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Widjaja NA, Hamida A, Purnomo MT, Satjadibrata A, Sari PP, Handini LS, Novi T, Hanindita MH, Irawan R. Effect of high-calorie formula on weight, height increment, IGF-1 and TLC in growth faltering children: A quasi-experimental study. Heliyon 2024; 10:e28834. [PMID: 38623243 PMCID: PMC11016603 DOI: 10.1016/j.heliyon.2024.e28834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2023] [Revised: 03/15/2024] [Accepted: 03/26/2024] [Indexed: 04/17/2024] Open
Abstract
High-calorie formulas have been used to promote catch-up growth in undernourished children. The level of insulin-like growth factor 1 (IGF-1) is closely related to weight and nutritional intake, whereas low a total lymphocyte count (TLC) is associated with impaired immune system function in undernourished children. This study was conducted to investigate the effect of high-calorie formula as an intervention on weight, height increment, IGF-1 and TLC in children with growth faltering or undernutrition. A quasi-experimental study with pre- and post-design was conducted in the outpatient clinic of a private hospital during October 2021-July 2022 on children with growth failure and underlying infection. For 90 days, subjects were given a high-calorie formula. An enzyme-linked immunosorbent assay was then conducted to measure IGF-1, followed by a complete blood count examination. Subjects were divided into two groups based on age: Group 1 (12-24 months) and Group 2 (>24-60 months). There was a significant increment in body weight and body length/height after intervention but no significant difference between the groups. The increment of body length/height after intervention was greater in Group 1 than Group 2 (p = 0.000) and reduced the incidence of stunted/severely stunted and wasted/severely wasted children (p > 0.05). IGF-1 increased after the intervention but with no significant difference (1.42 ± 8.31 ng/ml; p = 0.144). There was a significant reduction in TLC after the intervention (1194.34 + 4400.34 cells/mm3; p = 0.002) that was reduced in Group 1 and slightly increased in Group 2 (p = 0.003). Being underweight/severely underweight increased the risk of a low TLC by 27.658-fold but this risk was reduced by 25.904-fold after nutritional intervention. High-calorie formula intervention increases body weight and body length/height, reduces the incidence of underweight, stunted and wasted children and improves IGF-1 levels.
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Affiliation(s)
- Nur Aisiyah Widjaja
- Child Health Department, Airlangga/Dr.Soetomo General Academic Teaching Hospital, Surabaya, Indonesia
- Child Health, Husada Utama Hospital, Surabaya, Indonesia
| | - Azizah Hamida
- Child Health Department, Airlangga/Dr.Soetomo General Academic Teaching Hospital, Surabaya, Indonesia
| | - Marisa Tulus Purnomo
- Child Health Department, Airlangga/Dr.Soetomo General Academic Teaching Hospital, Surabaya, Indonesia
| | - Azarina Satjadibrata
- Child Health Department, Airlangga/Dr.Soetomo General Academic Teaching Hospital, Surabaya, Indonesia
| | - Putri Permata Sari
- Child Health Department, Airlangga/Dr.Soetomo General Academic Teaching Hospital, Surabaya, Indonesia
| | | | - Theresia Novi
- Clinical Pathology, Husada Utama Hospital, Surabaya, Indonesia
| | - Meta Herdiana Hanindita
- Child Health Department, Airlangga/Dr.Soetomo General Academic Teaching Hospital, Surabaya, Indonesia
| | - Roedi Irawan
- Child Health Department, Airlangga/Dr.Soetomo General Academic Teaching Hospital, Surabaya, Indonesia
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Cawood AL, Smith C, Kinnear FJ, Upton L, Trace S, O'Connor G, Stratton RJ. Effect of oral nutritional supplements on outcomes in children presenting with, or at risk of, faltering growth in clinical settings: A systematic review and meta-analysis. J Child Health Care 2023:13674935231185181. [PMID: 37406354 DOI: 10.1177/13674935231185181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/07/2023]
Abstract
This systematic review summarises evidence regarding oral nutritional supplement (ONS) use in children with, or at risk of, faltering growth (FG). Ten randomised controlled trials (RCTs), compared changes in outcomes amongst children receiving ONS versus control were included. Overall, 1116 children (weighted mean (WM) age 5 years; n658 (59%) male) were recruited, of which 585 (52%) received ONS (WM intake contribution 412 kcal, 16.3 g protein, 395 ml) for 116 days (WM). ONS use was associated with significantly greater gains in weight (mean difference (MD) 0.4 kg, 95% CI [0.36, 0.44]) and height (MD 0.3 cm, 95% CI [0.03, 0.57]), likely related to improvements in nutritional intake. Mean compliance to prescribed dose was 98%. Data suggested an association between ONS use and reduced infections. Further research is warranted to establish ONS dosage and effects upon other outcomes. This review provides evidence to support use of ONS in the management of children with, or at risk of, FG.
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Affiliation(s)
- A L Cawood
- Institute of Human Nutrition, Faculty of Medicine, University of Southampton, Southampton, UK
- Medical Affairs, Nutricia Ltd, Trowbridge, UK
| | - C Smith
- Nutrition and Dietetics, Royal Alexandra Children's Hospital, Brighton, UK
| | - F J Kinnear
- National Institute for Health and Care Research, Bristol Biomedical Research Centre, Bristol, UK
| | - L Upton
- Nutrition and Dietetics, The Children's Dietitian Ltd, Birmingham, UK
| | - S Trace
- Nutrition and Dietetics, Bristol Royal Hospital for Children, Bristol, UK
| | - G O'Connor
- Dietetics Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - R J Stratton
- Institute of Human Nutrition, Faculty of Medicine, University of Southampton, Southampton, UK
- Medical Affairs, Nutricia Ltd, Trowbridge, UK
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Zhang Z, Li F, Hannon BA, Hustead DS, Aw MM, Liu Z, Chuah KA, Low YL, Huynh DTT. Effect of Oral Nutritional Supplementation on Growth in Children with Undernutrition: A Systematic Review and Meta-Analysis. Nutrients 2021; 13:nu13093036. [PMID: 34578914 PMCID: PMC8468927 DOI: 10.3390/nu13093036] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 08/12/2021] [Accepted: 08/23/2021] [Indexed: 11/16/2022] Open
Abstract
Oral nutritional supplements (ONS) are used to promote catch-up growth in children with undernutrition. We conducted a systematic review and meta-analysis to summarize the evidence of ONS intervention effects on growth for 9-month- to 12-year-old children who were undernourished or at nutritional risk. Eleven randomized controlled trials met the inclusion criteria; trials compared changes in anthropometric measures in children using ONS or ONS + DC (dietary counselling) to measures for those following usual diet or placebo or DC alone. The RCTs included 2287 children without chronic diseases (mean age 5.87 years [SD, 1.35]; 56% boys). At follow-up time points up to 6 months, results showed that children in the ONS intervention group had greater gains in weight (0.423 kg, [95% confidence interval 0.234, 0.613], p < 0.001) and height (0.417 cm [0.059, 0.776], p = 0.022) versus control; greater gains in weight (0.089 kg [0.049, 0.130], p < 0.001) were evident as early as 7–10 days. Longitudinal analyses with repeated measures at 30, 60, and 90 days showed greater gains in weight parameters from 30 days onwards (p < 0.001), a trend towards greater height gains at 90 days (p = 0.056), and significantly greater gains in height-for-age percentiles and Z-scores at 30 and 90 days, respectively (p < 0.05). Similar results were found in subgroup analyses of studies comparing ONS + DC to DC alone. For children with undernutrition, particularly those who were mildly and moderately undernourished, usage of ONS in a nutritional intervention resulted in significantly better growth outcomes when compared to control treatments (usual diet, placebo or DC alone).
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Affiliation(s)
- Zhiying Zhang
- Abbott Nutrition Research and Development Asia-Pacific Center, 20 Biopolis Way, Unit 09-01/02 Centros Building, Singapore 138668, Singapore; (Z.Z.); (Z.L.); (K.A.C.)
| | - Fei Li
- Abbott Nutrition China Research and Development Center, Building 14, No. 1036 Tianlin Road, Shanghai 200233, China;
| | - Bridget A. Hannon
- Abbott Nutrition Research and Development, 3300 Stelzer Road, Columbus, OH 43219, USA; (B.A.H.); (D.S.H.); (Y.L.L.)
| | - Deborah S. Hustead
- Abbott Nutrition Research and Development, 3300 Stelzer Road, Columbus, OH 43219, USA; (B.A.H.); (D.S.H.); (Y.L.L.)
| | - Marion M. Aw
- Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119077, Singapore;
| | - Zhongyuan Liu
- Abbott Nutrition Research and Development Asia-Pacific Center, 20 Biopolis Way, Unit 09-01/02 Centros Building, Singapore 138668, Singapore; (Z.Z.); (Z.L.); (K.A.C.)
| | - Khun Aik Chuah
- Abbott Nutrition Research and Development Asia-Pacific Center, 20 Biopolis Way, Unit 09-01/02 Centros Building, Singapore 138668, Singapore; (Z.Z.); (Z.L.); (K.A.C.)
| | - Yen Ling Low
- Abbott Nutrition Research and Development, 3300 Stelzer Road, Columbus, OH 43219, USA; (B.A.H.); (D.S.H.); (Y.L.L.)
| | - Dieu T. T. Huynh
- Abbott Nutrition Research and Development Asia-Pacific Center, 20 Biopolis Way, Unit 09-01/02 Centros Building, Singapore 138668, Singapore; (Z.Z.); (Z.L.); (K.A.C.)
- Correspondence: ; Tel.: +65-8322-9798
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DeMuri GP, Lehtoranta LM, Eickhoff JC, Lehtinen MJ, Wald ER. Ex vivo peripheral blood mononuclear cell response to R848 in children after supplementation with the probiotic Lactobacillus acidophilus NCFM/ Bifidobacterium lactis Bi-07. Benef Microbes 2021; 12:85-93. [PMID: 33550937 DOI: 10.3920/bm2020.0068] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Several studies have demonstrated a decrease in upper respiratory infection (URI) frequency and severity in subjects taking probiotic supplements. We hypothesised beneficial effects of probiotics on viral URI in children are due to modulation of inflammatory innate immune responses. We tested this hypothesis, providing children with a probiotic combination of Lactobacillus acidophilus/Bidfidobacterium animalis ssp. lactis Bi-07 (NCFM/Bi-07) and measuring levels of cytokines in response to stimulation of peripheral blood mononuclear cells (PBMCs) to toll-like receptor (TLR) 7/8 agonist resiquimod (R848). In this open label study, 21 (2 dropouts) children received probiotic containing 5×109 cfu each of NCFM/(Bi-07) daily for 30 days. Whole blood was taken from each subject at study entry and 30 days for culture of PBMCs. PBMCs stimulated with resiquimod (R848) or unstimulated were incubated and a panel of immune markers was measured. There was a significant decrease in the net (stimulated-null) level of myeloid progenitor inhibitory factor 1 (MPIF-1) (mean decrease 0.1 ng/ml, 95% confidence interval 0.01-0.24, P=0.032) following probiotic supplementation. The change in immune marker levels after supplementation, when analysed together with respect to expected inflammatory/anti-inflammatory effects, was increased for interleukin (IL)-10 and decreased for MPIF-1, IL-8, interferon gamma induced protein 10, macrophage inflammatory protein 3 alpha (MIP-3α) and E-selectin (P=0.01). Adverse events were mild. In conclusion, supplementation with this probiotic combination was safe and resulted in significant modulation of PBMC limited immune response to TLR7/8 agonist R848 and in levels of MPIF-1 and MIP-3α. The anti-inflammatory effect may be one mechanism by which probiotics modulate the immune system however further study is needed.
