Randomized trial of probiotics and calcium on diarrhea and respiratory tract infections in Indonesian children

RNA therapeutics for diarrhea

Diarrhea is caused by a variety of bacterial and viral agents, inflammatory conditions, medications, and hereditary conditions. Secretory diarrhea involves several ion and solute transporters, activation of the cyclic nucleotide and Ca2+ signaling pathways, as well as intestinal epithelial secretion. In many cases of secretory diarrhea, activation of Cl- channels, such as the cystic transmembrane conduction regulator and the Ca2+stimulated Cl- channel fibrosis, promote secretion while concurrently inhibiting Na+ transport expressing fluid absorption. Current diarrhea therapies include rehydration and electrolyte replacement via oral rehydration solutions, as well as medications that target peristalsis or fluid secretion. The rising understanding of RNA function and its importance in illness has encouraged the use of various RNAs to operate selectively on "untreatable" proteins, transcripts, and genes. Some RNA-based medications have received clinical approval, while others are currently in research or preclinical studies. Despite major obstacles in the development of RNA-based therapies, many approaches have been investigated to improve intracellular RNA trafficking and metabolic stability.

Mg2+ supplementation treats secretory diarrhea in mice by activating calcium-sensing receptor in intestinal epithelial cells

Cholera is a global health problem with no targeted therapies. The Ca2+-sensing receptor (CaSR) is a regulator of intestinal ion transport and a therapeutic target for diarrhea, and Ca2+ is considered its main agonist. We found that increasing extracellular Ca2+ had a minimal effect on forskolin-induced Cl- secretion in human intestinal epithelial T84 cells. However, extracellular Mg2+, an often-neglected CaSR agonist, suppressed forskolin-induced Cl- secretion in T84 cells by 65% at physiological levels seen in stool (10 mM). The effect of Mg2+ occurred via the CaSR/Gq signaling that led to cAMP hydrolysis. Mg2+ (10 mM) also suppressed Cl- secretion induced by cholera toxin, heat-stable E. coli enterotoxin, and vasoactive intestinal peptide by 50%. In mouse intestinal closed loops, luminal Mg2+ treatment (20 mM) inhibited cholera toxin-induced fluid accumulation by 40%. In a mouse intestinal perfusion model of cholera, addition of 10 mM Mg2+ to the perfusate reversed net fluid transport from secretion to absorption. These results suggest that Mg2+ is the key CaSR activator in mouse and human intestinal epithelia at physiological levels in stool. Since stool Mg2+ concentrations in patients with cholera are essentially zero, oral Mg2+ supplementation, alone or in an oral rehydration solution, could be a potential therapy for cholera and other cyclic nucleotide-mediated secretory diarrheas.

MAMI: a comprehensive database of mother-infant microbiome and probiotic resources

Extensive evidence has demonstrated that the human microbiome and probiotics confer great impacts on human health, particularly during critical developmental stages such as pregnancy and infancy when microbial communities undergo remarkable changes and maturation. However, a major challenge in understanding the microbial community structure and interactions between mothers and infants lies in the current lack of comprehensive microbiome databases specifically focused on maternal and infant health. To address this gap, we have developed an extensive database called MAMI (Microbiome Atlas of Mothers and Infants) that archives data on the maternal and neonatal microbiome, as well as abundant resources on edible probiotic strains. By leveraging this resource, we can gain profound insights into the dynamics of microbial communities, contributing to lifelong wellness for both mothers and infants through precise modulation of the developing microbiota. The functionalities incorporated into MAMI provide a unique perspective on the study of the mother-infant microbiome, which not only advance microbiome-based scientific research but also enhance clinical practice. MAMI is publicly available at https://bioinfo.biols.ac.cn/mami/.

Acute gastroenteritis-changes to the recommended original oral rehydrating salts: a review

The World Health Organization recommended a formulation of oral rehydration salts as the intervention of choice for the treatment of acute gastroenteritis. While of value for the replacement of fluids and electrolytes, the formulation does not reduce stool volume, frequency, or symptom duration. This may prevent wide acceptance. To increase tolerability, shorten the duration of diarrhea and improve parental quality of life, several modifications to the original formula have been proposed. These include; low osmolarity, rice-based, glucose polymers as an alternative to glucose, the addition of probiotics, prebiotics and/or zinc, and various other ingredients. Here we summarize evidence regarding such changes and additions.

Role of multi-strain probiotics in preventing severity and frequency of recurrent respiratory tract infections in children

BACKGROUND

Respiratory tract infections are among the most common infections in the pediatric population throughout the globe. Globally around 20% of all deaths in children below 5 years of age are secondary to acute respiratory infections, mostly pneumonia. Probiotics are live microorganisms that when administered in adequate amounts confer a health benefit on the host. Their mechanism in preventing respiratory tract infections is not known but it is thought that probiotics act by modulating the immune system. This study was conducted to find out whether using probiotics is effective in decreasing the severity and frequency of recurrent respiratory tract infections or not.

METHODS

A Quasi-experimental study was conducted at the Pediatric Medicine Department of Abbassi Shaheed Hospital Karachi during 2021-2022. The study was approved by the institutional ethical review committee i.e. advanced studies and research board (ASRB). The sampling technique was non-probability consecutive sampling and the sample size was 70 patients with recurrent respiratory tract infections, aged six months to 12 years of age. All enrolled children were given probiotics containing Bifidobacterium, Lactobacillus Acidophilus for two weeks. Data were analyzed by using SPSS version 22. A p-value of < 0.05 was considered statistically significant.

RESULTS

Out of 70 children with recurrent respiratory tract infections, 39 (55.71%) were male and 31 (44.29%) female. Around 75% of the children were below five years of age. The most common presenting complaint was fever (72.86%), followed by cough (68.57%), wheezes (45.71%) and nasal discharge/sneezing (32.86%), respectively. The most common RRTI was infectious rhinitis (30% of the cases), otitis media (24%) and pharyngitis/tonsillitis (21%). After giving probiotics for two weeks most significant decrease was found in recurrent infectious rhinitis (p-value 0.02), recurrent otitis media (p-value 0.03) and recurrent bronchiolitis (p-value 0.05) over the next six months.

CONCLUSION

The results of our study indicate that the administration of probiotics reduces recurrent respiratory tract infections among children. This six months trial has demonstrated that there was a significant decline in respiratory symptoms among study participants. This study also observed a significant decrease in respiratory diseases during the follow-up.

Lactobacillus reuteri in digestive system diseases: focus on clinical trials and mechanisms

Objectives

Digestive system diseases have evolved into a growing global burden without sufficient therapeutic measures. Lactobacillus reuteri (L. reuteri) is considered as a new potential economical therapy for its probiotic effects in the gastrointestinal system. We have provided an overview of the researches supporting various L. reuteri strains' application in treating common digestive system diseases, including infantile colic, diarrhea, constipation, functional abdominal pain, Helicobacter pylori infection, inflammatory bowel disease, diverticulitis, colorectal cancer and liver diseases.

Methods

The summarized literature in this review was derived from databases including PubMed, Web of Science, and Google Scholar.

Results

The therapeutic effects of L. reuteri in digestive system diseases may depend on various direct and indirect mechanisms, including metabolite production as well as modulation of the intestinal microbiome, preservation of the gut barrier function, and regulation of the host immune system. These actions are largely strain-specific and depend on the activation or inhibition of various certain signal pathways. It is well evidenced that L. reuteri can be effective both as a prophylactic measure and as a preferred therapy for infantile colic, and it can also be recommended as an adjuvant strategy to diarrhea, constipation, Helicobacter pylori infection in therapeutic settings. While preclinical studies have shown the probiotic potential of L. reuteri in the management of functional abdominal pain, inflammatory bowel disease, diverticulitis, colorectal cancer and liver diseases, its application in these disease settings still needs further study.

Conclusion

This review focuses on the probiotic effects of L. reuteri on gut homeostasis via certain signaling pathways, and emphasizes the importance of these probiotics as a prospective treatment against several digestive system diseases.

