Positive Effect of Probiotics on Constipation in Children: A Systematic Review and Meta-Analysis of Six Randomized Controlled Trials

Probiotics in the New Era of Human Milk Oligosaccharides (HMOs): HMO Utilization and Beneficial Effects of Bifidobacterium longum subsp. infantis M-63 on Infant Health

A healthy gut microbiome is crucial for the immune system and overall development of infants. Bifidobacterium has been known to be a predominant species in the infant gut; however, an emerging concern is the apparent loss of this genus, in particular, Bifidobacterium longum subsp. infantis (B. infantis) in the gut microbiome of infants in industrialized nations, underscoring the importance of restoring this beneficial bacterium. With the growing understanding of the gut microbiome, probiotics, especially infant-type human-residential bifidobacteria (HRB) strains like B. infantis, are gaining prominence for their unique ability to utilize HMOs and positively influence infant health. This article delves into the physiology of a probiotic strain, B. infantis M-63, its symbiotic relationship with HMOs, and its potential in improving gastrointestinal and allergic conditions in infants and children. Moreover, this article critically assesses the role of HMOs and the emerging trend of supplementing infant formulas with the prebiotic HMOs, which serve as fuel for beneficial gut bacteria, thereby emulating the protective effects of breastfeeding. The review highlights the potential of combining B. infantis M-63 with HMOs as a feasible strategy to improve health outcomes in infants and children, acknowledging the complexities and requirements for further research in this area.

The oral cavity and intestinal microbiome in children with functional constipation

Constipation is a widespread problem in paediatric practice, affecting almost 30% of children. One of the key causal factors of constipation may be disturbances in the homeostasis of the gastrointestinal microbiome. The aim of the study was to determine whether the oral and fecal microbiomes differ between children with and without constipation. A total of 91 children over three years of age were included in the study. Of these, 57 were qualified to a group with constipation, and 34 to a group without. The saliva and stool microbiomes were evaluated using 16S rRNA gene amplicon sequencing. Functional constipation was associated with characteristic bacterial taxa in the fecal microbiota. Statistically significant differences were found at the family level: Burkholderiaceae (q = 0.047), Christensenellaceae (q = 0.047), Chlostridiaceae (q = 0.047) were significantly less abundant in the constipation group, while the Tannerellaceae (q = 0.007) were more abundant. At the genus level, the significant differences were observed for rare genera, including Christensenellaceae r-7 (q = 2.88 × 10-2), Fusicatenibacter (q = 2.88 × 10-2), Parabacteroides (q = 1.63 × 10-2), Romboutsia (q = 3.19 × 10-2) and Subdoligranulum (q = 1.17 × 10-2). All of them were less abundant in children with constipation. With the exception of significant taxonomic changes affecting only feces, no differences were found in the alpha and beta diversity of feces and saliva. Children with functional constipation demonstrated significant differences in the abundance of specific bacteria in the stool microbiome compared to healthy children. It is possible that the rare genera identified in our study which were less abundant in the constipated patients (Christensellaceae r-7, Fusicatenibacter, Parabacteroides, Romboutsia and Subdoligranulum) may play a role in protection against constipation. No significant differences were observed between the two groups with regard to the saliva microbiome.

Probiotics for functional constipation in children: an overview of overlapping systematic reviews

Background

This overview of systematic reviews (SRs) and meta-analysis (MAs) aimed to systematically collate, appraise and synthesize evidence of probiotics for functional constipation (FC) in children.

Methods

SRs/MAs of probiotics for FC in children were systematic identified by searching Cochrane Library, PubMed, Embase, and Web of science. Assessment of Multiple Systematic Reviews 2 (AMSTAR-2), Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), and Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) were unitized by two reviewers independently to assess the methodological quality, reporting quality, and quality of evidence, respectively.

Results

Seven SRs/MAs met the eligibility criteria and were included in this study. According to AMSTAR-2, a very low methodological quality assessment was given to the included SRs/MAs due to the limitations of items 2, 4 and 7. For the PRISMA statement, the overall quality of reporting was unsatisfactory due to the lack of reporting on protocol, risk of bias across studies, synthesis of results, and additional analysis. According to GRADE, the quality of evidence for outcomes was rated as very low to moderate.

Conclusions

Probiotics may be beneficial in improving FC in children. Because of limitations and inconsistent conclusions, further rigorous, normative and comprehensive SRs/MAs are needed to provide robust evidence for definitive conclusions.