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Affiliation(s)
- G P DeMuri
- Department of Pediatrics, University of Wisconsin-Madison School of Medicine and Public Health, 600 Highland Avenue, Madison, WI 53972, USA
| | - L M Lehtoranta
- DuPont Nutrition and Biosciences, Danisco Sweeteners Oy, Sokeritehtaantie 20, Kantvik 02460, Finland
| | - J C Eickhoff
- Department of Pediatrics, University of Wisconsin-Madison School of Medicine and Public Health, 600 Highland Avenue, Madison, WI 53972, USA
| | - M J Lehtinen
- DuPont Nutrition and Biosciences, Danisco Sweeteners Oy, Sokeritehtaantie 20, Kantvik 02460, Finland
| | - E R Wald
- Department of Pediatrics, University of Wisconsin-Madison School of Medicine and Public Health, 600 Highland Avenue, Madison, WI 53972, USA
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Collinson S, Deans A, Padua-Zamora A, Gregorio GV, Li C, Dans LF, Allen SJ. Probiotics for treating acute infectious diarrhoea. Cochrane Database Syst Rev 2020; 12:CD003048. [PMID: 33295643 PMCID: PMC8166250 DOI: 10.1002/14651858.cd003048.pub4] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Probiotics may be effective in reducing the duration of acute infectious diarrhoea. OBJECTIVES To assess the effects of probiotics in proven or presumed acute infectious diarrhoea. SEARCH METHODS We searched the trials register of the Cochrane Infectious Diseases Group, MEDLINE, and Embase from inception to 17 December 2019, as well as the Cochrane Controlled Trials Register (Issue 12, 2019), in the Cochrane Library, and reference lists from studies and reviews. We included additional studies identified during external review. SELECTION CRITERIA Randomized controlled trials comparing a specified probiotic agent with a placebo or no probiotic in people with acute diarrhoea that is proven or presumed to be caused by an infectious agent. DATA COLLECTION AND ANALYSIS Two review authors independently applied inclusion criteria, assessed risk of bias, and extracted data. Primary outcomes were measures of diarrhoea duration (diarrhoea lasting ≥ 48 hours; duration of diarrhoea). Secondary outcomes were number of people hospitalized in community studies, duration of hospitalization in inpatient studies, diarrhoea lasting ≥ 14 days, and adverse events. MAIN RESULTS We included 82 studies with a total of 12,127 participants. These studies included 11,526 children (age < 18 years) and 412 adults (three studies recruited 189 adults and children but did not specify numbers in each age group). No cluster-randomized trials were included. Studies varied in the definitions used for "acute diarrhoea" and "end of the diarrhoeal illness" and in the probiotic(s) tested. A total of 53 trials were undertaken in countries where both child and adult mortality was low or very low, and 26 where either child or adult mortality was high. Risk of bias was high or unclear in many studies, and there was marked statistical heterogeneity when findings for the primary outcomes were pooled in meta-analysis. Effect size was similar in the sensitivity analysis and marked heterogeneity persisted. Publication bias was demonstrated from funnel plots for the main outcomes. In our main analysis of the primary outcomes in studies at low risk for all indices of risk of bias, no difference was detected between probiotic and control groups for the risk of diarrhoea lasting ≥ 48 hours (risk ratio (RR) 1.00, 95% confidence interval (CI) 0.91 to 1.09; 2 trials, 1770 participants; moderate-certainty evidence); or for duration of diarrhoea (mean difference (MD) 8.64 hours shorter, 95% CI 29.4 hours shorter to 12.1 hours longer; 6 trials, 3058 participants; very low-certainty evidence). Effect size was similar and marked heterogeneity persisted in pre-specified subgroup analyses of the primary outcomes that included all studies. These included analyses limited to the probiotics Lactobacillus rhamnosus GG and Saccharomyces boulardii. In six trials (433 participants) of Lactobacillus reuteri, there was consistency amongst findings (I² = 0%), but risk of bias was present in all included studies. Heterogeneity also was not explained by types of participants (age, nutritional/socioeconomic status captured by mortality stratum, region of the world where studies were undertaken), diarrhoea in children caused by rotavirus, exposure to antibiotics, and the few studies of children who were also treated with zinc. In addition, there were no clear differences in effect size for the primary outcomes in post hoc analyses according to decade of publication of studies and whether or not trials had been registered. For other outcomes, the duration of hospitalization in inpatient studies on average was shorter in probiotic groups than in control groups but there was marked heterogeneity between studies (I² = 96%; MD -18.03 hours, 95% CI -27.28 to -8.78, random-effects model: 24 trials, 4056 participants). No differences were detected between probiotic and control groups in the number of people with diarrhoea lasting ≥ 14 days (RR 0.49, 95% CI 0.16 to 1.53; 9 studies, 2928 participants) or in risk of hospitalization in community studies (RR 1.26, 95% CI 0.84 to 1.89; 6 studies, 2283 participants). No serious adverse events were attributed to probiotics. AUTHORS' CONCLUSIONS Probiotics probably make little or no difference to the number of people who have diarrhoea lasting 48 hours or longer, and we are uncertain whether probiotics reduce the duration of diarrhoea. This analysis is based on large trials with low risk of bias.
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Affiliation(s)
- Shelui Collinson
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Andrew Deans
- Urgent Care, Team Medical, Paraparaumu, New Zealand
| | - April Padua-Zamora
- Department of Pediatrics, University of the Philippines Manila College of Medicine-Philippine General Hospital, Manila, Philippines
| | - Germana V Gregorio
- Department of Pediatrics, University of the Philippines Manila College of Medicine-Philippine General Hospital, Manila, Philippines
| | - Chao Li
- Tropical Clinical Trials Unit, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Leonila F Dans
- Department of Pediatrics, University of the Philippines Manila College of Medicine-Philippine General Hospital, Manila, Philippines
| | - Stephen J Allen
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
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van der Gaag EJ, Hummel TZ. Food or medication? The therapeutic effects of food on the duration and incidence of upper respiratory tract infections: a Review of the literature. Crit Rev Food Sci Nutr 2020; 61:2691-2704. [PMID: 32648776 DOI: 10.1080/10408398.2020.1784087] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
PURPOSE Upper respiratory tract infections are common in children and adults. Antiviral treatments are only available for specific groups of patients, stimulating the distribution of over-the-counter medication to relieve the symptoms for the other patients. Studies about whole foods and their effect on the incidence and duration of upper respiratory tract infections were reviewed. METHODS Randomized controlled trials and case-control studies available on MEDLINE, Web of Science, Cochrane Library and Embase were included. RESULTS AND CONCLUSIONS Thirty-three studies were included. The incidence of respiratory infections or symptoms was shown to be reduced in some studies when probiotics, prebiotics, growing-up milk, fish oil, kiwi, garlic and xylitol were taken. Duration was favorably influenced by the intake of elderberry, kiwi, probiotics and fish oil. When the risk of bias and repetition is taken into account, probiotics and elderberry repeatedly show favorable effects. Prudent conclusions can be made in selective patient groups. However, the studies were diverse and were only performed by a few study groups.
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Affiliation(s)
- Ellen José van der Gaag
- Pediatrics, Hospital Group Twente, Almelo, SZ, Netherlands.,Behaviourial Management and Social Sciences, University of Twente, Enschede, AE, Netherlands
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Hubbard GP, Fry C, Sorensen K, Casewell C, Collins L, Cunjamalay A, Simpson M, Wall A, Van Wyk E, Ward M, Hallowes S, Duggan H, Robison J, Gane H, Pope L, Clark J, Stratton RJ. Energy-dense, low-volume paediatric oral nutritional supplements improve total nutrient intake and increase growth in paediatric patients requiring nutritional support: results of a randomised controlled pilot trial. Eur J Pediatr 2020; 179:1421-1430. [PMID: 32170451 PMCID: PMC7413916 DOI: 10.1007/s00431-020-03620-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Revised: 02/20/2020] [Accepted: 02/25/2020] [Indexed: 11/30/2022]
Abstract
Children with or at risk of faltering growth require nutritional support and are often prescribed oral nutritional supplements (ONS). This randomised controlled trial investigated the effects of energy-dense paediatric ONS (2.4 kcal/ml, 125 ml: cONS) versus 1.5 kcal/ml, 200 ml ONS (sONS) in community-based paediatric patients requiring oral nutritional support. Fifty-one patients (mean age 5.8 years (SD 3)) with faltering growth and/or requiring ONS to meet their nutritional requirements were randomised to cONS (n = 27) or sONS (n = 24) for 28 days. Nutrient intake, growth, ONS compliance and acceptability, appetite and gastro-intestinal tolerance were assessed. Use of the cONS resulted in significantly greater mean total daily energy (+ 531 kcal/day), protein (+ 10.1 g/day) and key micronutrient intakes compared with the sONS group at day 28 and over time, due to high ONS compliance (81% of patients ≥ 75%), maintained intake from diet alone and improved appetite in the cONS group, compared with the sONS group. Although growth increased in both intervention groups, results were significant in the cONS group (weight (p = 0.007), height (p < 0.001) and height z-score (p = 0.006)).Conclusions: This study shows that use of energy-dense (2.4 kcal/ml) low-volume paediatric-specific ONS leads to improved nutrient intakes, growth and appetite in paediatric patients requiring oral nutrition support compared with standard energy density ONS.Trial registration: The trial is registered at clinicaltrials.gov , identification number NCT02419599. What is Known: • Faltering growth is the failure of children to achieve adequate growth at a normal rate for their age and requires nutritional support, including the use of oral nutritional supplements (ONS). • Energy-dense, low-volume ONS have benefits over standard ONS in adults. What is New: • This is the first RCT to investigate the effects of energy-dense, low-volume ONS (2.4 kcal/ml, 125 ml) in children with faltering growth, showing significant improvements in total nutrient intake and increased growth. • Energy-dense, low-volume ONS can play a key role in the management of faltering growth.