Low doses of diarrhoeagenic E. coli induce enhanced monocyte and mDC responses and prevent development of symptoms after homologous rechallenge

The experimental challenge with attenuated enterotoxigenic E. coli strain E1392/75-2A prevents diarrhea upon a secondary challenge with the same bacteria. A dose-response pilot study was performed to investigate which immunological factors are associated with this protection. Healthy subjects were inoculated with increasing E. coli doses of 1E6-1E10 CFU, and three weeks later, all participants were rechallenged with the highest dose (1E10 CFU). Gastrointestinal discomfort symptoms were recorded, and stool and blood samples were analyzed. After the primary challenge, stool frequency, diarrhea symptom scores, and E. coli-specific serum IgG (IgG-CFA/II) titer increased in a dose-dependent manner. Fecal calprotectin and serum IgG-CFA/II response after primary challenge were delayed in the lower dose groups. Even though stool frequency after the secondary challenge was inversely related to the primary inoculation dose, all E. coli doses protected against clinical symptoms upon rechallenge. Ex vivo stimulation of PBMCs with E. coli just before the second challenge resulted in increased numbers of IL-6+/TNF-α+ monocytes and mDCs than before the primary challenge, without dose-dependency. These data demonstrate that primary E. coli infection with as few as 1E6 CFU protects against a high-dose secondary challenge with a homologous attenuated strain. Increased serum IgG-CFA/II levels and E. coli-induced mDC and monocyte responses after primary challenge suggest that protection against secondary E. coli challenges is associated with adaptive as well as innate immune responses.

Comparison of two probiotics in follow-on formula: Bifidobacterium animalis subsp. lactis HN019 reduced upper respiratory tract infections in Chinese infants

A randomised, double-blind, placebo-controlled trial was performed to investigate the health benefits of probiotic bacteria in infants when delivered in a follow-on infant formula. The study was conducted in Fuyang (Anhui Province, China) during winter and enrolled 192 healthy infants aged six to 12 months. Infants received one of three follow-on formulae daily for 12 weeks: supplemented with 106 cfu/g Bifidobacterium animalis subsp. lactis HN019 (n=64); 106 cfu/g Lacticaseibacillus rhamnosus HN001 (n=64); or without added probiotics (n=64). The primary endpoint was physician-confirmed bacterial or viral infections during the treatment period. Secondary endpoints included parentally reported (confirmed and unconfirmed) infections; antiviral or antibiotic treatments, and hospitalisation; stool frequency and consistency; infant growth; infant temperament; and adverse events. There were 8 cases of confirmed infection, all upper respiratory tract infections (URTIs). Confirmed URTIs were observed in 9.4% of the control group, compared to 3.1% in the HN001 group (P=0.273), and 0.0% in the HN019 group (P=0.028). A similar trend was observed for parentally reported URTIs, with 25.0% in the control group, compared with 14.1% in the HN001 group (P=0.119) and 9.4% in the HN019 group (P=0.019). No infants in the HN019 group were prescribed antibiotics or antivirals, compared with 3 (4.7%) in the HN001 group and 7 (10.9%) in the control group. No infants required hospitalisation. The probiotic-containing formulae were well-tolerated: there were no cases of diarrhoea or differences in stool frequency or characteristics, no differences in infant growth or temperament, and no treatment-related adverse events. This study directly compared the benefits of two different probiotics when added to follow-on infant formula at 106 cfu/g and consumed over a 12-week period. While HN001 showed trends toward reduced infections, HN019 showed better performance in terms of significantly reduced incidence of both physician-confirmed and parentally reported URTIs, and antibiotic/antiviral use compared to a control in Chinese infants. The trial is registered at ClinicalTrials.gov (NCT01724203).

Probiotics for preventing acute upper respiratory tract infections

BACKGROUND

Probiotics are live micro-organisms that may give a beneficial physiological effect when administered in adequate amounts. Some trials show that probiotic strains can prevent respiratory infections. Even though our previously published review showed the benefits of probiotics for acute upper respiratory tract infections (URTIs), several new studies have been published. This is an update of a review first published in 2011 and updated in 2015.

OBJECTIVES

To assess the effectiveness and safety of probiotics (any specified strain or dose), compared with placebo or no treatment, in the prevention of acute URTIs in people of all ages, at risk of acute URTIs.

SEARCH METHODS

We searched CENTRAL (2022, Issue 6), MEDLINE (1950 to May week 2, 2022), Embase (1974 to 10 May 2022), Web of Science (1900 to 10 May 2022), the Chinese Biomedical Literature Database, which includes the China Biological Medicine Database (from 1978 to 10 May 2022), the Chinese Medicine Popular Science Literature Database (from 2000 to 10 May 2022), and the Master's Degree Dissertation of Beijing Union Medical College Database (from 1981 to 10 May 2022). We searched the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov for completed and ongoing trials on 10 May 2022.

SELECTION CRITERIA

We included individual randomised controlled trials (RCTs) and cluster-RCTs comparing probiotics with placebo or no treatment to prevent acute URTIs. The participants were children, adults, or the elderly in the community, care facilities, schools, or hospitals. Our main outcomes were the number of participants diagnosed with URTIs (at least one event and at least three events), the incidence rate (number of cases/person year) of acute URTIs, and the mean duration of an episode of URTIs. Our secondary outcomes were the number of participants who were absent from childcare centre, school, or work due to acute URTIs; the number of participants who used prescribed antibiotics for acute URTIs; and the number of participants who experienced at least one adverse event from probiotics. We excluded studies if they did not specify acute respiratory infections as 'upper'; studies with more than 50% of participants vaccinated against influenza or other acute URTIs within the last 12 months; and studies with significantly different proportions of vaccinated participants between the probiotics arm and the placebo or no treatment arm.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the eligibility of trials and extracted data using standard Cochrane methodological procedures. We analysed both intention-to-treat and per-protocol data and used a random-effects model. We expressed results as risk ratios (RRs) for dichotomous outcomes and mean differences (MDs) for continuous outcomes, both with 95% confidence intervals (CIs). We assessed the certainty of the evidence using the GRADE approach.

MAIN RESULTS

We included 23 individual RCTs and one cluster-RCT. As one of the individual RCTs did not report outcomes in a usable way, we could only meta-analyse data from 23 trials, involving a total of 6950 participants including children (aged from one month to 11 years old), adults (mean age 37.3), and older people (mean age 84.6 years). One trial reported 22.5% flu-vaccine participants within the last 12 months, and 25.4% flu-vaccine participants during the intervention. Probiotics were more likely to be given with milk-based food in children; administered in powder form in adults; and given with milk-based food or in capsules in the elderly. Most of the studies used one or two strains (e.g. Lactobacillus plantarum HEAL9, Lactobacillus paracasei (8700:2 or N1115)) and 109 or 1011 colony-forming units (CFU)/day of probiotics for more than three months. We found that probiotics may reduce the number of participants diagnosed with URTIs (at least one event) (RR 0.76, 95% CI 0.67 to 0.87; P < 0.001; 16 studies, 4798 participants; low-certainty evidence); likely reduce the number of participants diagnosed with URTIs (at least three events) (RR 0.59, 95% CI 0.38 to 0.91; P = 0.02; 4 studies, 763 participants; moderate-certainty evidence); may reduce the incidence rate (number of cases/person year) of URTIs (rate ratio 0.82, 95% CI 0.73 to 0.92, P = 0.001; 12 studies, 4364 participants; low-certainty evidence); may reduce the mean duration of an episode of acute URTIs (MD -1.22 days, 95% CI -2.12 to -0.33; P = 0.007; 6 studies, 2406 participants; low-certainty evidence); likely reduce the number of participants who used prescribed antibiotics for acute URTIs (RR 0.58, 95% CI 0.42 to 0.81; P = 0.001; 6 studies, 1548 participants; moderate-certainty evidence); and may not increase the number of participants who experienced at least one adverse event (RR 1.02, 95% CI 0.90 to 1.15; P = 0.79; 8 studies, 2456 participants; low-certainty evidence). Evidence showing a decrease in the number of people absent from childcare centre, school, or work due to acute URTIs with probiotics is very uncertain (RR 0.14, 95% CI 0.03 to 0.59; 1 study, 80 participants; very low-certainty evidence). Adverse events from probiotics were minor, and most commonly gastrointestinal symptoms, such as vomiting, flatulence, diarrhoea, and bowel pain.  AUTHORS' CONCLUSIONS: Overall, we found that probiotics were better than placebo or no treatment in preventing acute URTIs.

