight: <1500 g). Very low birth weight infants who survived to start enteral feeding were eligible and were assigned randomly to 2 groups after parental informed consent was obtained. Infants in the study group were given Bifidobacterium bifidum and Lactobacillus acidophilus, added to breast milk or mixed feeding (breast milk and formula), twice daily for 6 weeks. Infants in the control group were fed with breast milk or mixed feeding. The clinicians caring for the infants were blinded to the group assignment. The primary outcome measurement was death or necrotizing enterocolitis (Bell's stage >or=2).

RESULTS

Four hundred thirty-four infants were enrolled, 217 in the study group and 217 in the control group. The incidence of death or necrotizing enterocolitis (stage >or=2) was significantly lower in the study group (4 of 217 infants vs 20 of 217 infants). The incidence of necrotizing enterocolitis (stage >or=2) was lower in the study group, compared with the control group (4 of 217 infants vs 14 of 217 infants). No adverse effect, such as sepsis, flatulence, or diarrhea, was noted.

CONCLUSION

Probiotics, in the form of Bifidobacterium and Lactobacillus, fed enterally to very low birth weight preterm infants for 6 weeks reduced the incidence of death or necrotizing enterocolitis.

Necrotizing enterocolitis

In necrotizing enterocolitis (NEC) the small (most often distal) and/or large bowel becomes injured, develops intramural air, and may progress to frank necrosis with perforation. Even with early, aggressive treatment, the progression of necrosis, which is highly characteristic of NEC, can lead to sepsis and death. This article reviews the current scientific knowledge related to the etiology and pathogenesis of NEC and discusses some possible preventive measures.

Formula fortified with live probiotic culture reduces pulmonary and gastrointestinal bacterial colonization and translocation in a newborn animal model

BACKGROUND/PURPOSE

Acidified diets are protective against intestinal bacterial colonization and translocation. Probiotic diets are designed to modulate the intestinal flora to enhance mucosal immunity. This study was designed to determine if formula acidified with live probiotic decreases bacterial gut colonization and translocation, and is equally tolerated as other acidified diets.

METHODS

One hundred twenty-eight rabbit pups delivered via cesarean section [cesarean delivery, cesarean birth, abdominal delivery] were randomly assigned to 4 feeding groups: NAN Nestle (control, pH 7.0), NAN acidified with citric acid (pH 4.55), biologically acidified Pelargon (pH 4.55), and NAN with live Lactococcus lactis culture (pH 4.2). Pups were gavage fed every 12 hours with Enterobacter cloacae challenges of 10 colony-forming units/mL per feed and killed on day of life 3. Lungs, liver, spleen, mesenteric lymph nodes (MLNs), stomach, and cecum were cultured and quantitatively analyzed for target organism growth. Results were analyzed using chi(2) tests.

RESULTS

NAN with live probiotic culture, when compared with Pelargon, acidified NAN, and NAN, significantly reduced the incidence of Enterobacter pulmonary colonization (P < .01), bacterial translocation (liver, P < .025; spleen and MLN, P < .05), and gastric and intestinal colonization (P < .001 for both).

CONCLUSION

Probiotic-fortified formula provides superior protection against pulmonary and gastrointestinal bacterial colonization and translocation compared with neutral and acidified formulas, and is equally tolerated.

Probiotics for prevention of necrotising enterocolitis in preterm neonates with very low birthweight: a systematic review of randomised controlled trials

BACKGROUND

Results of recent clinical trials suggest that probiotic supplementation reduces the risk of necrotising enterocolitis in preterm neonates. We aimed to systematically review randomised controlled trials evaluating efficacy and safety of any probiotic supplementation (started within first 10 days, duration > or =7 days) in preventing stage 2 or greater necrotising enterocolitis in preterm neonates (gestation <33 weeks) with very low birthweight (<1500 g).

METHODS

We followed the standard search strategy of the Cochrane Neonatal Review Group. We searched the Cochrane Central Register of Controlled Trials (CENTRAL), Medline, Embase, CINAHL databases, and proceedings of the Pediatric Academic Society meetings (from 1980) and Pediatric Gastroenterology conferences (from 1980) in November, 2006.

RESULTS

Seven of 12 randomised controlled trials retrieved (n=1393) were eligible for inclusion in the analysis. Meta-analysis using a fixed effects model estimated a lower risk of necrotising enterocolitis (relative risk 0.36, 95% CI 0.20-0.65) in the probiotic group than in controls. Risk of sepsis did not differ significantly between groups (0.94, 0.74-1.20). Risk of death was reduced in the probiotic group (0.47, 0.30-0.73). The time to full feeds was significantly shorter in the probiotic group (weighted mean difference -2.74 days, 95% CI -4.98 to -0.51) than in controls.

CONCLUSION

Probiotics might reduce the risk of necrotising enterocolitis in preterm neonates with less than 33 weeks' gestation. However, the short-term and long-term safety of probiotics needs to be assessed in large trials. Unanswered questions include the dose, duration, and type of probiotic agents (species, strain, single or combined, live or killed) used for supplementation.

Probiotics in paediatric gastrointestinal diseases

Probiotics have become increasingly popular and are now promoted as having a wide range of benefits. Probiotics are generally very well tolerated and safe but many of the purported uses are not yet well supported with adequate scientific evidence. Two well-established roles for probiotics in children are acute diarrhoeal illness and antibiotic-associated diarrhoea. This review summarises the evidence supporting probiotics for various gastrointestinal disorders with particular reference to their role in the management of acute diarrhoea and antibiotic-associated diarrhoea in children.