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Affiliation(s)
| | | | | | - Catherine Casewell
- Department of Nutrition and Dietetics, Ashford and St Peter’s Hospitals NHS Foundation Trust, Chertsey, UK
| | - Lydia Collins
- Department of Nutrition and Dietetics, Cumbria Partnership NHS Foundation Trust, Whitehaven, UK
| | - Annaruby Cunjamalay
- Department of Nutrition and Dietetics, Hampshire Hospitals NHS Foundation Trust, Winchester, UK
| | - Michelle Simpson
- Department of Nutrition and Dietetics, Hampshire Hospitals NHS Foundation Trust, Winchester, UK
| | - Amanda Wall
- Department of Nutrition and Dietetics, East Lancashire Hospitals NHS Trust, Blackburn, UK
| | - Elmarie Van Wyk
- Department of Nutrition and Dietetics, Great Western Hospitals NHS Foundation Trust, Swindon, UK
| | - Matthew Ward
- Department of Nutrition and Dietetics, Cwm Taf University Health Board, Prince Charles Hospital, Merthyr Tydfil, UK
| | - Sophie Hallowes
- Department of Nutrition and Dietetics, Guy’s and St Thomas’ NHS Trust, London, UK
| | - Hannah Duggan
- Department of Nutrition and Dietetics, Guy’s and St Thomas’ NHS Trust, London, UK
| | - Jennifer Robison
- Department of Nutrition and Dietetics, Lewisham and Greenwich NHS Trust, London, UK
| | - Helen Gane
- Department of Nutrition and Dietetics, Western Sussex Hospitals NHS Foundation Trust, Chichester, UK
| | - Lucy Pope
- Department of Nutrition and Dietetics, Western Sussex Hospitals NHS Foundation Trust, Chichester, UK
| | - Jennifer Clark
- Department of Nutrition and Dietetics, Airedale NHS Foundation Trust, Keighley, UK
| | - Rebecca J. Stratton
- Nutricia Ltd, Medical Affairs, Trowbridge, UK ,Faculty of Medicine, University of Southampton, Southampton, UK
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Scott AM, Clark J, Julien B, Islam F, Roos K, Grimwood K, Little P, Del Mar CB. Probiotics for preventing acute otitis media in children. Cochrane Database Syst Rev 2019; 6:CD012941. [PMID: 31210358 PMCID: PMC6580359 DOI: 10.1002/14651858.cd012941.pub2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND Acute otitis media (AOM), or acute middle ear infection, is one of the most frequently occurring childhood diseases, and the most common reason given for prescribing antibiotics in this age group. Guidelines often recommend antibiotics as first-line treatment for severe AOM. However, antibiotics also lead to antibiotic resistance, so preventing episodes of AOM is an urgent priority. OBJECTIVES To assess the effects of probiotics to prevent the occurrence and reduce the severity of acute otitis media in children. SEARCH METHODS We searched CENTRAL, PubMed, Embase, and three other databases (October 2018), two trial registers (October 2018), and conducted a backwards and forwards citation analysis (August 2018). We did not apply any language, publication date, or publication status restrictions. SELECTION CRITERIA Randomised controlled trials (RCTs) of children (aged up to 18 years), comparing probiotics with placebo, usual care, or no probiotic. DATA COLLECTION AND ANALYSIS Two review authors independently assessed the eligibility of trials for inclusion and risk of bias of the included trials, and extracted data using pre-piloted data extraction forms. We analysed dichotomous data as either risk ratio (RR) or odds ratios (OR) and continuous data as mean differences (MD). MAIN RESULTS We included 17 RCTs involving 3488 children, of which 16 RCTs were included in the meta-analyses. Of the 16 RCTs that reported the mean age of children, mean age overall was 2.4 years; in 4 RCTs the mean age of children participating in the trial was less than 1 year old; in 2 RCTs the mean age was between 1 and 2 years old; and in 10 RCTs the mean age was older than 2 years. Probiotic strains evaluated by the trials varied, with 11 of the included RCTs evaluating Lactobacillus-containing probiotics, and six RCTs evaluating Streptococcus-containing probiotics.The proportion of children (i.e. the number of children in each group) experiencing one or more episodes of AOM during the treatment was lower for those taking probiotics (RR 0.77, 95% confidence interval (CI) 0.63 to 0.93; 16 trials; 2961 participants; number needed to treat for an additional beneficial outcome (NNTB) = 10; moderate-certainty evidence).Post hoc subgroup analysis found that among children not prone to otitis media, a lower proportion of children receiving probiotics experienced AOM (RR 0.64, 95% CI 0.49 to 0.84; 11 trials; 2227 participants; NNTB = 9; moderate-certainty evidence). However, among children who were otitis prone, there was no difference between probiotic and comparator groups (RR 0.97, 95% CI 0.85 to 1.11; 5 trials; 734 participants; high-certainty evidence). The test for subgroup differences was significant (P = 0.007).None of the included trials reported on the severity of AOM.The proportion of children experiencing adverse events did not differ between the probiotic and comparator groups (OR 1.54, 95% CI 0.60 to 3.94; 4 trials; 395 participants; low-certainty evidence).Probiotics decreased the proportion of children taking antibiotics for any infection (RR 0.66, 95% CI 0.51 to 0.86; 8 trials; 1768 participants; NNTB = 8; moderate-certainty evidence). Test for subgroup differences (use of antibiotic specifically for AOM, use of antibiotic for infections other than AOM) was not significant.There was no difference in the mean number of school days lost (MD -0.95, 95% CI -2.47 to 0.57; 5 trials; 1280 participants; moderate-certainty evidence). There was no difference between groups in the level of compliance in taking the intervention (RR 1.02, 95% CI 0.99 to 1.05; 5 trials; 990 participants).Probiotics decreased the proportion of children having other infections (RR 0.75, 95% CI 0.65 to 0.87; 11 trials; 3610 participants; NNTB = 12; moderate-certainty evidence). Test for subgroup differences (acute respiratory infections, gastrointestinal infections) was not significant.Probiotic strains trialled and their dose, frequency, and duration of administration varied considerably across studies, which likely contributed to the substantial levels of heterogeneity. Sensitivity testing of funnel plots did not reveal publication bias. AUTHORS' CONCLUSIONS Probiotics may prevent AOM in children not prone to AOM, but the inconsistency of the subgroup analyses suggests caution in interpreting these results. Probiotics decreased the proportion of children taking antibiotics for any infection. The proportion of children experiencing adverse events did not differ between the probiotic and comparator groups. The optimal strain, duration, frequency, and timing of probiotic administration still needs to be established.
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Affiliation(s)
- Anna M Scott
- Bond UniversityCentre for Research in Evidence‐Based Practice (CREBP)14 University DriveGold CoastQueenslandAustralia4229
| | - Justin Clark
- Bond UniversityCentre for Research in Evidence‐Based Practice (CREBP)14 University DriveGold CoastQueenslandAustralia4229
| | - Blair Julien
- Bond University14 University DriveRobinaQueenslandAustralia4229
| | - Farhana Islam
- Bond University14 University DriveRobinaQueenslandAustralia4229
| | - Kristian Roos
- Lundby HospitalENT DepartmentWieselgrensplatesen 2AGoteborgSweden41717
| | - Keith Grimwood
- Griffith University and Departments of Infectious Diseases and Paediatrics, Gold Coast HealthSchool of Medicine and Menzies Health Institute QueenslandGold CoastQueenslandAustralia
| | - Paul Little
- Aldermoor Health Centre, University of SouthamptonPrimary Care and Population Sciences, Faculty of MedicineAldermoor CloseSouthamptonUKS016 5ST
| | - Chris B Del Mar
- Bond UniversityCentre for Research in Evidence‐Based Practice (CREBP)14 University DriveGold CoastQueenslandAustralia4229
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Lai HH, Chiu CH, Kong MS, Chang CJ, Chen CC. Probiotic Lactobacillus casei: Effective for Managing Childhood Diarrhea by Altering Gut Microbiota and Attenuating Fecal Inflammatory Markers. Nutrients 2019; 11:nu11051150. [PMID: 31126062 PMCID: PMC6566348 DOI: 10.3390/nu11051150] [Citation(s) in RCA: 69] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 05/18/2019] [Accepted: 05/20/2019] [Indexed: 02/07/2023] Open
Abstract
Background: Acute diarrhea is a major cause of childhood morbidity and an economic burden for families. The aim of this study is to explore the effect of probiotics on clinical symptoms, intestinal microbiota, and inflammatory markers during childhood diarrhea. Methods: Children (n = 81) aged six months to six years (mean age 2.31 years) hospitalized for acute diarrhea were randomized to receive probiotics (Lactobacillus casei variety rhamnosus; n = 42) or no probiotics (n = 39) orally twice daily for seven days. Feces samples were also collected to evaluate microbial content using a traditional agar plate and next-generation sequencing. Immunoglobulin A (IgA), lactoferrin, and calprotectin were determined by enzyme-linked immunosorbent assay (ELISA) and compared in different groups. Other clinical symptoms or signs, including fever, vomiting, diarrhea, abdominal pain, bloated abdomen, daily intake, appetite, and body weight were also assessed. Results: Data were collected from 81 individuals across three different time points. Total fecal IgA levels in fecal extracts of the probiotics group were higher than those in the control group, reaching statistical significance (p < 0.05). Concentrations of fecal lactoferrin and calprotectin were significantly downregulated in patients with probiotic Lactobacillus casei variety rhamnosus (Lc) consumption compared to those of the control (p < 0.05). Probiotic Lc administration may be beneficial for gut-microbiota modulation, as shown by the data collected at one week after enrollment. Counts of Bifidobacteria and Lactobacillus species were elevated in stool culture of the probiotic group. Appetite and oral intake, body-weight gain, abdominal pain, bloating, as well as bowel habits (diarrhea) were much better in children receiving probiotics compared with those in the control group. Conclusion: Fecal IgA increased during acute diarrhea under Lc treatment; in contrast, fecal lactoferrin and calprotectin were downregulated during acute diarrhea under Lc treatment. Probiotic Lc may be a useful supplement for application in children during acute diarrhea to reduce clinical severity and intestinal inflammatory reaction.
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Affiliation(s)
- Hung-Hsiang Lai
- Division of Gastroenterology, Department of Pediatrics, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan 33303, Taiwan.
| | - Cheng-Hsun Chiu
- Division of Infectious Disease, Department of Pediatrics, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan 33303, Taiwan.
| | - Man-Shan Kong
- Division of Gastroenterology, Department of Pediatrics, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan 33303, Taiwan.
| | - Chee-Jen Chang
- Graduate Institute of Clinical Medical Sciences, Clinical Informatics and Medical Statistics Research Center, Chang Gung University College of Medicine, Taoyuan 33303, Taiwan.
| | - Chien-Chang Chen
- Division of Gastroenterology, Department of Pediatrics, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan 33303, Taiwan.
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Guo Q, Goldenberg JZ, Humphrey C, El Dib R, Johnston BC. Probiotics for the prevention of pediatric antibiotic-associated diarrhea. Cochrane Database Syst Rev 2019; 4:CD004827. [PMID: 31039287 PMCID: PMC6490796 DOI: 10.1002/14651858.cd004827.pub5] [Citation(s) in RCA: 90] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Antibiotics alter the microbial balance commonly resulting in antibiotic-associated diarrhea (AAD). Probiotics may prevent AAD via providing gut barrier, restoration of the gut microflora, and other potential mechanisms of action. OBJECTIVES The primary objectives were to assess the efficacy and safety of probiotics (any specified strain or dose) used for the prevention of AAD in children. SEARCH METHODS MEDLINE, Embase, CENTRAL, CINAHL, and the Web of Science (inception to 28 May 2018) were searched along with registers including the ISRCTN and Clinicaltrials.gov. We also searched the NICE Evidence Services database as well as reference lists from relevant articles. SELECTION CRITERIA Randomized, parallel, controlled trials in children (0 to 18 years) receiving antibiotics, that compare probiotics to placebo, active alternative prophylaxis, or no treatment and measure the incidence of diarrhea secondary to antibiotic use were considered for inclusion. DATA COLLECTION AND ANALYSIS Study selection, data extraction, and risk of bias assessment were conducted independently by two authors. Dichotomous data (incidence of AAD, adverse events) were combined using a pooled risk ratio (RR) or risk difference (RD), and continuous data (mean duration of diarrhea) as mean difference (MD), along with corresponding 95% confidence interval (95% CI). We calculated the number needed to treat for an additional beneficial outcome (NNTB) where appropriate. For studies reporting on microbiome characteristics using heterogeneous outcomes, we describe the results narratively. The certainty of the evidence was evaluated using GRADE. MAIN RESULTS Thirty-three studies (6352 participants) were included. Probiotics assessed included Bacillus spp., Bifidobacterium spp., Clostridium butyricum, Lactobacilli spp., Lactococcus spp., Leuconostoc cremoris, Saccharomyces spp., orStreptococcus spp., alone or in combination. The risk of bias was determined to be high in 20 studies and low in 13 studies. Complete case (patients who did not complete the studies were not included in the analysis) results from 33 trials reporting on the incidence of diarrhea show a precise benefit from probiotics compared to active, placebo or no treatment control.After 5 days to 12 weeks of follow-up, the incidence of AAD in the probiotic group was 8% (259/3232) compared to 19% (598/3120) in the control group (RR 0.45, 95% CI 0.36 to 0.56; I² = 57%, 6352 participants; NNTB 9, 95% CI 7 to 13; moderate certainty evidence). Nineteen studies had loss to follow-up ranging from 1% to 46%. After making assumptions for those lost, the observed benefit was still statistically significant using an extreme plausible intention-to-treat (ITT) analysis, wherein the incidence of AAD in the probiotic group was 12% (436/3551) compared to 19% (664/3468) in the control group (7019 participants; RR 0.61; 95% CI 0.49 to 0.77; P <0.00001; I² = 70%). An a priori available case subgroup analysis exploring heterogeneity indicated that high dose (≥ 5 billion CFUs per day) is more effective than low probiotic dose (< 5 billion CFUs per day), interaction P value = 0.01. For the high dose studies the incidence of AAD in the probiotic group was 8% (162/2029) compared to 23% (462/2009) in the control group (4038 participants; RR 0.37; 95% CI 0.30 to 0.46; P = 0.06; moderate certainty evidence). For the low dose studies the incidence of AAD in the probiotic group was 8% (97/1155) compared to 13% (133/1059) in the control group (2214 participants; RR 0.68; 95% CI 0.46 to 1.01; P = 0.02). Again, assumptions for loss to follow-up using an extreme plausible ITT analysis was statistically significant. For high dose studies the incidence of AAD in the probiotic group was 13% (278/2218) compared to 23% (503/2207) in control group (4425 participants; RR 0.54; 95% CI 0.42 to 0.70; P <0.00001; I² = 68%; moderate certainty evidence).None of the 24 trials (4415 participants) that reported on adverse events reported any serious adverse events attributable to probiotics. Adverse event rates were low. After 5 days to 4 weeks follow-up, 4% (86/2229) of probiotics participants had an adverse event compared to 6% (121/2186) of control participants (RD 0.00; 95% CI -0.01 to 0.01; P < 0.00001; I² = 75%; low certainty evidence). Common adverse events included rash, nausea, gas, flatulence, abdominal bloating, and constipation.After 10 days to 12 weeks of follow-up, eight studies recorded data on our secondary outcome, the mean duration of diarrhea; with probiotics reducing diarrhea duration by almost one day (MD -0.91; 95% CI -1.38 to -0.44; P <0.00001; low certainty evidence). One study reported on microbiome characteristics, reporting no difference in changes with concurrent antibiotic and probiotic use. AUTHORS' CONCLUSIONS The overall evidence suggests a moderate protective effect of probiotics for preventing AAD (NNTB 9, 95% CI 7 to 13). Using five criteria to evaluate the credibility of the subgroup analysis on probiotic dose, the results indicate the subgroup effect based on high dose probiotics (≥ 5 billion CFUs per day) was credible. Based on high-dose probiotics, the NNTB to prevent one case of diarrhea is 6 (95% CI 5 to 9). The overall certainty of the evidence for the primary endpoint, incidence of AAD based on high dose probiotics was moderate due to the minor issues with risk of bias and inconsistency related to a diversity of probiotic agents used. Evidence also suggests that probiotics may moderately reduce the duration of diarrhea, a reduction by almost one day. The benefit of high dose probiotics (e.g. Lactobacillus rhamnosus orSaccharomyces boulardii) needs to be confirmed by a large well-designed multi-centered randomized trial. It is premature to draw firm conclusions about the efficacy and safety of 'other' probiotic agents as an adjunct to antibiotics in children. Adverse event rates were low and no serious adverse events were attributable to probiotics. Although no serious adverse events were observed among inpatient and outpatient children, including small studies conducted in the intensive care unit and in the neonatal unit, observational studies not included in this review have reported serious adverse events in severely debilitated or immuno-compromised children with underlying risk factors including central venous catheter use and disorders associated with bacterial/fungal translocation.