Ingestion, Immunity, and Infection: Nutrition and Viral Respiratory Tract Infections

Respiratory infections place a heavy burden on the health care system, particularly in the winter months. Individuals with a vulnerable immune system, such as very young children and the elderly, and those with an immune deficiency, are at increased risk of contracting a respiratory infection. Most respiratory infections are relatively mild and affect the upper respiratory tract only, but other infections can be more serious. These can lead to pneumonia and be life-threatening in vulnerable groups. Rather than focus entirely on treating the symptoms of infectious disease, optimizing immune responsiveness to the pathogens causing these infections may help steer towards a more favorable outcome. Nutrition may have a role in such prevention through different immune supporting mechanisms. Nutrition contributes to the normal functioning of the immune system, with various nutrients acting as energy sources and building blocks during the immune response. Many micronutrients (vitamins and minerals) act as regulators of molecular responses of immune cells to infection. It is well described that chronic undernutrition as well as specific micronutrient deficiencies impair many aspects of the immune response and make individuals more susceptible to infectious diseases, especially in the respiratory and gastrointestinal tracts. In addition, other dietary components such as proteins, pre-, pro- and synbiotics, and also animal- and plant-derived bioactive components can further support the immune system. Both the innate and adaptive defense systems contribute to active antiviral respiratory tract immunity. The initial response to viral airway infections is through recognition by the innate immune system of viral components leading to activation of adaptive immune cells in the form of cytotoxic T cells, the production of neutralizing antibodies and the induction of memory T and B cell responses. The aim of this review is to describe the effects of a range different dietary components on anti-infective innate as well as adaptive immune responses and to propose mechanisms by which they may interact with the immune system in the respiratory tract.

The direct and indirect effects of bioactive compounds against coronavirus

Emerging viruses are known to pose a threat to humans in the world. COVID‐19, a newly emerging viral respiratory disease, can spread quickly from people to people via respiratory droplets, cough, sneeze, or exhale. Up to now, there are no specific therapies found for the treatment of COVID‐19. In this sense, the rising demand for effective antiviral drugs is stressed. The main goal of the present study is to cover the current literature about bioactive compounds (e.g., polyphenols, glucosinolates, carotenoids, minerals, vitamins, oligosaccharides, bioactive peptides, essential oils, and probiotics) with potential efficiency against COVID‐19, showing antiviral activities via the inhibition of coronavirus entry into the host cell, coronavirus enzymes, as well as the virus replication in human cells. In turn, these compounds can boost the immune system, helping fight against COVID‐19. Overall, it can be concluded that bioactives and the functional foods containing these compounds can be natural alternatives for boosting the immune system and defeating coronavirus.

Relationships of Child-, Parents-, and Environment-Associated Determinants with Diet Quality, Physical Activity, and Smoking Habits among Indonesian Urban Adolescents

BACKGROUND

The trend of unhealthy lifestyles is increasing among adolescents and has been associated with the rising burden of noncommunicable diseases (NCDs). However, specific determinants of unhealthy lifestyles among adolescents in low- and middle-income countries remain limited.

OBJECTIVE

To investigate the relationships of child-, parents-, and environment-associated determinants with diet quality, physical activity, and smoking habits among low-socioeconomic urban adolescents.

METHODS

A cross-sectional study involving 238 adolescents aged 11 to 17 years was conducted in Jakarta, Indonesia. Adolescents and their parents were interviewed to assess the determinants of healthy lifestyles that included diet quality, physical activity, and smoking habits. Diet and physical activity were quantified using the Diet Quality Index for Adolescents (DQI-A) and Physical Activity Questionnaire for Older Children (PAQ-C), respectively. Multiple regression was used to determine the β coefficients and odds ratios predictive of healthy lifestyles.

RESULTS

Mean scores of DQI-A and PAQ-C were considered low (33.5% ± 8.9% and 2.1 ± 0.5, respectively). Overall, 17.6% of adolescents were smokers, with 88% of these being males. Predictors of diet quality were child- (age, gender) and environment-associated (house size, access to a computer) determinants with β coefficients of -6.52 to 3.26. The PAQ-C score was associated with child- (female) and environment-associated (living area) determinants with β coefficients of -0.45 and 0.14, respectively. Younger adolescents and females were protective factors for smoking. Parents-associated determinants were not associated with any lifestyle indicators.

CONCLUSIONS

Child- and environment-associated determinants were predictors of healthy lifestyles among adolescents. Thus, personal empowerment and environment transformation are needed to facilitate a healthy lifestyle and reduce the burden of NCDs among adolescents.

The effect of calcium on the duration of acute gastroenteritis in children: A randomized clinical trial

Background: Currently, the role of calcium in reducing the duration and severity of diarrhea and its consequences has been considered as a topic of concern. The aim of this study was to evaluate the effect of oral calcium on the duration of acute gastroenteritis in children.

Methods: This single-blind randomized clinical trial was performed from 2014 to 2016 at Ali Asghar Children’s Hospital, Tehran, Iran. Totally, 124 patients (one month to twelve years old) with acute gastroenteritis were enrolled in this study. The patients were divided equally into intervention and placebo groups and received the calcium gluconate 10%, 0.5cc/kg/day and distinct water, respectively. Data analysis was performed using the statistical software SPSS version 20.0 for windows (SPSS Inc., Chicago, IL) and p<0.05 was considered significant.

Results: The mean age of the intervention and placebo groups was 26.43±3.74 and 20.84±2.70 months, respectively, and the difference was not significant (p=0.228). The duration of diarrhea in the intervention and placebo groups was 5.27±2.01 and 6.71 ± 2.44 days respectively (p=0.001). In the placebo group, the plasma calcium level was less than 8mg/dl in 1 (1.6%), 8 - 10 mg/dl in 55 (88.7%) and more than 10mg/dl in 6 cases (9. 7%). In the intervention group, there were 7 (11.3%), 55 (88.7%) and 0 (0%) cases in three groups, respectively (p=0.005).

Conclusion: The oral calcium gluconate might shorten the duration of acute gastroenteritis. Therefore, it could be considered as an adjunctive therapy. Whether the formulation of the oral rehydration solution (ORS) will be updated in the future with adding the calcium salts remains to be defined and needs more investigations.

Effect of probiotic fermented dairy products on incidence of respiratory tract infections: a systematic review and meta-analysis of randomized clinical trials

BACKGROUND

Previous studies have suggested that the consumption of probiotic fermented dairy products (PFDP) may have a protective effect on respiratory tract infections (RTIs). However, the results of studies are inconclusive. We aimed to systematically investigate the effect of PFDP on RTIs by performing a meta-analysis of randomized controlled trials (RCTs).

METHODS

PubMed and Scopus databases were systematically searched up to October 2020 to identify eligible RCTs. Meta-analysis outcomes were risk of incidence of upper (URTIs ) and lower (LRTIs ) respiratory tract infections. A random-effects model was used to pool the relative risks (RR) and corresponding 95 % confidence intervals (CI) for outcomes following conception of PFDP.

RESULTS

A total of 22 RCTs, with a total sample size of 10,190 participants, were included in this meta-analysis. Compared with placebo, consumption of PFDP had a significant protective effect against RTIs in the overall analysis (RR = 0.81, 95 %CI: 0.74 to 0.89) and in children (RR = 0.82, 95 %CI: 0.73 to 0.93), adults (RR = 0.81, 95 %CI: 0.66 to 1.00), and elderly population (RR = 0.78, 95 %CI: 0.61 to 0.98). The significant decreased risk of RTIs was also observed for URTIs (RR = 0.83, 95 %CI: 0.73 to 0.93), while, this effect was marginal for LRTIs (RR = 0.78, 95 %CI: 0.60 to 1.01, P = 0.06). The disease-specific analysis showed that PFDP have a protective effect on pneumonia (RR = 0.76, 95 %CI: 0.61 to 0.95) and common cold (RR = 0.68, 95 %CI: 0.49 to 0.96).

CONCLUSIONS

Consumption of PFDP is a potential dietary approach for the prevention of RTIs.

Practical Recommendations of Scientific Society for the Study of Human Microbiome and the Russian Gastroenterological Association on Use of Probiotics, Prebiotics, Synbiotics and Functional Foods in Treatment and Prevention of Gastroenterological Diseases in Children and Adults

Aim. The practical guidelines are intended for primary care physicians, general practitioners, paediatricians, gastroenterologists and general internists to advance the treatment and prevention of gastroenterological diseases in adults and children in therapies with probiotics, prebiotics, synbiotics and their enriched functional foods.

Key points. Probiotics are live microorganisms that sustain health of the host when supplied in adequate amounts. Prebiotics include human-indigestible but accessible to gut microbiota substances expediting specific changes in the composition and/or activity of gastrointestinal microbiota that favour the host health. The mechanism of probiotic action comprises the quorum resistance maintenance, nutrient substrate metabolism and end metabolite recycling, macroorganism-sustaining substrate production, as well as the mediation of local and adaptive immune responses.