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Affiliation(s)
- Qin Guo
- West China Second University Hospital, West China Women's and Children's HospitalDepartment of PediatricsChengduChina
| | - Joshua Z Goldenberg
- National University of Natural MedicineHelfgott Research Institute2220 SW 1st AvePortlandORUSA97102
| | | | - Regina El Dib
- Institute of Science and Technology, UNESP ‐ Univ Estadual PaulistaDepartment of Biosciences and Oral DiagnosisSão José dos CamposSPBrazil
| | - Bradley C Johnston
- Dalhousie UniversityDepartment of Community Health and Epidemiology5790 University AvenueHalifaxNSCanadaB3H 1V7
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Goldenberg JZ, Yap C, Lytvyn L, Lo CK, Beardsley J, Mertz D, Johnston BC. Probiotics for the prevention of Clostridium difficile-associated diarrhea in adults and children. Cochrane Database Syst Rev 2017; 12:CD006095. [PMID: 29257353 PMCID: PMC6486212 DOI: 10.1002/14651858.cd006095.pub4] [Citation(s) in RCA: 185] [Impact Index Per Article: 26.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Antibiotics can disturb gastrointestinal microbiota which may lead to reduced resistance to pathogens such as Clostridium difficile (C. difficile). Probiotics are live microbial preparations that, when administered in adequate amounts, may confer a health benefit to the host, and are a potential C. difficile prevention strategy. Recent clinical practice guidelines do not recommend probiotic prophylaxis, even though probiotics have the highest quality evidence among cited prophylactic therapies. OBJECTIVES To assess the efficacy and safety of probiotics for preventing C.difficile-associated diarrhea (CDAD) in adults and children. SEARCH METHODS We searched PubMed, EMBASE, CENTRAL, and the Cochrane IBD Group Specialized Register from inception to 21 March 2017. Additionally, we conducted an extensive grey literature search. SELECTION CRITERIA Randomized controlled (placebo, alternative prophylaxis, or no treatment control) trials investigating probiotics (any strain, any dose) for prevention of CDAD, or C. difficile infection were considered for inclusion. DATA COLLECTION AND ANALYSIS Two authors (independently and in duplicate) extracted data and assessed risk of bias. The primary outcome was the incidence of CDAD. Secondary outcomes included detection of C. difficile infection in stool, adverse events, antibiotic-associated diarrhea (AAD) and length of hospital stay. Dichotomous outcomes (e.g. incidence of CDAD) were pooled using a random-effects model to calculate the risk ratio (RR) and corresponding 95% confidence interval (95% CI). We calculated the number needed to treat for an additional beneficial outcome (NNTB) where appropriate. Continuous outcomes (e.g. length of hospital stay) were pooled using a random-effects model to calculate the mean difference and corresponding 95% CI. Sensitivity analyses were conducted to explore the impact of missing data on efficacy and safety outcomes. For the sensitivity analyses, we assumed that the event rate for those participants in the control group who had missing data was the same as the event rate for those participants in the control group who were successfully followed. For the probiotic group, we calculated effects using the following assumed ratios of event rates in those with missing data in comparison to those successfully followed: 1.5:1, 2:1, 3:1, and 5:1. To explore possible explanations for heterogeneity, a priori subgroup analyses were conducted on probiotic species, dose, adult versus pediatric population, and risk of bias as well as a post hoc subgroup analysis on baseline risk of CDAD (low 0% to 2%; moderate 3% to 5%; high > 5%). The overall quality of the evidence supporting each outcome was independently assessed using the GRADE criteria. MAIN RESULTS Thirty-nine studies (9955 participants) met the eligibility requirements for our review. Overall, 27 studies were rated as either high or unclear risk of bias. A complete case analysis (i.e. participants who completed the study) among trials investigating CDAD (31 trials, 8672 participants) suggests that probiotics reduce the risk of CDAD by 60%. The incidence of CDAD was 1.5% (70/4525) in the probiotic group compared to 4.0% (164/4147) in the placebo or no treatment control group (RR 0.40, 95% CI 0.30 to 0.52; GRADE = moderate). Twenty-two of 31 trials had missing CDAD data ranging from 2% to 45%. Our complete case CDAD results proved robust to sensitivity analyses of plausible and worst-plausible assumptions regarding missing outcome data and results were similar whether considering subgroups of trials in adults versus children, inpatients versus outpatients, different probiotic species, lower versus higher doses of probiotics, or studies at high versus low risk of bias. However, in a post hoc analysis, we did observe a subgroup effect with respect to baseline risk of developing CDAD. Trials with a baseline CDAD risk of 0% to 2% and 3% to 5% did not show any difference in risk but trials enrolling participants with a baseline risk of > 5% for developing CDAD demonstrated a large 70% risk reduction (interaction P value = 0.01). Among studies with a baseline risk > 5%, the incidence of CDAD in the probiotic group was 3.1% (43/1370) compared to 11.6% (126/1084) in the control group (13 trials, 2454 participants; RR 0.30, 95% CI 0.21 to 0.42; GRADE = moderate). With respect to detection of C. difficile in the stool pooled complete case results from 15 trials (1214 participants) did not show a reduction in infection rates. C. difficile infection was 15.5% (98/633) in the probiotics group compared to 17.0% (99/581) in the placebo or no treatment control group (RR 0.86, 95% CI 0.67 to 1.10; GRADE = moderate). Adverse events were assessed in 32 studies (8305 participants) and our pooled complete case analysis indicates probiotics reduce the risk of adverse events by 17% (RR 0.83, 95% CI 0.71 to 0.97; GRADE = very low). In both treatment and control groups the most common adverse events included abdominal cramping, nausea, fever, soft stools, flatulence, and taste disturbance. AUTHORS' CONCLUSIONS Based on this systematic review and meta-analysis of 31 randomized controlled trials including 8672 patients, moderate certainty evidence suggests that probiotics are effective for preventing CDAD (NNTB = 42 patients, 95% CI 32 to 58). Our post hoc subgroup analyses to explore heterogeneity indicated that probiotics are effective among trials with a CDAD baseline risk >5% (NNTB = 12; moderate certainty evidence), but not among trials with a baseline risk ≤5% (low to moderate certainty evidence). Although adverse effects were reported among 32 included trials, there were more adverse events among patients in the control groups. The short-term use of probiotics appears to be safe and effective when used along with antibiotics in patients who are not immunocompromised or severely debilitated. Despite the need for further research, hospitalized patients, particularly those at high risk of CDAD, should be informed of the potential benefits and harms of probiotics.
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Affiliation(s)
| | | | - Lyubov Lytvyn
- McMaster UniversityDepartment of Clinical Epidemiology and BiostatisticsHamiltonCanada
| | - Calvin Ka‐Fung Lo
- The University of British ColumbiaFaculty of MedicineVancouverCanada
| | | | - Dominik Mertz
- McMaster UniversityDivision of Infectious Diseases, Department of MedicineJuravinski Hospital and Cancer Center711 Concession Street, Section G, Level 0, Room 12HamiltonCanadaL8V 1C3
| | - Bradley C Johnston
- Dalhousie UniversityDepartment of Community Health and Epidemiology5790 University AvenueHalifaxCanadaB3H 1V7
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12
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Flach J, van der Waal MB, van den Nieuwboer M, Claassen E, Larsen OFA. The underexposed role of food matrices in probiotic products: Reviewing the relationship between carrier matrices and product parameters. Crit Rev Food Sci Nutr 2017; 58:2570-2584. [DOI: 10.1080/10408398.2017.1334624] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Affiliation(s)
- Joost Flach
- Vrije Universiteit Amsterdam, Athena Institute, Amsterdam, Netherlands
- CR2O, Marconistraat 16, Rotterdam, Netherlands
| | - Mark B. van der Waal
- Vrije Universiteit Amsterdam, Athena Institute, Amsterdam, Netherlands
- CR2O, Marconistraat 16, Rotterdam, Netherlands
| | | | - Eric Claassen
- Vrije Universiteit Amsterdam, Athena Institute, Amsterdam, Netherlands
| | - Olaf F. A. Larsen
- Vrije Universiteit Amsterdam, Athena Institute, Amsterdam, Netherlands
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Nagata JM, Gippetti J, Wager S, Chavez A, Wise PH. Prevalence and Predictors of Malnutrition among Guatemalan Children at 2 Years of Age. PLoS One 2016; 11:e0164772. [PMID: 27806066 PMCID: PMC5091788 DOI: 10.1371/journal.pone.0164772] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Accepted: 10/01/2016] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE To identify the prevalence and predictors of malnutrition among 2-year old children in the Western Highlands of Guatemala. METHODS Prospective cohort of 852 Guatemalan children in San Lucas Toliman, Guatemala followed from birth to age 2 from May 2008 to December 2013. Socio-demographic, anthropometric, and health data of children was collected at 2 month intervals. RESULTS Among the 402 males and 450 females in the cohort, mean weight-for-age Z-score (WAZ) declined from -0.67 ± 1.01 at 1 year to -1.07 ± 0.87 at 2 years, while mean height-for-age Z-score (HAZ) declined from -1.88 ± 1.19 at 1 year to -2.37 ± 0.99 at 2 years. Using multiple linear regression modeling, number of children <5 years old, vomiting in the past week, fever in the past week, and WAZ at 1 year were significant predictors of WAZ at 2 years. Significant predictors of HAZ at 2 years included household size, number of children <5 years old, diarrhea in the past week, WAZ at 1 year, and HAZ at 1 year. Vomiting in the past week and WAZ at 1 year were significant predictors of weight-for-height z-score (WHZ) at 2 years. CONCLUSIONS Number of children <5 years old, symptoms such as vomiting or diarrhea in the previous week, and prior nutritional status were the most significant predictors of malnutrition in this cohort. Future research may focus on the application of models to develop predictive algorithms for mobile device technology, as well as the identification of other predictors of malnutrition that are not well characterized such as the interaction of environmental exposures with protein consumption and epigenetics.