The Russian Federation regulates market differently for biologically active food additives (BAFA), medicinal products (drugs) and functional food products (FFP). We overview the probiotic strains regulated in Russia as BAFAs, drugs and FFPs and provide recommendations on the use of these strains in treatment and prevention of gastroenterological diseases in children and adults.

Conclusion. The clinical efficacy of probiotics, prebiotics, synbiotics and fortified functional foods depends on the prebiotic and strain properties and is verified in appropriate comparative clinical trials. Not all probiotics registered in Russia as BAFAs, drugs and FFPs have a strain identity, which provides no warranty of the clinical effect expected. The FFP legislation demands improved regulation mechanisms and control for therapeutic efficacy.

Limosilactobacillus reuteri ATCC PTA 5289 and DSM 17938 as adjuvants to improve evolution of pharyngitis/tonsillitis in children: randomised controlled trial

Pharyngitis and tonsillitis are the most common acute respiratory infections (ARIs) in children aged ≤5 years. The analysis of published data showed that some probiotics could decrease the frequency and number of days with ARIs. This study evaluated the safety and efficacy of Limosilactobacillus reuteri ATCC PTA 5289 and DSM 17938 to reduce the duration and severity of ARI symptoms. This randomised controlled trial included children aged from 6 months to 5 years, with pharyngitis or tonsillitis, who were randomised to receive a probiotic product containing L. reuteri ATCC PTA 5289 and L. reuteri DSM 17938 or placebo, as drops, ingested orally for 10 days as adjuvants to the use of non-steroidal anti-inflammatory drugs. The main outcomes were the duration and severity of ARI symptoms. The secondary outcomes were changes in salivary immunoglobulin A and inflammatory biomarkers. There was no fever on day 2 and subsequent days in the L. reuteri group (37.3 ±0.5 °C vs 38.6±0.3 °C, P<0.05). Beginning on day 3, the severity of sore throat (5±0.9 vs 8±1.2, P<0.05) was lower in the L. reuteri group. Significant differences in the days with runny nose, nasal congestion, days of non-programmed visits to the medical office or emergency department, levels in tumoral necrosis factor-alpha (TNF-alpha) and related costs of treatment were observed in the L. reuteri group. The frequency of adverse events was similar between the groups. Therefore, L. reuteri ATCC PTA 5289 combined with L. reuteri DSM 17938 is a safe and effective adjunct to reduce the symptoms of pharyngitis or tonsillitis in children.

The emerging role of probiotics as a mitigation strategy against coronavirus disease 2019 (COVID-19)

COVID-19 is an acute respiratory infection accompanied by pneumonia caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which has affected millions of people globally. To date, there are no highly efficient therapies for this infection. Probiotic bacteria can interact with the gut microbiome to strengthen the immune system, enhance immune responses, and induce appropriate immune signaling pathways. Several probiotics have been confirmed to reduce the duration of bacterial or viral infections. Immune fitness may be one of the approaches by which protection against viral infections can be reinforced. In general, prevention is more efficient than therapy in fighting viral infections. Thus, probiotics have emerged as suitable candidates for controlling these infections. During the COVID-19 pandemic, any approach with the capacity to induce mucosal and systemic reactions could potentially be useful. Here, we summarize findings regarding the effectiveness of various probiotics for preventing virus-induced respiratory infectious diseases, especially those that could be employed for COVID-19 patients. However, the benefits of probiotics are strain-specific, and it is necessary to identify the bacterial strains that are scientifically established to be beneficial.

A randomized controlled trial of different young child formulas on upper respiratory and gastrointestinal tract infections in Chinese toddlers

BACKGROUND

Bioactive proteins and human milk oligosaccharides (HMOs), important ingredients in breast milk, that protect against infections are lacking in young child formula (YCF). This study investigated the effects of new YCFs on respiratory and gastrointestinal infections in toddlers.

METHODS

Four hundred and sixty one healthy Chinese children aged 1-2.5 years were recruited in this randomized, controlled, double-blind, parallel-group clinical trial of different YCFs. They were randomly assigned to either standard milk formula (YCF-Ref) or one of three new YCFs containing bioactive proteins and/or the HMO 2'-fucosyllactose (2'-FL) and/or milk fat for six months. Primary outcomes were incidence of upper respiratory tract infection (URTI) and duration of gastrointestinal tract infections (GITI).

RESULTS

There were no significant between-group differences in primary outcomes. For secondary outcomes, subjects receiving 2'-FL-supplemented YCF had longer URTI. Subjects receiving YCF supplemented with milk fat and intact bioactive proteins, and 2'-FL at levels found in breast milk, had more GITI episodes and shorter time to first GITI but similar effects on URTI duration than YCF-Ref recipients. No effects on URTI and GITI were observed in toddlers receiving YCF with bioactive proteins at lower levels than breast milk. Occurrence of adverse events and anthropometry were similar in all groups.

CONCLUSIONS

All three YCFs supplemented with different combinations of intact bioactive proteins, 2'-FL, and milk fat are safe in toddlers. No difference is detected among YCFs on URTI incidence and GITI duration. Further studies are needed to verify these findings especially in infants who may benefit most from the immune-boosting effects of bioactive proteins and HMOs.

Lack of Efficacy of Lactobacillus reuteri DSM 17938 for the Treatment of Acute Gastroenteritis: A Randomized Controlled Trial

OBJECTIVE

To assess the efficacy of Lactobacillus reuteri DSM 17938 (L. reuteri) for the treatment of acute gastroenteritis in children.

STUDY DESIGN

Children younger than 5 years with acute diarrhea, defined as a change in stool consistency to a loose or liquid form and/or an increase in the frequency of evacuations (≥3 in 24 hours), lasting for no longer than 5 days, were eligible for inclusion. Participants (n = 100) were recruited from the pediatrics department of a Polish hospital and randomly assigned to receive L. reuteri in a dose 2 × 10 colony-forming units or placebo, for 5 days, in addition to standard rehydration therapy. The primary outcome measure was duration of diarrhea.

RESULTS

Ninety-one of the 100 children randomized were included in the intention-to-treat analysis (L. reuteri n = 44; placebo n = 47). The duration of diarrhea after randomization in both groups was similar (P = 0.6). The groups were also similar with respect to all secondary outcome measures, with one exception. Compared with the placebo group, patients in the L. reuteri group had a shorter duration of hospitalization (P = 0.048). Adverse events were similar in both groups.

CONCLUSIONS

Among children with acute gastroenteritis who were younger than 5 years of age, L. reuteri compared with placebo, as an adjunct to rehydration therapy, did not reduce the duration of diarrhea; however, it reduced the duration of hospitalization.

Probiotics for preventing acute otitis media in children

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.

In Vitro Antimicrobial Activity and Probiotic Potential of Bifidobacterium and Lactobacillus against Species of Clostridium

Many Clostridium species are found as commensal members of the intestinal microbiota. However, imbalances of the microbiota may lead to certain infections caused by these microorganisms, mainly Clostridium butyricum, Clostridium difficile, and Clostridium perfringens. In many cases, infection recurrence can occur after antibiotics, indicating the need for novel therapeutic options that act on the pathogens and also restore the microbiota. Herein, the in vitro antimicrobial activity and probiotic potential of clinical and reference strains of Bifidobacterium and Lactobacillus were investigated against Clostridium species. Antimicrobial activity was evaluated by the agar spot test and inhibition of gas production. Then, the probiotic potential of selected strains was assessed by analyzing their coaggregation ability, adhesive properties to host cells and mucin, tolerance to acidic pH and bile salts, and antimicrobial susceptibility profiles. Lactobacillus plantarum ATCC 8014 was the most promising strain based on its inhibitory activity against Clostridium spp. Also, this strain met criteria to be considered a probiotic based on its coaggregation ability, adhesive properties, and tolerance to harsh pH and bile acid salt conditions. The results indicate that among the studied strains, L. plantarum ATCC 8014 presents probiotic potential for controlling infections induced by the studied Clostridium species and should be further evaluated in in vivo animal models.

Lactobacillus rhamnosus GG can protect malnourished children

Malnutrition affects virtually all organ systems, and malnourished children are more prone to infections. These children have dysbiosis, but probiotics can restore the disrupted gut microbiome. We investigated the protective effects of Lactobacillus rhamnosus GG in malnourished children in terms of incidence of infection, and anthropometric and metabolic parameters. 50 intervention and 50 control patients, aged 6 months to 5 years, with body weight and height below -2 SD, were randomly and prospectively recruited. The controls received a calorie and protein-appropriate diet for 3 months, while the study group additionally received approximately 10⁹ L. rhamnosus GG for 3 months. Infection episodes and nutritional status were compared between the groups. 38 intervention, 33 control patients completed the study and the two groups were similar at baseline. The study group had fewer upper respiratory tract infections and gastroenteritis episodes at each month and at the end of the study. Children in the study group experienced fewer total upper respiratory infections and urinary tract infections. Hospitalisation was more frequent in the control group during the third month and at the end of the study. Total infection numbers were higher in the control group at each month and at the end of the study (P<0.001 for each). Increments in body mass index (BMI) and BMI Z-scores were more pronounced in the study group (P=0.008 and P=0.02, respectively). Daily prophylactic use of L. rhamnosus GG at 10⁹ bacteria in malnourished children prevents most infections and improves nutritional status when used together with appropriate diet.

Acute Infectious Diarrhea

Acute infectious diarrhea (AID) is one of the most common diseases in pediatric age with relevant burden both in high- and in low-income countries.Thanks to their direct action on enterocyte functions and indirect actions on mucosal and systemic immune system and intestinal microenvironment, probiotics are an ideal intervention to manage AID in childhood. However, their efficacy is strictly related to strains and indications, and practitioners should take this information into account in clinical practice.This chapter summarizes the main mechanisms of action of probiotics in AID, with a focus on proof of efficacy supporting their use in prevention and treatment of infant AID.The use of selected strains in appropriate doses is strongly recommended by guidelines of AID, based on large and consistent proofs of efficacy and safety. At present, therapy with probiotics of AID is arguably the strongest indication for probiotics in medicine. Future research should investigate probiotic efficacy in at-risk populations and settings where the evidence is missing.Their role in prevention of AID is however questionable in healthy population, whereas it should be considered in at-risk population. Evidence for prevention of diarrhea in day-care centers and communities is lacking, but consistent evidence supports efficacy in prevention of hospital acquired diarrhea.Overall, AID is the most convincing area for probiotic use in children, and effective strains should be used early after onset of symptoms.

Probiotics in human health and disease: from nutribiotics to pharmabiotics

Probiotics are the most useful tools for balancing the gut microbiota and thereby influencing human health and disease. Probiotics have a range of effects, from those on nutritional status to medical conditions throughout the body from the gut to non-intestinal body sites such as the brain and skin. Research interest in probiotics with nutritive claims (categorized as nutribiotics) has evolved into interest in therapeutic and pharmacological probiotics with health claims (pharmabiotics). The concept of pharmabiotics emerged only two decades ago, and the new categorization of probiotics to nutribiotics and pharmabiotics was recently suggested, which are under the different regulation depending on that they are food or drug. Information of the gut microbiome has been continuously accumulating, which will make possible the gut microbiome-based healthcare in the future, when nutribiotics show potential for maintaining health while pharmabiotics are effective therapeutic tools for human diseases. This review describes the current understanding in the conceptualization and classification of probiotics. Here, we reviewed probiotics as nutribiotics with nutritional functions and pharmabiotics with pharmaceutic functions in different diseases.

The impact of human activities and lifestyles on the interlinked microbiota and health of humans and of ecosystems

Plants, animals and humans, are colonized by microorganisms (microbiota) and transiently exposed to countless others. The microbiota affects the development and function of essentially all organ systems, and contributes to adaptation and evolution, while protecting against pathogenic microorganisms and toxins. Genetics and lifestyle factors, including diet, antibiotics and other drugs, and exposure to the natural environment, affect the composition of the microbiota, which influences host health through modulation of interrelated physiological systems. These include immune system development and regulation, metabolic and endocrine pathways, brain function and epigenetic modification of the genome. Importantly, parental microbiotas have transgenerational impacts on the health of progeny. Humans, animals and plants share similar relationships with microbes. Research paradigms from humans and other mammals, amphibians, insects, planktonic crustaceans and plants demonstrate the influence of environmental microbial ecosystems on the microbiota and health of organisms, and indicate links between environmental and internal microbial diversity and good health. Therefore, overlapping compositions, and interconnected roles of microbes in human, animal and plant health should be considered within the broader context of terrestrial and aquatic microbial ecosystems that are challenged by the human lifestyle and by agricultural and industrial activities. Here, we propose research priorities and organizational, educational and administrative measures that will help to identify safe microbe-associated health-promoting modalities and practices. In the spirit of an expanding version of "One health" that includes environmental health and its relation to human cultures and habits (EcoHealth), we urge that the lifestyle-microbiota-human health nexus be taken into account in societal decision making.

Role of Lactobacillus reuteri in Human Health and Diseases

Lactobacillus reuteri (L. reuteri) is a well-studied probiotic bacterium that can colonize a large number of mammals. In humans, L. reuteri is found in different body sites, including the gastrointestinal tract, urinary tract, skin, and breast milk. The abundance of L. reuteri varies among different individuals. Several beneficial effects of L. reuteri have been noted. First, L. reuteri can produce antimicrobial molecules, such as organic acids, ethanol, and reuterin. Due to its antimicrobial activity, L. reuteri is able to inhibit the colonization of pathogenic microbes and remodel the commensal microbiota composition in the host. Second, L. reuteri can benefit the host immune system. For instance, some L. reuteri strains can reduce the production of pro-inflammatory cytokines while promoting regulatory T cell development and function. Third, bearing the ability to strengthen the intestinal barrier, the colonization of L. reuteri may decrease the microbial translocation from the gut lumen to the tissues. Microbial translocation across the intestinal epithelium has been hypothesized as an initiator of inflammation. Therefore, inflammatory diseases, including those located in the gut as well as in remote tissues, may be ameliorated by increasing the colonization of L. reuteri. Notably, the decrease in the abundance of L. reuteri in humans in the past decades is correlated with an increase in the incidences of inflammatory diseases over the same period of time. Direct supplementation or prebiotic modulation of L. reuteri may be an attractive preventive and/or therapeutic avenue against inflammatory diseases.

Immune-Mediated Mechanisms of Action of Probiotics and Synbiotics in Treating Pediatric Intestinal Diseases

The pediatric population is continually at risk of developing infectious and inflammatory diseases. The treatment for infections, particularly gastrointestinal conditions, focuses on oral or intravenous rehydration, nutritional support and, in certain case, antibiotics. Over the past decade, the probiotics and synbiotics administration for the prevention and treatment of different acute and chronic infectious diseases has dramatically increased. Probiotic microorganisms are primarily used as treatments because they can stimulate changes in the intestinal microbial ecosystem and improve the immunological status of the host. The beneficial impact of probiotics is mediated by different mechanisms. These mechanisms include the probiotics' capacity to increase the intestinal barrier function, to prevent bacterial transferation and to modulate inflammation through immune receptor cascade signaling, as well as their ability to regulate the expression of selected host intestinal genes. Nevertheless, with respect to pediatric intestinal diseases, information pertaining to these key mechanisms of action is scarce, particularly for immune-mediated mechanisms of action. In the present work, we review the biochemical and molecular mechanisms of action of probiotics and synbiotics that affect the immune system.

Lipoteichoic Acid of Probiotic Lactobacillus plantarum Attenuates Poly I:C-Induced IL-8 Production in Porcine Intestinal Epithelial Cells

Probiotics in livestock feed supplements are considered a replacement for antibiotics that enhance gastrointestinal immunity. Although bacterial cell wall components have been proposed to be associated with probiotic function, little evidence demonstrates that they are responsible for probiotic functions in livestock. The present study demonstrated that lipoteichoic acid (LTA) of Lactobacillus plantarum (Lp.LTA) confers anti-inflammatory responses in porcine intestinal epithelial cell line, IPEC-J2. A synthetic analog of viral double-stranded RNA, poly I:C, dose-dependently induced IL-8 production at the mRNA and protein levels in IPEC-J2 cells. Lp.LTA, but not lipoprotein or peptidoglycan from L. plantarum, exclusively suppressed poly I:C-induced IL-8 production. Compared with LTAs from other probiotic Lactobacillus strains including L. delbrueckii, L. sakei, and L. rhamnosus GG, Lp.LTA had higher potential to suppress poly I:C-induced IL-8 production. Dealanylated or deacylated Lp.LTA did not suppress poly I:C-induced IL-8 production, suggesting that D-alanine and lipid moieties in the Lp.LTA structure were responsible for the inhibition. Furthermore, Lp.LTA attenuated the phosphorylation of ERK and p38 kinase as well as the activation of NF-κB, resulting in decreased IL-8 production. Taken together, these results suggest that Lp.LTA acts as an effector molecule to inhibit viral pathogen-induced inflammatory responses in porcine intestinal epithelial cells.