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Affiliation(s)
- Jason M. Nagata
- Department of Pediatrics, Stanford University, Palo Alto, California, United States of America
- * E-mail:
| | - James Gippetti
- Center for Health Policy and the Center for Primary Care and Outcomes Research, Stanford University, Palo Alto, California, United States of America
| | - Stefan Wager
- Graduate School of Business, Stanford University, Palo Alto, California, United States of America
| | - Alejandro Chavez
- Center for Health Policy and the Center for Primary Care and Outcomes Research, Stanford University, Palo Alto, California, United States of America
| | - Paul H. Wise
- Department of Pediatrics, Stanford University, Palo Alto, California, United States of America
- Center for Health Policy and the Center for Primary Care and Outcomes Research, Stanford University, Palo Alto, California, United States of America
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Goldenberg JZ, Lytvyn L, Steurich J, Parkin P, Mahant S, Johnston BC. Probiotics for the prevention of pediatric antibiotic-associated diarrhea. Cochrane Database Syst Rev 2015:CD004827. [PMID: 26695080 DOI: 10.1002/14651858.cd004827.pub4] [Citation(s) in RCA: 78] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Antibiotics are frequently prescribed in children. They alter the microbial balance within the gastrointestinal tract, commonly resulting in antibiotic-associated diarrhea (AAD). Probiotics may prevent AAD via restoration of the gut microflora. OBJECTIVES The primary objectives were to assess the efficacy and safety of probiotics (any specified strain or dose) used for the prevention of AAD in children. SEARCH METHODS MEDLINE, EMBASE, CENTRAL, CINAHL, AMED, and the Web of Science (inception to November 2014) were searched along with specialized registers including the Cochrane IBD/FBD review group, CISCOM (Centralized Information Service for Complementary Medicine), NHS Evidence, the International Bibliographic Information on Dietary Supplements as well as trial registries. Letters were sent to authors of included trials, nutraceutical and pharmaceutical companies, and experts in the field requesting additional information on ongoing or unpublished trials. Conference proceedings, dissertation abstracts, and reference lists from included and relevant articles were also searched. SELECTION CRITERIA Randomized, parallel, controlled trials in children (0 to 18 years) receiving antibiotics, that compare probiotics to placebo, active alternative prophylaxis, or no treatment and measure the incidence of diarrhea secondary to antibiotic use were considered for inclusion. DATA COLLECTION AND ANALYSIS Study selection, data extraction as well as methodological quality assessment using the risk of bias instrument was conducted independently and in duplicate by two authors. Dichotomous data (incidence of diarrhea, adverse events) were combined using a pooled risk ratio (RR) or risk difference (RD), and continuous data (mean duration of diarrhea, mean daily stool frequency) as mean difference (MD), along with their corresponding 95% confidence interval (95% CI). For overall pooled results on the incidence of diarrhea, sensitivity analyses included available case versus extreme-plausible analyses and random- versus fixed-effect models. To explore possible explanations for heterogeneity, a priori subgroup analysis were conducted on probiotic strain, dose, definition of antibiotic-associated diarrhea, as well as risk of bias. We also conducted post hoc subgroup analyses by patient diagnosis, single versus multi-strain, industry sponsorship, and inpatient status. The overall quality of the evidence supporting the outcomes was evaluated using the GRADE criteria. MAIN RESULTS Twenty-three studies (3938 participants) met the inclusion criteria. Trials included treatment with either Bacillus spp., Bifidobacterium spp., Clostridium butyricum, Lactobacilli spp., Lactococcus spp., Leuconostoc cremoris, Saccharomyces spp., orStreptococcus spp., alone or in combination. Eleven studies used a single strain probiotic, four combined two probiotic strains, three combined three probiotic strains, one combined four probiotic strains, two combined seven probiotic strains, one included ten probiotic strains, and one study included two probiotic arms that used three and two strains respectively. The risk of bias was determined to be high or unclear in 13 studies and low in 10 studies. Available case (patients who did not complete the studies were not included in the analysis) results from 22/23 trials reporting on the incidence of diarrhea show a precise benefit from probiotics compared to active, placebo or no treatment control. The incidence of AAD in the probiotic group was 8% (163/1992) compared to 19% (364/1906) in the control group (RR 0.46, 95% CI 0.35 to 0.61; I(2) = 55%, 3898 participants). A GRADE analysis indicated that the overall quality of the evidence for this outcome was moderate. This benefit remained statistically significant in an extreme plausible (60% of children loss to follow-up in probiotic group and 20% loss to follow-up in the control group had diarrhea) sensitivity analysis, where the incidence of AAD in the probiotic group was 14% (330/2294) compared to 19% (426/2235) in the control group (RR 0.69; 95% CI 0.54 to 0.89; I(2) = 63%, 4529 participants). None of the 16 trials (n = 2455) that reported on adverse events documented any serious adverse events attributable to probiotics. Meta-analysis excluded all but an extremely small non-significant difference in adverse events between treatment and control (RD 0.00; 95% CI -0.01 to 0.01). The majority of adverse events were in placebo, standard care or no treatment group. Adverse events reported in the studies include rash, nausea, gas, flatulence, abdominal bloating, abdominal pain, vomiting, increased phlegm, chest pain, constipation, taste disturbance, and low appetite. AUTHORS' CONCLUSIONS Moderate quality evidence suggests a protective effect of probiotics in preventing AAD. Our pooled estimate suggests a precise (RR 0.46; 95% CI 0.35 to 0.61) probiotic effect with a NNT of 10. Among the various probiotics evaluated, Lactobacillus rhamnosus or Saccharomyces boulardii at 5 to 40 billion colony forming units/day may be appropriate given the modest NNT and the likelihood that adverse events are very rare. It is premature to draw conclusions about the efficacy and safety of other probiotic agents for pediatric AAD. Although no serious adverse events were observed among otherwise healthy children, serious adverse events have been observed in severely debilitated or immuno-compromised children with underlying risk factors including central venous catheter use and disorders associated with bacterial/fungal translocation. Until further research has been conducted, probiotic use should be avoided in pediatric populations at risk for adverse events. Future trials would benefit from a standard and valid outcomes to measure AAD.
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Lakdawalla DN, Mascarenhas M, Jena AB, Vanderpuye-Orgle J, LaVallee C, Linthicum MT, Snider JT. Impact of Oral Nutrition Supplements on Hospital Outcomes in Pediatric Patients. JPEN J Parenter Enteral Nutr 2014; 38:42S-9S. [DOI: 10.1177/0148607114549769] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Darius N. Lakdawalla
- Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, California
| | | | - Anupam B. Jena
- Harvard Medical School and Massachusetts General Hospital, Boston, Massachusetts
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Liu S, Hu P, Du X, Zhou T, Pei X. Lactobacillus rhamnosus GG supplementation for preventing respiratory infections in children: a meta-analysis of randomized, placebo-controlled trials. Indian Pediatr 2013; 50:377-81. [PMID: 23665598 DOI: 10.1007/s13312-013-0123-z] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To systematically review the effectiveness of administering Lactobacillus rhamnosus GG (LGG) for preventing respiratory infections in children. DESIGN Systematic Review and Meta-analysis. DATA SOURCES Electronic databases and trial registries. RESULTS Four RCTs involving 1805 participants met the inclusion criteria. Compared with placebo, LGG administration was associated with a reduced incidence of acute otitis media (four RCTs, n=1805, RR 0.76, 95% CI 0.64-0.91, fixed effects model, NNT 17, 95% CI 11-46), a reduced risk of upper respiratory infections (one RCT, n=281, RR 0.62, 95% CI 0.50-0.78, NNT 4, 95% CI 3-8) and antibiotic treatments (four RCTs, n=1805, RR 0.80, 95% CI 0.71-0.91, fixed effects model). There was no significant difference between the LGG and the control groups in the risk of overall respiratory infections and the incidence of lower respiratory infections. However, subgroup analysis of two studies on children older than 1 year showed significant reduction in the risk of overall respiratory infections (two RCTs, n=794, RR 0.73, 95% CI 0.57-0.92, random effects model, NNT 8, 95% CI 5-14). Adverse effects were similar in both groups. No serious adverse events were reported. CONCLUSION The administration of Lactobacillus rhamnosus GG compared with placebo has the potential to reduce the incidence of acute otitis media, the upper respiratory infections and antibiotic use in children.
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Affiliation(s)
- Shan Liu
- Department of Public Health Microbiology, West China School of Public Health, Sichuan University, China
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In vitro fermentation of prebiotic oligosaccharides by Bifidobacterium lactis HN019 and Lactobacillus spp. Anaerobe 2013; 25:11-7. [PMID: 24239979 DOI: 10.1016/j.anaerobe.2013.11.001] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2013] [Revised: 10/03/2013] [Accepted: 11/01/2013] [Indexed: 11/23/2022]
Abstract
The utilisation of various prebiotic oligosaccharides by probiotic strains of Bifidobacterium lactis, Lactobacillus rhamnosus and Lactobacillus acidophilus was investigated in order to determine the synbiotic potential of various prebiotic/probiotic combinations. Analysis by HPLC and high-performance anion-exchange chromatography of the cell-free medium taken during growth of the three probiotic bacteria showed differences in the consumption of the various oligosaccharides. Analysis of galactooligosaccharides showed that both L. rhamnosus and B. lactis consumed mostly mono- and di-saccharide, while L. acidophilus consumed oligosaccharides up to trisaccharide. Both B. lactis and L. acidophilus utilised fructooligosaccharides and inulin, but showed different patterns of oligosaccharide consumption. Only L. rhamnosus grew on β-glucan oligosaccharides and preferentially consumed the trisaccharide. The results indicate the synbiotic potential of the various probiotic/prebiotic combinations, particularly L. acidophilus/galactooligosaccharides, L. acidophilus/fructooligosaccharides or inulin and L. rhamnosus/β-glucan oligosaccharides.
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Pyar H, Liong MT, Peh K. Recent Advances in Probiotics and Biomedical Applications. JOURNAL OF MEDICAL SCIENCES 2013. [DOI: 10.3923/jms.2013.601.614] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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The use of probiotic strains in caries prevention: a systematic review. Nutrients 2013; 5:2530-50. [PMID: 23857225 PMCID: PMC3738986 DOI: 10.3390/nu5072530] [Citation(s) in RCA: 91] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2013] [Revised: 06/13/2013] [Accepted: 06/17/2013] [Indexed: 02/06/2023] Open
Abstract
This paper aims to provide a systematic review of the caries-prevention effect of probiotics in human. The hypothesis was that the administration of probiotic strains might play a role in caries lesion prevention and in the control of caries-related risk factors. The main relevant databases (Medline, Embase) were searched. Quality of the Randomized Clinical Trials (RCTs) was classified using the “Consolidated Standards of Reporting Trials” (CONSORT) checklist and the Impact Factor (IF) value of each journal was recorded. Sixty-six papers were identified, and 23 fulfilled the inclusion criteria. Only three studies had caries lesion development as outcome, all the others reported caries risk factors as interim evaluation. Using the CONSORT Score, the papers were coded as 4 excellent, 9 good and 10 poor. The mean IF value recorded was 1.438. Probiotics may play a role as antagonistic agent on mutans streptococci (MS), acidogenic/aciduric bacteria that contributes to the caries process. In two-thirds of the selected papers, probiotics have demonstrated the capacity to reduce MS counts in saliva and/or plaque in short-term. The effect of probiotics on the development of caries lesion seems encouraging, but to date, RCTs on this topic are insufficient to provide scientific clinical evidence.