Preventive Effect of Cow's Milk Fermented with Lactobacillus paracasei CBA L74 on Common Infectious Diseases in Children: A Multicenter Randomized Controlled Trial

Background: Fermented foods have been proposed to prevent common infectious diseases (CIDs) in children attending day care or preschool.

OBJECTIVES

To investigate the efficacy of dietary supplementation with cow's skim milk fermented with the probiotic Lactobacillus paracasei CBA L74 in reducing CIDs in children attending day care or preschool. Methods: Multicenter, randomized, double-blind, placebo-controlled trial on healthy children (aged 12-48 months) consuming daily 7 grams of cow's skim milk fermented with L. paracasei CBA L74 (group A), or placebo (maltodextrins group B) attending day care or preschool during the winter season. The main outcome was the proportion of children who experienced ≥1 episode of CID during a 3-month follow-up. Fecal biomarkers of innate (α- and β-defensins, cathelicidin) and acquired immunity (secretory IgA) were also monitored. Results: A total of 126 children (71 males, 56%) with a mean (SD) age of 33 (9) months completed the study, 66 in group A and 60 in group B. At intention to treat analysis, the proportion of children presenting ≥1 CID was 60% in group A vs. 83% in group B, corresponding to an absolute risk difference (ARD) of -23% (95% CI: -37% to -9%, p < 0.01). At per-protocol-analysis (PPA), the proportion of children presenting ≥1 CID was 18% in group A vs. 40% in group B, corresponding to an absolute risk difference (ARD) of -22% (95% CI: -37% to -6%, p < 0.01). PPA showed that the proportion of children presenting ≥1 acute gastroenteritis (AGE) was significantly lower in group A (18% vs. 40%, p < 0.05). The ARD for the occurrence of ≥1 AGE was -22% (95% CI: -37% to -6%, p < 0.01) in group A. Similar findings were obtained at PPA regarding the proportion of children presenting ≥1 upper respiratory tract infection (URTI), which was significantly lower in group A (51% vs. 74%, p < 0.05), corresponding to an ARD of -23% (95% CI: -40% to -7%, p < 0.01). Significant changes in innate and acquired immunity biomarkers were observed only in subjects in group A. Conclusions: Dietary supplementation with cow's skim milk fermented with L. paracasei CBA L74 is an efficient strategy in preventing CIDs in children.

Network meta-analysis of probiotics to prevent respiratory infections in children and adolescents

Probiotics have emerged as a promising intervention for the prevention of respiratory tract infections (RTIs) in children. Assess the effect of probiotics on prevention of RTIs in children and adolescents. MEDLINE, EMBASE, LILACS, SCIELO, CINAHL, SCOPUS, and Web of Science. Key words: "respiratory tract infections" AND probiotics. Randomized controlled trials RCT assessing the effect of probiotics on RTIs in children and adolescents were included. Two reviewers, working independently, to identify studies that met the eligibility criteria. Main and secondary outcomes were RTIs and adverse effects, respectively. Twenty-one trials with 6.603 participants were included. Pairwise meta-analysis suggested that Lactobacillus casei rhamnosus (LCA) was the only effective probiotic to the rate of RTIs compared to placebo (RR0.38; Crl 0.19-0.45). Network analysis showed that the LCA exhibited 54.7% probability of being classified in first, while the probability of Lactobacillus fermentum CECT5716 (LFC) being last in the ranking was 15.3%. LCA showed no better effect compared to other probiotic strains by indirect analysis. This systematic review found a lack of evidence to support the effect of probiotic on the incidence rate of respiratory infections in children and adolescents. Pediatr Pulmonol. 2017;52:833-843. © 2017 Wiley Periodicals, Inc.

'Nutrimune®' and immune defence against pathogens in the gastrointestinal and upper respiratory tracts: evaluation of a health claim pursuant to Article 14 of Regulation (EC) No 1924/2006

Following an application from H.J. Heinz Supply Chain Europe B.V., submitted for authorisation of a health claim pursuant to Article 14 of Regulation (EC) No 1924/2006 via the Competent Authority of the Netherlands, the EFSA Panel on Dietetic Products, Nutrition and Allergies (NDA) was asked to deliver an opinion on the scientific substantiation of a health claim related to ‘Nutrimune^®’ and immune defence against pathogens in the gastrointestinal (GI) tract and upper respiratory tract (URT). The food ‘Nutrimune^®’ (a pasteurised cow's skim milk fermented with Lactobacillus paracasei CBA L74) which is the subject of the health claim is sufficiently characterised. The Panel considers that immune defence against pathogens in GI tract and URT is a beneficial physiological effect. One human intervention study from which conclusions can be drawn showed an effect of ‘Nutrimune^®’ on immune defence against pathogens in the GI tract and the URT, and the results from one animal study could support an effect of ‘Nutrimune^®’ on defence against pathogens in the GI tract. However, there were inconsistencies in the reporting of the process and criteria used for the diagnosis of URTI in the human intervention study, the results of this study have not been replicated, and no evidence was provided for a plausible mechanism by which ‘Nutrimune^®’ could exert the claimed effect in vivo in humans. The Panel concludes that the evidence provided is insufficient to establish a cause and effect relationship between the consumption of ‘Nutrimune^®’ and immune defence against pathogens in the gastrointestinal and upper respiratory tracts.

This publication is linked to the following EFSA Supporting Publications article: http://onlinelibrary.wiley.com/doi/10.2903/sp.efsa.2017.EN-1267/full

Effect of Formula Containing Lactobacillus reuteri DSM 17938 on Fecal Microbiota of Infants Born by Cesarean-Section

OBJECTIVES

Microbiota modulation by probiotics in infants born by cesarean (C)-section is poorly understood. We aimed at assessing the response of C-section-delivered infant microbiota to a formula containing Lactobacillus reuteri Deutsche Sammlung von Mikroorganismen und Zellkulturen GmbH (DSM) 17938 and comparing it with that of vaginally delivered infants.

METHODS

Infants delivered by C-section (C) and vaginally (V) were randomized to receive either control formula (CCt, n = 10; VCt, n = 10) or the same formula containing L reuteri (CLr, n = 11; VLr, n = 9) within 72 hours following birth. Stool samples were collected at 2 weeks and 4 months of age. Microbial DNA was extracted, amplified, and pyrosequenced.

RESULTS

The phylogenetic profiles of the CLr, VCt, and VLr microbiota were not significantly different at any age but diverged from that of CCt at 2 weeks. Compared with VCt, CCt displayed lower Bifidobacterium and higher Enterobacter, unclassified Enterobacteriaceae, Enterococcus, Clostridium, and unclassified Clostridiaceae relative abundance at 2 weeks, as well as lower Collinsella and higher Enterococcus and Coprococcus abundance at 4 months. The level of most of these taxa was not significantly different between the CLr and the vaginal-delivery groups. Compared with VCt, the only difference observed in VLr microbiota was higher Lactobacillus at the 2 study ages and Coprococcus at 4 months.

CONCLUSIONS

Our results show that a formula containing L reuteri DSM 17938 does not essentially alter the microbiota in vaginally born infants. In C-section-delivered infants, however, this strain seems to play the role of keystone species by modulating the early development of the microbiota toward the composition found after vaginal delivery.

Systematic review with meta-analysis: Lactobacillus reuteri DSM 17938 for diarrhoeal diseases in children

BACKGROUND

Not all probiotics are equal.

AIM

To investigate the efficacy of Lactobacillus reuteri DSM 17938 (L. reuteri) in the management of various types of diarrhoeal diseases in children.

METHODS

Medline, Embase, the Cochrane Library, trial registries and reference lists of included studies were searched in January 2016, with no language restriction, for randomised controlled trials (RCTs).

RESULTS

Eight RCTs (n = 1229) met the inclusion criteria. In treatment trials, L. reuteri administration reduced the duration of diarrhoea (three RCTs, n = 256, mean difference, MD -24.82 h, 95% CI -38.8 to -10.8) and increased the cure rate on day 1 and day 2. However, heterogeneity and wide confidence intervals call for caution in interpreting results. In preventive trials carried out in hospitalised children, based on the findings from two RCTs (n = 290), there was no significant reduction in the risk of nosocomial diarrhoea, rotavirus diarrhoea or diarrhoea of any origin with L. reuteri administration. Based on one RCT (n = 97), there was no effect of L. reuteri on the risk of antibiotic-associated diarrhoea. However, the evidence is limited because the overall frequency of diarrhoea was surprisingly low. In preventive studies carried out in apparently healthy children, L. reuteri reduced diarrhoeal outcomes in one RCT; the evidence from another trial was less convincing.

CONCLUSIONS

In therapeutic settings, L. reuteri administration reduces the duration of diarrhoea and increases the chance of cure. In preventive settings, L. reuteri has the potential to reduce the risk of community-acquired diarrhoea in otherwise healthy children.

What are the indications for using probiotics in children?

The health benefits of probiotics have been the subject of extensive research. Still, some questions are being repeatedly asked: should one use or not use probiotics? If yes, how and when should probiotics be used? The purpose of this review is to summarise current evidence on specific probiotics' efficacy and safety to help healthcare professionals make evidence-based decisions on the indications for using specific probiotic strains or combinations in children. To identify relevant data, searches of MEDLINE and the Cochrane Library databases were performed in July 2015 to locate randomised controlled trials or their meta-analyses published in the last five years. The MEDLINE database also was searched for evidence-based clinical practice guidelines, developed by scientific societies. Considering that probiotics have strain-specific effects, the main focus was on data on individual probiotic strains, not on probiotics in general.

Bifidobacterium bifidum R0071 decreases stress-associated diarrhoea-related symptoms and self-reported stress: a secondary analysis of a randomised trial

Psychological stress is associated with gastrointestinal (GI) distress. This secondary analysis from a randomised, double-blind, placebo-controlled study examined whether three different probiotics could normalise self-reported stress-associated GI discomfort and reduce overall self-reported stress. Undergraduate students (n=581) received Lactobacillus helveticus R0052, Bifidobacterium longum ssp. infantis R0033, Bifidobacterium bifidum R0071, or placebo. Participants self-reported 2 outcomes for a 6-week period, which included final academic exams: daily level of stress (0=no stress to 10=extremely stressed) and weekly three diarrhoea-related symptoms (DS, 1=no discomfort to 7=severe discomfort) using the GI Symptom Rating Scale. Self-reported stress was positively related to DS (P=0.0068). Mean DS scores were lower with B. bifidum versus placebo at week 2 at the average level of stress and the average body mass index (BMI). DS scores were lower with B. bifidum at week 5 versus week 0 and 1 and with B. infantis R0033 at week 6 versus week 0. DS scores were higher when antibiotics were used in the prior week with placebo (P=0.0092). DS were not different with or without antibiotic use with the probiotics. Only B. bifidum had an effect on self-reported stress scores (P=0.0086). The self-reported stress score was also dependent on hours of sleep per day where it decreased by 0.13 for each additional hour of sleep. During a stressful period, B. bifidum R0071 decreases DS and self-reported stress scores. This trial was registered at clinicaltrials.gov as NCT01709825.

Probiotics and prebiotics in infectious gastroenteritis

Acute gastroenteritis (AGE) is worldwide a common problem in infants and children. While AGE is still an important cause of morbidity and mortality in developing countries, it is mainly a problem with high socioeconomic impact in the rest of the world. Oral rehydration solutions (ORS) and rapid refeeding remain the cornerstone of the management. However, ORS does not decrease the duration of diarrhea. There is evidence that selected strains of probiotics decrease the duration of AGE with 24 h, both in ambulatory care and in hospitalized children, resulting also in a decrease of the duration of hospitalization. Synbiotics are equally effective as probiotics alone, but prebiotics are not effective. Both pro- and prebiotics have limited to no efficacy in the prevention of AGE. The administration of pre- and probiotics is considered to be safe, even in newborns. Only these pre-, pro and synbiotics that have been clinically tested can be recommended.

Effectiveness of Lactobacillus reuteri DSM 17938 for the Prevention of Nosocomial Diarrhea in Children: A Randomized, Double-blind, Placebo-controlled Trial

BACKGROUND

Multiple studies of probiotics used to prevent nosocomial diarrhea have provided conflicting results. The effects likely depend on the probiotic strain and/or dosage. The aim of this study was to assess the effectiveness of Lactobacillus reuteri DSM 17938 (L. reuteri; daily dose of 1 × 10 colony forming units) for preventing nosocomial diarrhea in children.

METHODS

We conducted a multicenter, randomized, double-blind, placebo-controlled trial in 184 children, 1-48 months of age, admitted to the hospital for reasons other than diarrhea. A computer-generated randomization scheme was used to allocate participants to receive either L. reuteri (n = 91) at a daily dose of 1 × 10 colony forming units, for the duration of hospitalization, or an identical appearing placebo (n = 93). Patients, study personnel and data analysts were blinded to assignment. The primary outcome was the occurrence of nosocomial diarrhea (≥3 loose or watery stools in 24 hours that occurred >72 hours after admission). Analysis was by intention-to-treat.

RESULTS

Baseline characteristics were similar in the 2 groups. Nosocomial diarrhea occurred in 13 (7.1%) children. No difference was found between the L. reuteri and the placebo groups (7/91 vs 6/93, respectively; relative risk: 1.19; 95% confidence interval: 0.43-3.27). There was also no difference between the L. reuteri and placebo groups for any of the secondary outcomes, including adverse effects. Rotavirus vaccination status had no effect on the results.

CONCLUSION

L. reuteri in the dosage regimen used was not effective in preventing nosocomial diarrhea in children.

Microbiota manipulation for weight change

Manipulation of the intestinal microbiota has been linked to weight changes and obesity. To explore the influence of specific agents that alter the intestinal flora on weight in different patient groups we conducted a meta-analysis of randomized controlled trials (RCTs) reporting on the effects of probiotics, prebiotics, synbiotics, and antibiotics on weight. We searched the Pubmed and Cochrane Library databases for trials on adults, children, and infants evaluating the effects of these substances on weight. Our primary outcome was weight change from baseline. Standardized mean differences (SMDs) with 95% confidence intervals were calculated. We identified and included 13 adult, 17 children, and 23 infant RCTs. Effects were opposite among adults and children, showing weight loss among adults (SMD -0.54 [-0.83, -0.25)) and minor weight gains among children (SMD 0.20 [0.04, 0.36]) and infants (SMD 0.30 [-0.01, 0.62]) taking mainly Lactobacillus probiotic supplements. Heterogeneity was substantial in the adult and infant analyses and could not be explained by intervention or patient characteristics. Azithromycin administration in children with pulmonary disease was associated with weight gain (SMD 0.39 [0.24, 0.54]), without heterogeneity. A high risk of selective reporting and attrition bias was detected across the studies, making it difficult to draw firm conclusions. Overall, our meta-analysis suggests that there may be a role for probiotics in promoting weight loss in adults and weight gain in children, however additional studies are needed. Though we cannot recommend antibiotic administration for weight manipulation, its use provides advantageous weight gain in children with cystic fibrosis and bronchiectasis.

Cow's milk and rice fermented with Lactobacillus paracasei CBA L74 prevent infectious diseases in children: A randomized controlled trial

BACKGROUND & AIM

Fermented foods have been proposed for the prevention of infectious diseases. We evaluated the efficacy of fermented foods in reducing common infectious diseases (CIDs) in children attending daycare.

METHODS

Prospective randomized, double-blind, placebo-controlled trial (registered under Clinical Trials.gov identifier NCT01909128) on healthy children (aged 12-48 months) consuming daily cow's milk (group A) or rice (group B) fermented with Lactobacillus paracasei CBA L74, or placebo (group C) for three months during the winter season. The main study outcome was the proportion of children who experienced at least one CID. All CIDs were diagnosed by family pediatricians. Fecal concentrations of innate (α- and β-defensins and cathelicidin LL-37) and acquired immunity biomarkers (secretory IgA) were also evaluated.

RESULTS

377 children (193 males, 51%) with a mean (SD) age of 32 (10) months completed the study: 137 in group A, 118 in group B and 122 in group C. Intention-to-treat analysis showed that the proportion of children who experienced at least one CID was lower in group A (51.8%) and B (65.9%) compared to group C (80.3%). Per-protocol analysis showed that the proportion of children presenting upper respiratory tract infections was lower in group A (48.2%) and group B (58.5%) compared with group C (70.5%). The proportion of children presenting acute gastroenteritis was also lower in group A (13.1%) and group B (19.5%) compared with group C (31.1%). A net increase of all fecal biomarkers of innate and acquired immunity was observed for groups A and B compared to group C. Moreover, there was a negative association between fecal biomarkers and the occurrence of CID.

CONCLUSION

Dietary supplementation with cow's milk or rice fermented with L. paracasei CBA L74 prevents CIDs in children attending daycare possibly by means of a stimulation of innate and acquired immunity.