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Goldenberg JZ, Ma SSY, Saxton JD, Martzen MR, Vandvik PO, Thorlund K, Guyatt GH, Johnston BC. Probiotics for the prevention of Clostridium difficile-associated diarrhea in adults and children. Cochrane Database Syst Rev 2013:CD006095. [PMID: 23728658 DOI: 10.1002/14651858.cd006095.pub3] [Citation(s) in RCA: 165] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Antibiotics are widely prescribed; however they can cause disturbances in gastrointestinal flora which may lead to reduced resistance to pathogens such as Clostridium difficile (C. difficile). Probiotics are live organisms thought to balance the gastrointestinal flora. OBJECTIVES The primary objectives were to assess the efficacy and safety of probiotics for preventing Clostridium difficile-associated diarrhea (CDAD) or C. difficile infection in adults and children. SEARCH METHODS On February 21, 2013 we searched PubMed (1966-2013), EMBASE (1966-2013), Cochrane Central Register of Controlled Trials (The Cochrane Library 2013, Issue 1), CINAHL (1982-2013), AMED (1985-2013), and ISI Web of Science. Additionally, we conducted an extensive grey literature search including contact with industry representatives. SELECTION CRITERIA Randomized controlled (placebo, alternative prophylaxis, or no treatment control) trials investigating probiotics (any strain, any dose) for prevention of CDAD, or C. difficile infection were considered for inclusion. DATA COLLECTION AND ANALYSIS Two authors independently and in duplicate extracted data and assessed risk of bias using pre-constructed, and piloted, data extraction forms. Any disagreements were resolved by a third adjudicator. For articles published in abstract form only, further information was sought by contacting principal authors. The primary outcome was the incidence of CDAD. Secondary outcomes included the incidence of C. difficile infection, adverse events, antibiotic-associated diarrhea (AAD) and length of hospital stay. Dichotomous outcomes (e.g. incidence of CDAD) were pooled using a random-effects model to calculate the relative risk and corresponding 95% confidence interval (95% CI). Continuous outcomes (e.g. length of hospital) were pooled using a random-effects model to calculate the mean difference and corresponding 95% CI. Sensitivity analyses were conducted to explore the impact of missing data on efficacy and safety outcomes. For the sensitivity analyses, we assumed that the event rate for those participants in the control group who had missing data was the same as the event rate for those participants in the control group who were successfully followed. For the probiotic group we calculated effects using the following assumed ratios of event rates in those with missing data in comparison to those successfully followed: 1.5:1, 2:1, 3:1, and 5:1. To explore possible explanations for heterogeneity, a priori subgroup analysis were conducted on probiotic species, dose, adult versus pediatric population, and risk of bias.The overall quality of the evidence supporting each outcome was assessed using the GRADE criteria. MAIN RESULTS A total of 1871 studies were identified with 31 (4492 participants) meeting eligibility requirements for our review. Overall 11 studies were rated as a high risk of bias due mostly to missing outcome data. A complete case analysis (i.e. participants who completed the study) of those trials investigating CDAD (23 trials, 4213 participants) suggests that probiotics significantly reduce this risk by 64%. The incidence of CDAD was 2.0% in the probiotic group compared to 5.5% in the placebo or no treatment control group (RR 0.36; 95% CI 0.26 to 0.51). Sixteen of 23 trials had missing CDAD data ranging from 5% to 45%. These results proved robust to sensitivity analyses of plausible and worst-plausible assumptions regarding missing outcome data and were similar whether considering trials in adults versus children, lower versus higher doses, different probiotic species, or higher versus lower risk of bias. Our judgment is that the overall evidence warrants moderate confidence in this large relative risk reduction. We downgraded the overall quality of evidence for CDAD to 'moderate' due to imprecision. There were few events (154) and the calculated optimal information size (n = 8218) was more than the total sample size. With respect to the incidence of C. difficile infection, a secondary outcome, pooled complete case results from 13 trials (961 participants) did not show a statistically significant reduction. The incidence of C. difficile infection was 12.6% in the probiotics group compared to 12.7% in the placebo or no treatment control group (RR 0.89; 95% CI 0.64 to 1.24). Adverse events were assessed in 26 studies (3964 participants) and our pooled complete case analysis indicates probiotics reduce the risk of adverse events by 20% (RR 0.80; 95% CI 0.68 to 0.95). In both treatment and control groups the most common adverse events included abdominal cramping, nausea, fever, soft stools, flatulence, and taste disturbance. For the short-term use of probiotics in patients that are not immunocompromised or severely debilitated, we consider the strength of this evidence to be moderate. AUTHORS' CONCLUSIONS Based on this systematic review and meta-analysis of 23 randomized controlled trials including 4213 patients, moderate quality evidence suggests that probiotics are both safe and effective for preventing Clostridium difficile-associated diarrhea.
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Abstract
Fiber intake is critical for optimal health. This review covers the anti-inflammatory roles of fibers using results from human epidemiological observations, clinical trials, and animal studies. Fiber has body weight-related anti-inflammatory activity. With its lower energy density, a diet high in fiber has been linked to lower body weight, alleviating obesity-induced chronic inflammation evidenced by reduced amounts of inflammatory markers in human and animal studies. Body weight-unrelated anti-inflammatory activity of fiber has also been extensively studied in animal models in which the type and amount of fiber intake can be closely monitored. Fermentable fructose-, glucose-, and galactose-based fibers as well as mixed fibers have shown systemic and local intestinal anti-inflammatory activities when plasma inflammatory markers and tissue inflammation were examined. Similar anti-inflammatory activities have also been demonstrated in some human studies that controlled total fiber intake. The anti-inflammatory activities of synbiotics (probiotics plus fiber) were reviewed as well, but there was no convincing evidence indicating higher efficacy of synbiotics compared with that of fiber alone. Adverse effects have not been observed with the amount of fiber intake or supplementation used in studies, although patients with Crohn's disease may be more sensitive to inulin intake. Several possible mechanisms that may mediate the body weight-unrelated anti-inflammatory activity of fibers are discussed based on the in vitro and in vivo evidence. Fermentable fibers are known to affect the intestinal microbiome. The immunomodulatory role of the intestinal microbiome and/or microbial metabolites could contribute to the systemic and local anti-inflammatory activities of fibers.
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Affiliation(s)
- Shiu-Ming Kuo
- Department of Exercise and Nutrition Sciences, University at Buffalo, NY, USA.
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Videlock EJ, Cremonini F. Meta-analysis: probiotics in antibiotic-associated diarrhoea. Aliment Pharmacol Ther 2012; 35:1355-69. [PMID: 22531096 DOI: 10.1111/j.1365-2036.2012.05104.x] [Citation(s) in RCA: 110] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2012] [Revised: 03/06/2012] [Accepted: 04/02/2012] [Indexed: 12/12/2022]
Abstract
BACKGROUND Diarrhoea is a common occurrence in association with antibiotic administration. Earlier studies and meta-analyses have suggested that probiotic administration reduces the incidence of antibiotic-associated diarrhoea (AAD). AIM To estimate the reduction in risk of AAD with administration of probiotics in randomised placebo-controlled trials and to identify factors associated with such reduction. METHODS Meta-analysis of randomised, double-blinded, placebo-controlled trials including patients treated with antibiotics and administered a probiotic for at least the duration of the antibiotic treatment. The outcome was incidence of diarrhoea irrespective of the presence of Clostridium difficile or the development of pseudomembranous colitis. Meta-analysis and meta-regression methods were used to synthesise data and to assess influence of: mean age, duration of antibiotics, risk of bias and incidence of diarrhoea in the placebo group on outcomes. Subgroup analyses explored effects of different probiotic species, patient populations and treatment indications. RESULTS A total of 34 studies were included with 4138 patients. The pooled relative risk (RR) for AAD in the probiotic group vs. placebo was 0.53 (95% CI 0.44-0.63), corresponding to a number needed to treat (NNT) of 8 (95% CI 7-11). The preventive effect of probiotics remained significant when grouped by probiotic species, population age group, relative duration of antibiotics and probiotics, study risk of bias and probiotic administered. The pooled RR for AAD during treatment for Helicobacter pylori (H. pylori) was 0.37 (95% CI 0.20-0.69), corresponding to a NNT of 5 (95% CI 4-10). CONCLUSIONS This updated meta-analysis confirms earlier results supporting the preventive effects of probiotics in AAD.
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Affiliation(s)
- E J Videlock
- Beth Israel Deaconess Medical Center, Boston, MA, USA
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Johnston BC, Goldenberg JZ, Vandvik PO, Sun X, Guyatt GH. Probiotics for the prevention of pediatric antibiotic-associated diarrhea. Cochrane Database Syst Rev 2011:CD004827. [PMID: 22071814 DOI: 10.1002/14651858.cd004827.pub3] [Citation(s) in RCA: 107] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Antibiotics alter the microbial balance within the gastrointestinal tract. Probiotics may prevent antibiotic-associated diarrhea (AAD) via restoration of the gut microflora. Antibiotics are prescribed frequently in children and AAD is common in this population. OBJECTIVES The primary objectives were to assess the efficacy and safety of probiotics (any specified strain or dose) used for the prevention of AAD in children. SEARCH METHODS MEDLINE, EMBASE, CENTRAL, CINAHL, AMED, and the Web of Science (inception to May 2010) were searched along with specialized registers including the Cochrane IBD/FBD review group, CISCOM (Centralized Information Service for Complementary Medicine), NHS Evidence, the International Bibliographic Information on Dietary Supplements as well as trial registries. Letters were sent to authors of included trials, nutra/pharmaceutical companies, and experts in the field requesting additional information on ongoing or unpublished trials. Conference proceedings, dissertation abstracts, and reference lists from included and relevant articles were also searched. SELECTION CRITERIA Randomized, parallel, controlled trials in children (0 to 18 years) receiving antibiotics, that compare probiotics to placebo, active alternative prophylaxis, or no treatment and measure the incidence of diarrhea secondary to antibiotic use were considered for inclusion. DATA COLLECTION AND ANALYSIS Study selection, data extraction as well as methodological quality assessment using the risk of bias instrument was conducted independently and in duplicate by two authors. Dichotomous data (incidence of diarrhea, adverse events) were combined using a pooled relative risk and risk difference (adverse events), and continuous data (mean duration of diarrhea, mean daily stool frequency) as weighted mean differences, along with their corresponding 95% confidence intervals. For overall pooled results on the incidence of diarrhea, sensitivity analyses included available case versus extreme-plausible analyses and random- versus fixed-effect models. To explore possible explanations for heterogeneity, a priori subgroup analysis were conducted on probiotic strain, dose, definition of antibiotic-associated diarrhea, antibiotic agent as well as risk of bias. MAIN RESULTS Sixteen studies (3432 participants) met the inclusion criteria. Trials included treatment with either Bacillus spp., Bifidobacterium spp., Lactobacilli spp., Lactococcus spp., Leuconostoc cremoris, Saccharomyces spp., or Streptococcus spp., alone or in combination. Nine studies used a single strain probiotic agent, four combined two probiotic strains, one combined three probiotic strains, one product included ten probiotic agents, and one study included two probiotic arms that used three and two strains respectively. The risk of bias was determined to be high in 8 studies and low in 8 studies. Available case (patients who did not complete the studies were not included in the analysis) results from 15/16 trials reporting on the incidence of diarrhea show a large, precise benefit from probiotics compared to active, placebo or no treatment control. The incidence of AAD in the probiotic group was 9% compared to 18% in the control group (2874 participants; RR 0.52; 95% CI 0.38 to 0.72; I(2) = 56%). This benefit was not statistically significant in an extreme plausible (60% of children loss to follow-up in probiotic group and 20% loss to follow-up in the control group had diarrhea) intention to treat (ITT) sensitivity analysis. The incidence of AAD in the probiotic group was 16% compared to 18% in the control group (3392 participants; RR 0.81; 95% CI 0.63 to 1.04; I(2) = 59%). An a priori available case subgroup analysis exploring heterogeneity indicated that high dose (≥5 billion CFUs/day) is more effective than low probiotic dose (< 5 billion CFUs/day), interaction P value = 0.010. For the high dose studies the incidence of AAD in the probiotic group was 8% compared to 22% in the control group (1474 participants; RR 0.40; 95% CI 0.29 to 0.55). For the low dose studies the incidence of AAD in the probiotic group was 8% compared to 11% in the control group (1382 participants; RR 0.80; 95% CI 0.53 to 1.21). An extreme plausible ITT subgroup analysis was marginally significant for high dose probiotics. For the high dose studies the incidence of AAD in the probiotic group was 17% compared to 22% in the control group (1776 participants; RR 0.72; 95% CI 0.53 to 0.99; I(2) = 58%). None of the 11 trials (n = 1583) that reported on adverse events documented any serious adverse events. Meta-analysis excluded all but an extremely small non-significant difference in adverse events between treatment and control (RD 0.00; 95% CI -0.01 to 0.02). AUTHORS' CONCLUSIONS Despite heterogeneity in probiotic strain, dose, and duration, as well as in study quality, the overall evidence suggests a protective effect of probiotics in preventing AAD. Using 11 criteria to evaluate the credibility of the subgroup analysis on probiotic dose, the results indicate that the subgroup effect based on dose (≥5 billion CFU/day) was credible. Based on high-dose probiotics, the number needed to treat (NNT) to prevent one case of diarrhea is seven (NNT 7; 95% CI 6 to 10). However, a GRADE analysis indicated that the overall quality of the evidence for the primary endpoint (incidence of diarrhea) was low due to issues with risk of bias (due to high loss to follow-up) and imprecision (sparse data, 225 events). The benefit for high dose probiotics (Lactobacillus rhamnosus or Saccharomyces boulardii) needs to be confirmed by a large well-designed randomized trial. More refined trials are also needed that test strain specific probiotics and evaluate the efficacy (e.g. incidence and duration of diarrhea) and safety of probiotics with limited losses to follow-up. It is premature to draw conclusions about the efficacy and safety of other probiotic agents for pediatric AAD. Future trials would benefit from a standard and valid outcomes to measure AAD.