Use of probiotics in pediatric infectious diseases

We summarize current evidence and recommendations for the use of probiotics in childhood infectious diseases. Probiotics may be of benefit in treating acute infectious diarrhea and reducing antibiotic-associated diarrhea. Potential benefits of probiotic on prevention of traveler's diarrhea,Clostridium difficile-associated diarrhea, side effects of triple therapy in Helicobacter pylori eradication, necrotizing enterocolitis, acute diarrhea, acute respiratory infections and recurrent urinary tract infections remain unclear. More studies are needed to investigate optimal strain, dosage, bioavailability of drops and tablets, duration of treatment and safety. Probiotics and recombinant probiotic strain represent a promising source of molecules for the development of novel anti-infectious therapy.

Role of short-term use of L. acidophilus DDS-1 and B. lactis UABLA-12 in acute respiratory infections in children: a randomized controlled trial

BACKGROUND/OBJECTIVES

Evidence suggests that the long-term consumption of probiotics may help in reducing the incidence of or modifying acute respiratory infection (ARI). We assessed the role of the short-term use of probiotics in ARI in children.

SUBJECTS/METHODS

This was a randomized, double-blind, controlled study that enrolled 315 children with 90 dropouts. On the first day of appearance of a sick household member, otherwise healthy children of both sexes aged 3-12 years were allocated to receive Lactobacillus acidophilus DDS-1 and Bifidobacterium lactis UABLA-12 (Up4-Junior) in a dose of 5 billion colony-forming units daily with 50 mg of fructooligosaccharide (the probiotic group) or rice maltodexrin (the control group). Test supplementation and follow-up lasted for 2 weeks or until the end of the secondary ARI in a child. The primary outcome measure was the incidence of ARI. Time to resolution and the severity of ARI served the secondary outcome measures.

RESULTS

In all, 64 of 113 children in the probiotic group (57%) and 73 of 112 children in the control group (65%) developed ARI (P=0.261). Time to resolution of the secondary ARI was shorter in the probiotic group (5.0 (interquartile range (IQR): 4.0-6.0) vs 7.0 (IQR: 6.0-8.0) days, P<0.001). The median severity of ARI was 240 (IQR: 163-350) score-days in the probiotic vs 525 (IQR: 364-736) score-days in the control group (P<0.001).

CONCLUSIONS

The short-term use of probiotics does not reduce the incidence, but shortens ARI in preschool and elementary school children.

Secretory diarrhoea: mechanisms and emerging therapies

Diarrhoeal disease remains a major health burden worldwide. Secretory diarrhoeas are caused by certain bacterial and viral infections, inflammatory processes, drugs and genetic disorders. Fluid secretion across the intestinal epithelium in secretory diarrhoeas involves multiple ion and solute transporters, as well as activation of cyclic nucleotide and Ca(2+) signalling pathways. In many secretory diarrhoeas, activation of Cl(-) channels in the apical membrane of enterocytes, including the cystic fibrosis transmembrane conductance regulator and Ca(2+)-activated Cl(-) channels, increases fluid secretion, while inhibition of Na(+) transport reduces fluid absorption. Current treatment of diarrhoea includes replacement of fluid and electrolyte losses using oral rehydration solutions, and drugs targeting intestinal motility or fluid secretion. Therapeutics in the development pipeline target intestinal ion channels and transporters, regulatory proteins and cell surface receptors. This Review describes pathogenic mechanisms of secretory diarrhoea, current and emerging therapeutics, and the challenges in developing antidiarrhoeal therapeutics.

Novel microbiome-based therapeutics for chronic rhinosinusitis

The human microbiome, i.e. the collection of microbes that live on, in and interact with the human body, is extraordinarily diverse; microbiota have been detected in every tissue of the human body interrogated to date. Resident microbiota interact extensively with immune cells and epithelia at mucosal surfaces including the airways, and chronic inflammatory and allergic respiratory disorders are associated with dysbiosis of the airway microbiome. Chronic rhinosinusitis (CRS) is a heterogeneous disease with a large socioeconomic impact, and recent studies have shown that sinus inflammation is associated with decreased sinus bacterial diversity and the concomitant enrichment of specific sinus pathogens. Here, we discuss the potential role for probiotic supplementation for CRS in light of this increasing understanding of the airway microbiome and microbial interactions with the host. We focus on the ecological significance of microbiome-based probiotic supplementation and potential interactions with the gastrointestinal tract and consider microbial administration methods for treatment of CRS.

Lactobacillus reuteri DSM 17938 shortens acute infectious diarrhea in a pediatric outpatient setting

OBJECTIVE

Two randomized controlled clinical trials have shown that Lactobacillus (L) reuteri DSM 17938 reduces the duration of diarrhea in children hospitalized due to acute infectious diarrhea. This was the first trial evaluating the efficacy of L. reuteri DSM 17938 in outpatient children with acute infectious diarrhea.

METHODS

This was a multicenter, randomized, single-blinded, case control clinical trial in children with acute watery diarrhea. A total of 64 children who presented at outpatient clinics were enrolled. The probiotic group received 1×10(8)CFU L. reuteri DSM 17938 for five days in addition to oral rehydration solution (ORS) and the second group was treated with ORS only. The primary endpoint was the duration of diarrhea (in hours). The secondary endpoint was the number of children with diarrhea at each day of the five days of intervention. Adverse events were also recorded.

RESULTS

The mean duration of diarrhea was significantly reduced in the L. reuteri group compared to the control group (approximately 15h, 60.4±24.5h [95% CI: 51.0-69.7h] vs. 74.3±15.3h [95% CI: 68.7-79.9h], p<0.05). The percentage of children with diarrhea was lower in the L. reuteri group (13/29; 44.8%) after 48h than the control group (27/31; 87%; RR: 0.51; 95% CI: 0.34-0.79, p<0.01). From the 72nd hour of intervention onwards, there was no difference between the two groups in the percentage of children with diarrhea. No adverse effects related to L. reuteri were noted.

CONCLUSION

L. reuteri DSM 17938 is effective, safe, and well-tolerated in outpatient children with acute infectious diarrhea.

A double blind randomized trial showing probiotics to be ineffective in acute diarrhea in Indonesian children

OBJECTIVE

To investigate the efficacy of probiotics added to oral rehydration solution and zinc in the treatment of acute infectious diarrhea in Indonesian children.

METHODS

A prospective randomized double blind placebo-controlled trial was performed to test the efficacy of a probiotic food supplement in 112 children in the Kenari subdistrict, central Jakarta, aged 6-36 mo with acute infectious diarrhea and moderate dehydration. The supplemented group was given standard therapy (oral rehydration solution and zinc) and the probiotic strains Lactobacillus (L.) rhamnosus R0011 1.9 × 10(9) colony forming units (cfu) and L. acidophilus R0052 0.1 × 10(9) cfu/d for 7 d, while the control group was given standard therapy and placebo.

RESULTS

Median duration of diarrhea was 68.5 h (range 13-165) in the supplemented and 61.5 h (range 21-166) in the control group (P = 0.596). Median daily frequency of defecation until diarrhea stopped was 5.0 in the supplemented vs. 5.5 in the control group (P = 0.795).

CONCLUSIONS

This probiotic food supplement tested did not reduce the duration of acute infectious diarrhea as compared to oral rehydration and zinc.

Safety of probiotics and synbiotics in children under 18 years of age

This study aimed to systematically evaluate safety of probiotics and synbiotics in children ageing 0-18 years. This study is the third and final part in a safety trilogy and an update is provided using the most recent available clinical data (2008-2013) by means of the Common Terminology Clinical Adverse Events (CTCAE version 4.0) classification. Safety aspects are represented and related to number of participants per probiotic strain/culture, study duration, dosage, clinical condition and selected afflictions. Analysis of 74 clinical studies indicated that probiotic and/or synbiotic administration in children is safe with regard to the specific evaluated strains, dosages and duration. The population of children include healthy, immune compromised and obese subjects, as well as subjects with intestinal disorders, infections and inflammatory disorders. This study revealed no major safety concerns, as the adverse events (AEs) were unrelated, or not suspected to be related, to the probiotic or synbiotic product. In general the study products were well tolerated. Overall, AEs occurred more frequent in the control arm compared to children receiving probiotics and/or synbiotics. Furthermore, the results indicate inadequate reporting and classification of AEs in the majority of the studies. In addition, generalizability of conclusions are greatly limited by the inconsistent, imprecise and potentially incomplete reporting as well as the variation in probiotic strains, dosages, administration regimes, study populations and reported outcomes.