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Affiliation(s)
- Bradley C Johnston
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada.
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Smith TJ, Anderson D, Margolis LM, Sikes A, Young AJ. Persistence ofLactobacillus reuteriDSM17938 in the Human Intestinal Tract: Response to Consecutive and Alternate-Day Supplementation. J Am Coll Nutr 2011; 30:259-64. [DOI: 10.1080/07315724.2011.10719968] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Borchert D, Sheridan L, Papatsoris A, Faruquz Z, Barua JM, Junaid I, Pati Y, Chinegwundoh F, Buchholz N. Prevention and treatment of urinary tract infection with probiotics: Review and research perspective. Indian J Urol 2011; 24:139-44. [PMID: 19468386 PMCID: PMC2684288 DOI: 10.4103/0970-1591.40604] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
The spiralling costs of antibiotic therapy, the appearance of multiresistant bacteria and more importantly for patients and clinicians, unsatisfactory therapeutic options in recurrent urinary tract infection (RUTI) calls for alternative and advanced medical solutions. So far no sufficient means to successfully prevent painful and disabling RUTI has been found. Even though long-term oral antibiotic treatment has been used with some success as a therapeutic option, this is no longer secure due to the development of bacterial resistance. One promising alternative is the use of live microorganisms (probiotics) to prevent and treat recurrent complicated and uncomplicated urinary tract infection (UTI). The human normal bacterial flora is increasingly recognised as an important defence to infection. Since the advent of antibiotic treatment five decades ago, a linear relation between antibiotic use and reduction in pathogenic bacteria has become established as medical conventional wisdom. But with the use of antibiotics the beneficial bacterial flora hosted by the human body is destroyed and pathogenic bacteria are selectively enabled to overgrow internal and external surfaces. The benign bacterial flora is crucial for body function and oervgrowth with pathogenic microorganisms leads to illness. Thus the concept of supporting the human body's normal flora with live microorganisms conferring a beneficial health effect is an important medical strategy.
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Abstract
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.
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Affiliation(s)
- Judit Wacha
- Semmelweis Egyetem, Általános Orvostudományi Kar I. Sebészeti Klinika Budapest Üllői út 78. 1082.
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Abstract
BACKGROUND Probiotics may offer a safe intervention in acute infectious diarrhoea to reduce the duration and severity of the illness. OBJECTIVES To assess the effects of probiotics in proven or presumed acute infectious diarrhoea. SEARCH STRATEGY We searched the Cochrane Infectious Diseases Group's trials register (July 2010), the Cochrane Controlled Trials Register (The Cochrane Library Issue 2, 2010), MEDLINE (1966 to July 2010), EMBASE (1988 to July 2010), and reference lists from studies and reviews. We also contacted organizations and individuals working in the field, and pharmaceutical companies manufacturing probiotic agents. SELECTION CRITERIA Randomized and quasi-randomized controlled trials comparing a specified probiotic agent with a placebo or no probiotic in people with acute diarrhoea that is proven or presumed to be caused by an infectious agent. DATA COLLECTION AND ANALYSIS Two reviewers independently assessed the methodological quality of the trial and extracted data. Primary outcomes were the mean duration of diarrhoea, stool frequency on day 2 after intervention and ongoing diarrhoea on day 4. A random-effects model was used. MAIN RESULTS Sixty-three studies met the inclusion criteria with a total of 8014 participants. Of these, 56 trials recruited infants and young children. The trials varied in the definition used for acute diarrhoea and the end of the diarrhoeal illness, as well as in the risk of bias. The trials were undertaken in a wide range of different settings and also varied greatly in organisms tested, dosage, and participants' characteristics. No adverse events were attributed to the probiotic intervention.Probiotics reduced the duration of diarrhoea, although the size of the effect varied considerably between studies.The average of the effect was significant for mean duration of diarrhoea (mean difference 24.76 hours; 95% confidence interval 15.9 to 33.6 hours; n=4555, trials=35) diarrhoea lasting ≥4 days (risk ratio 0.41; 0.32 to 0.53; n=2853, trials=29) and stool frequency on day 2 (mean difference 0.80; 0.45 to 1.14; n=2751, trials=20).The differences in effect size between studies was not explained by study quality, probiotic strain, the number of different strains, the viability of the organisms, dosage of organisms, the causes of diarrhoea, or the severity of the diarrhoea, or whether the studies were done in developed or developing countries. AUTHORS' CONCLUSIONS Used alongside rehydration therapy, probiotics appear to be safe and have clear beneficial effects in shortening the duration and reducing stool frequency in acute infectious diarrhoea. However, more research is needed to guide the use of particular probiotic regimens in specific patient groups.
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Affiliation(s)
- Stephen J Allen
- Swansea UniversitySchool of MedicineRoom 314, The Grove BuildingSingleton ParkSwanseaWest GlamorganUKSA2 8PP
| | - Elizabeth G Martinez
- University of the Philippines College of MedicineDepartment of PediatricsPhilippine General HospitalTaft AvenueManilaNational Capital RegionPhilippines1000
| | - Germana V Gregorio
- University of the Philippines College of MedicineDepartment of PediatricsPhilippine General HospitalTaft AvenueManilaNational Capital RegionPhilippines1000
| | - Leonila F Dans
- University of the Philippines College of MedicineDepartments of Pediatrics and Clinical EpidemiologyPhilippine General HospitalTaft AvenueManilaNational Capital RegionPhilippines1000
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Picaud JC, Chapalain V, Paineau D, Zourabichvili O, Bornet FRJ, Duhamel JF. Incidence of infectious diseases in infants fed follow-on formula containing synbiotics: an observational study. Acta Paediatr 2010; 99:1695-700. [PMID: 20560895 PMCID: PMC3034191 DOI: 10.1111/j.1651-2227.2010.01896.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Aim Infectious diseases in infants are a major public health issue. Synbiotic-enriched formulas (EF) are intended to mimic the beneficial effects of human milk on infectious diseases. We performed an observational study in infants switching to follow-on formula to determine the effects of synbiotic-enriched formula compared to standard formula (SF). Methods We recorded family characteristics, medical history and growth data, as well as the symptoms, severity and treatment of infectious diseases. Main outcome measures were compared after adjustments for baseline characteristics. Results Between January and June 2007, 771 healthy infants were included in the study; 35.4% experienced at least one infectious disease during the 3-month study period. The most common were upper respiratory tract (24.1%), otitis (6.6%) and gastrointestinal infectious diseases (5.0%). Infants fed synbiotic-enriched formula had fewer infectious diseases overall (EF: 31.0%; SF: 40.6%; p = 0.005) and significantly fewer gastrointestinal infectious diseases (EF: 3.5%; SF: 6.8%; p = 0.03). During follow-up, weight gain was significantly higher (p = 0.0467) in infants fed synbiotic-enriched formula (18.3 ± 8.7 g/day) versus SF (16.9 ± 7.5 g/day). Conclusions Supplementation with synbiotics may have beneficial effects on the incidence of infectious disease and growth in infants. Further studies are needed determine optimal doses and composition of synbiotics in infant formula.
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Affiliation(s)
- Jean-Charles Picaud
- Department of Neonatology, Croix-Rousse University Hospital, Claude Bernard University Lyon1, Lyon, France.
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Effects of Bifidobacterium lactis HN019 and prebiotic oligosaccharide added to milk on iron status, anemia, and growth among children 1 to 4 years old. J Pediatr Gastroenterol Nutr 2010; 51:341-6. [PMID: 20601905 DOI: 10.1097/mpg.0b013e3181d98e45] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVE To evaluate the effect of Bifidobacterium lactis HN019 and prebiotic-fortified milk on iron status, anemia, and growth among 1- to 4-year-old children. PATIENTS AND METHODS In a community-based double-masked, controlled trial in a periurban population, 624 children were enrolled and randomly allocated to receive either milk fortified with additional probiotic and prebiotic (n = 312) or control milk (n = 312) for 1 year. Probiotic and prebiotic milk contained an additional 1.9 x 10 colony-forming units per day of probiotic B lactis HN019 and 2.4 g/day of prebiotic oligosaccharides milk. Hematological parameters were estimated at baseline and at the end of the study. Height and weight measurements were recorded at baseline, mid study, and the end of the study. Difference of means and multivariate regression models was used to examine the effect of intervention. RESULTS Both study groups were similar at baseline. Compliance was high (>85%) and did not vary by intervention groups. As compared with non-fortified milk, consumption of probiotic- and prebiotic-fortified milk for a period of 1 year reduced the risk of being anemic and iron deficient by 45% (95% CI 11%, 66%; P = 0.01) and increased weight gain by 0.13 kg/year (95% CI 0.03, 0.23; P = 0.02). CONCLUSIONS Preschoolers are usually fed milk, which has good acceptance and can be easily fortified for delivery of probiotics. Consumption of B lactis HN019 and prebiotic-fortified milk resulted in a smaller number of iron-deficient preschoolers and increased weight gain.
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Vouloumanou EK, Makris GC, Karageorgopoulos DE, Falagas ME. Probiotics for the prevention of respiratory tract infections: a systematic review. Int J Antimicrob Agents 2009; 34:197.e1-10. [PMID: 19179052 DOI: 10.1016/j.ijantimicag.2008.11.005] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2008] [Accepted: 11/04/2008] [Indexed: 12/16/2022]
Abstract
We evaluated the clinical evidence regarding probiotic use for the prevention of respiratory tract infections (RTIs). Randomised controlled trials (RCTs) studying the effects of probiotics for the prevention of upper or lower RTIs were systematically identified. Fourteen RCTs (twelve involving healthy subjects and two involving patients with RTIs) were included. Various Lactobacillus strains were used in seven RCTs, combinations of Lactobacillus and Bifidobacterium strains were used in five RCTs, and a Bifidobacterium strain and a non-pathogenic Enterococcus faecalis strain were used in one RCT, respectively. In ten RCTs no difference was found regarding the incidence of RTIs in the probiotic arm compared with the control arm, whereas the remaining four RCTs favoured the use of probiotics. Reduction in the severity of symptoms related to RTIs was noted in five of six RCTs that provided relevant data. In three of nine RCTs that provided relevant data, the clinical course of RTIs was shorter in the probiotic arm, whereas no difference was found in the remaining six RCTs. In conclusion, probiotics may have a beneficial effect on the severity and duration of symptoms of RTIs but do not appear to reduce the incidence of RTIs.
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Affiliation(s)
- Evridiki K Vouloumanou
- Alfa Institute of Biomedical Sciences, 9 Neapoleos Street, 151 23 Marousi, Athens, Greece
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Probiotics, prebiotics, and synbiotics. ADVANCES IN BIOCHEMICAL ENGINEERING/BIOTECHNOLOGY 2008; 111:1-66. [PMID: 18461293 DOI: 10.1007/10_2008_097] [Citation(s) in RCA: 344] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
According to the German definition, probiotics are defined viable microorganisms, sufficient amounts of which reach the intestine in an active state and thus exert positive health effects. Numerous probiotic microorganisms (e.g. Lactobacillus rhamnosus GG, L. reuteri, bifidobacteria and certain strains of L. casei or the L. acidophilus-group) are used in probiotic food, particularly fermented milk products, or have been investigated--as well as Escherichia coli strain Nissle 1917, certain enterococci (Enterococcus faecium SF68) and the probiotic yeast Saccharomyces boulardii--with regard to their medicinal use. Among the numerous purported health benefits attributed to probiotic bacteria, the (transient) modulation of the intestinal microflora of the host and the capacity to interact with the immune system directly or mediated by the autochthonous microflora, are basic mechanisms. They are supported by an increasing number of in vitro and in vivo experiments using conventional and molecular biologic methods. In addition to these, a limited number of randomized, well-controlled human intervention trials have been reported. Well-established probiotic effects are: 1. Prevention and/or reduction of duration and complaints of rotavirus-induced or antibiotic-associated diarrhea as well as alleviation of complaints due to lactose intolerance. 2. Reduction of the concentration of cancer-promoting enzymes and/or putrefactive (bacterial) metabolites in the gut. 3. Prevention and alleviation of unspecific and irregular complaints of the gastrointestinal tracts in healthy people. 4. Beneficial effects on microbial aberrancies, inflammation and other complaints in connection with: inflammatory diseases of the gastrointestinal tract, Helicobacter pylori infection or bacterial overgrowth. 5. Normalization of passing stool and stool consistency in subjects suffering from obstipation or an irritable colon. 6. Prevention or alleviation of allergies and atopic diseases in infants. 7. Prevention of respiratory tract infections (common cold, influenza) and other infectious diseases as well as treatment of urogenital infections. Insufficient or at most preliminary evidence exists with respect to cancer prevention, a so-called hypocholesterolemic effect, improvement of the mouth flora and caries prevention or prevention or therapy of ischemic heart diseases or amelioration of autoimmune diseases (e.g. arthritis). A prebiotic is "a selectively fermented ingredient that allows specific changes, both in the composition and/or activity in the gastrointestinal microflora that confers benefits upon host well being and health", whereas synergistic combinations of pro- and prebiotics are called synbiotics. Today, only bifidogenic, non-digestible oligosaccharides (particularly inulin, its hydrolysis product oligofructose, and (trans)galactooligosaccharides), fulfill all the criteria for prebiotic classification. They are dietary fibers with a well-established positive impact on the intestinal microflora. Other health effects of prebiotics (prevention of diarrhoea or obstipation, modulation of the metabolism of the intestinal flora, cancer prevention, positive effects on lipid metabolism, stimulation of mineral adsorption and immunomodulatory properties) are indirect, i.e. mediated by the intestinal microflora, and therefore less-well proven. In the last years, successful attempts have been reported to make infant formula more breast milk-like by the addition of fructo- and (primarily) galactooligosaccharides.
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Johnston BC, Supina AL, Ospina M, Vohra S. Probiotics for the prevention of pediatric antibiotic-associated diarrhea. Cochrane Database Syst Rev 2007:CD004827. [PMID: 17443557 DOI: 10.1002/14651858.cd004827.pub2] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Antibiotics alter the microbial balance within the gastrointestinal tract. Probiotics may prevent antibiotic-associated diarrhea (AAD) via restoration of the gut microflora. Antibiotics are prescribed frequently in children and AAD is common in this population. OBJECTIVES To assess the efficacy and adverse effects of probiotics (any specified strain or dose) for the prevention of antibiotic-associated diarrhea in children. To assess adverse events associated with the use of probiotics when co-administered with antibiotics in children. SEARCH STRATEGY MEDLINE, EMBASE, CENTRAL, CINAHL , AMED, and the Web of Science (inception to August 2006) were searched along with specialized registers including the Cochrane IBD/FBD Review Group, CISCOM, Chalmers PedCAM Research Register and trial registries from inception to 2005. Letters were sent to authors of included trials, nutra/pharmaceutical companies, and experts in the field requesting additional information on ongoing or unpublished trials. Conference proceedings, dissertation abstracts, and reference lists from included and relevant articles were hand searched. SELECTION CRITERIA Randomized, parallel, controlled (placebo, active, or no treatment) trials comparing co-administered probiotics with antibiotics for the prevention of diarrhea secondary to antibiotic use in children (0 to 18 years). DATA COLLECTION AND ANALYSIS Methodological quality assessment and data extraction were conducted independently by two authors (BCJ, AS). Dichotomous data (incidence of diarrhea, adverse events) were combined using pooled relative risks, and continuous data (mean duration of diarrhea, mean daily stool frequency) as weighted mean differences, along with their corresponding 95% confidence intervals. Adverse events were summarized using risk difference. For overall pooled results on the incidence of diarrhea, a priori sensitivity analyses included per protocol versus intention to treat, random versus fixed effects, and methodological quality criterion. Subgroup analysis were conducted on probiotic strain, dose, definition of antibiotic-associated diarrhea, and antibiotic agent. MAIN RESULTS Ten studies met the inclusion criteria. Trials included treatment with either Lactobacilli spp., Bifidobacterium spp., Streptococcus spp., or Saccharomyces boulardii alone or in combination. Six studies used a single strain probiotic agent and four combined two probiotic strains. The per protocol analysis for 9/10 trials reporting on the incidence of diarrhea show statistically significant results favouring probiotics over active/non active controls (RR 0.49; 95% CI 0.32 to 0.74). However, intention to treat analysis showed non-significant results overall (RR 0.90; 95% CI 0.50 to 1.63). Five of ten trials monitored for adverse events (n = 647); none reported a serious adverse event. AUTHORS' CONCLUSIONS Probiotics show promise for the prevention of pediatric AAD. While per protocol analysis yields treatment effect estimates that are both statistically and clinically significant, as does analysis of high quality studies, the estimate from the intention to treat analysis was not statistically significant. Future studies should involve probiotic strains and doses with the most promising evidence (e.g., Lactobacillus GG, Lactobacillus sporogenes, Saccharomyces boulardii at 5 to 40 billion colony forming units/day). Research done to date does not permit determination of the effect of age (e.g., infant versus older children) or antibiotic duration (e.g., 5 days versus 10 days). Future trials would benefit from a validated primary outcome measure for antibiotic-associated diarrhea that is sensitive to change and reflects what treatment effect clinicians, parents, and children consider important. The current data are promising, but it is premature to routinely recommend probiotics for the prevention of pediatric AAD.
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Johnston BC, Supina AL, Vohra S. Probiotics for pediatric antibiotic-associated diarrhea: a meta-analysis of randomized placebo-controlled trials. CMAJ 2006; 175:377-83. [PMID: 16908901 PMCID: PMC1534112 DOI: 10.1503/cmaj.051603] [Citation(s) in RCA: 116] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Antibiotic treatment is known to disturb gastrointestinal microflora, which results in a range of clinical symptoms--most notably, diarrhea. This is especially important in children, for whom antibiotics are prescribed frequently. Although meta-analyses have been conducted to evaluate the ability of probiotics to prevent antibiotic-induced diarrhea in the general population, little is known about which probiotic strains and doses might be of most benefit to children. Our objective in this study was to assess the efficacy of probiotics (of any specified strain or dose) for the prevention of antibiotic-associated diarrhea in children and to assess adverse events associated with the use of probiotics when coadministered with antibiotics to children. METHODS A comprehensive search was performed of the major electronic databases (e.g., CENTRAL, MEDLINE, EMBASE, CINAHL, AMED) from their inception to January 2005. We also contacted experts and searched registries and meeting abstracts for additional relevant articles. Randomized controlled trials that compared probiotic treatment with placebo or no treatment, involving pediatric subjects less than 19 years of age were included. Two reviewers independently applied eligibility criteria and assessed the studies for methodological quality. Data were independently extracted by 2 reviewers and analyzed via the standard Cochrane methodology. RESULTS Six studies were included (total n = 707 patients). The combined results, analyzed with a per-protocol method that reported on the incidence of diarrhea during antibiotic treatment, showed significant benefit for the use of probiotics over placebo (relative risk [RR] 0.43, 95% confidence interval [CI] 0.25-0.75, Iota2 = 70.1%). In contrast, results from intention-to-treat analysis were nonsignificant overall (RR 1.01, 95% CI 0.64-1.61). Subgroup analysis on 4 studies that provided at least 5 billion single-strain colony-forming units (CFUs) daily (range 5.5-40 x 10(9) Lactobacillus GG, L. sporogens or Saccharomyces boulardii) showed strong evidence with narrow CIs for the preventative effects of probiotics for antibiotic-associated diarrhea (RR 0.36, 95% CI 0.25-0.53, Iota2 = 3.5%). No serious adverse events were reported. INTERPRETATION The potential protective effects of probiotics to prevent antibiotic-associated diarrhea in children do not withstand intention-to-treat analysis. Before routine use is recommended, further studies (with limited losses of subjects to follow-up) are merited. Trials should involve those probiotic strains and doses with the most promising evidence (i.e., Lactobacillus GG, L. sporogens or S. boulardii at 5-40 x 10(9) CFUs daily).
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Affiliation(s)
- Bradley C Johnston
- Complementary and Alternative Research and Education (CARE) Program, Stollery Children's Hospital, Department of Pediatrics, University of Alberta, Edmonton, Alta
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Ogawa T, Asai Y, Tamai R, Makimura Y, Sakamoto H, Hashikawa S, Yasuda K. Natural killer cell activities of synbiotic Lactobacillus casei ssp. casei in conjunction with dextran. Clin Exp Immunol 2006; 143:103-9. [PMID: 16367940 PMCID: PMC1809552 DOI: 10.1111/j.1365-2249.2005.02975.x] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
We have reported previously that Lactobacillus casei ssp. casei, together with specific substrate dextran, exhibited an adjuvant effect of stimulating humoral immune responses against bovine serum albumin (BSA) as a model antigen in BALB/c mice. In the present study, among the Lactobacillus species tested, L. casei ssp. casei with dextran significantly elevated the natural killer (NK) cell activities in spleen mononuclear cells from BALB/c mice in comparison to L. casei ssp. casei alone or other Lactobacillus species with or without dextran. Oral administration of L. casei ssp. casei together with dextran also resulted in a significant increase of NK cell activities in healthy human volunteers. Further, L. casei ssp. casei induced significant production of interleukin (IL)-12 in human peripheral blood mononuclear cells and IL-15 mRNA expression in the human intestinal epithelial cell line Caco-2. L. casei ssp. casei with dextran in food also significantly elevated the survival rate of BALB/c mice bearing Meth-A cells. Taken together, these results demonstrate that dietary synbiotic supplementation which is a combination of the L. casei ssp. casei used as a probiotic together with the dextran, a specific substrate as a prebiotic, efficiently elicits murine and human NK cell activities.
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Affiliation(s)
- T Ogawa
- Department of Oral Microbiology, Asahi University School of Dentistry, Gifu, Japan.
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Abstract
PURPOSE OF REVIEW This review reports on the recent progress understanding mechanisms of action and clinical applications of probiotics. RECENT FINDINGS New insights on regulating mechanisms of intestinal commensal bacteria to prevent and treat different gastrointestinal diseases have been reported. Some probiotics, though not all, exert beneficial effects by modulating the mucosal barrier function and immune activity. It seems that a combination of different probiotics is more effective than a single strain. It was demonstrated that not only viable bacteria administered to the intestinal tract but also isolated probiotic DNA is active, even if injected subcutaneously. There is reasonable evidence to recommend probiotics in infectious diarrhoea for prevention and treatment (mainly in children) and to prevent antibiotic-induced gastrointestinal side effects. Furthermore, probiotics are effective in maintaining remission in ulcerative colitis and preventing and treating pouchitis. Promising positive effects were published in major surgery patients (gastric resection, pancreatic resection, liver transplantation) and in severe necrotising acute pancreatitis. SUMMARY Increasing knowledge on probiotics is exciting, but in the near future it must be defined which probiotics (single strains or a combination) are most effective in specific diseases. Well-designed, randomized clinical trials are still required to further define the role of probiotics as preventive and therapeutic agents.
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Affiliation(s)
- Rémy Meier
- Division of Gastroenterology, Hepatology and Nutrition, University of Basel, Liestal, Switzerland.
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