Effect of probiotics intake on constipation in children: an umbrella review

Based on existing systematic reviews and meta-analyse we conducted this comprehensive review to evaluate the quality, effectiveness, and bias of evidence regarding the relationship between probiotic intake and improved constipation outcomes in children. A total of nine meta-analyses and systematic reviews were extracted from 628 articles, summarizing seven effectiveness indicators and the incidence of adverse reactions in the treatment of constipation. According to the results, our study revealed that the intake of probiotics in children with FC significantly improved treatment success rate and defecation frequency, while decreased the recurrence rate of constipation. However, no significant association was detected between probiotics intake and frequency of abdominal pain, stool consistency, frequency of defecation pain, frequency of fecal incontinence of children with FC. The intake of probiotics did not increase the incidence of adverse reactions and demonstrated good safety.

A Double-Blind, Randomized, Placebo-Controlled Trial of the Effect of 1-Kestose on Defecation Habits in Constipated Kindergarten Children: A Pilot Study

Constipation is common in children and can significantly affect quality of life. Prebiotics are reportedly helpful for constipation in adults, but few studies have examined their use in young children. In this study, the effect of 1-kestose (kestose), which has excellent bifidobacterial growth properties, on constipation in kindergarten children (n = 11) was compared with that of maltose (n = 12) in a randomized, double-blind study. Three grams of kestose per day for 8 weeks did not affect stool properties, but significantly increased the number of defecations per week (Median; 3 → 4 times/week, p = 0.017, effect size = 0.53). A significant decrease in Intestinibacter, a trend toward increased bifidobacteria, and a trend toward decreased Clostridium sensu stricto were observed after kestose ingestion, while concentrations of short-chain fatty acids in stools were unchanged.

A narrative review on the diagnosis and management of constipation in infants

INTRODUCTION

Functional constipation is one of the common disorders of gut-brain interaction in infancy, and decreases the quality of life of infants and parents.

AREAS COVERED

Relevant articles up to November 2022 were reviewed. We searched in PubMed, Google Scholar, and MEDLINE for guidelines, position papers, reviews, and randomized controlled trials on infant constipation.

EXPERT OPINION

Randomized controlled trials in this specific age group are mostly limited to trials with infant formula. The prevalence of infant constipation in formula-fed infants is decreasing, and can be associated with adaptations in formula composition. While the supplementation of infant formula with pro-, pre- and/or synbiotics decreases the prevalence of constipation, their efficacy in constipated infants is disappointing. There is limited evidence to support the addition of magnesium to infant formula to treat constipation. The evidence for the efficacy and safety of polyethylene glycol in children < 2 years has expanded over the past years. The administration of lactulose or polyethylene glycol is the preferred medical management, in case nutritional management does result in insufficient improvement.

Efficacy and safety of probiotics in Parkinson's constipation: A systematic review and meta-analysis

Background: Parkinson's disease (PD) is the most common neurodegenerative disease closely related to the immune system, among whose prodromes constipation is a representative symptom. Recent Randomized Controlled Trials (RCTs) have proved that probiotics can be used to effectively treat PD constipation, but the results are inconsistent. We performed a meta-analysis to assess the efficacy and safety of probiotic therapy on Parkinson's constipation. Methods: Questions about the research focus were constructed based on the Participants, Intervention, Comparison and Outcomes (PICO) Criteria. We searched electronic databases such as PubMed, Web of Science, EMBASE, Scopus, EBSCO, Cochrane and Google Scholar until March 2022 for eligible literatures. Our primary endpoints were stool frequency, stool consistency, the number of laxatives uses, UPDRS-III scores and adverse events. Results: 12 eligible studies (n = 818 patients) met the inclusion and endpoint criteria. Meta-analysis results showed that constipation symptoms were improved after probiotic treatment, including an increased stool frequency (WMD = 0.94, 95% CI:0.53 to 1.34; OR = 3.22, 95% CI:1.97-5.29), an improved stool consistency (WMD = 1.46, 95% CI:0.54-2.37), a reduced use of laxatives (WMD = -0.72, 95%CI: -1.04 to-0.41), and also a reduced Parkinson's UPDRS-III score (WMD = -6.58, 95%CI: -12.02 to -1.14); there was no significant difference in total adverse events (OR = 0.82, 95%CI:0.39-1.72). Conclusion: Our analysis suggests that probiotics can be used to improve the constipation and motor symptoms for patients with Parkinson's constipation, possibly by reducing the inflammatory response and improving gut-brain axis neuron function, whose safety also proved to be good.

Efficacy and Safety of Probiotics in Geriatric Patients with Constipation: Systematic Review and Meta-Analysis

BACKGROUND

Probiotics may be an effective alternative to traditional drug therapy for constipation in the elderly.

OBJECTIVE

To assess the efficacy and safety of probiotics in managing constipation among the elderly.

METHODS

Eight databases were queried for randomized controlled trials (RCTs) investigating probiotics' efficacy in addressing constipation among the elderly until January 2023. The meta-analysis was conducted employing R software version 4.2.2. The Cochrane risk of bias tool was utilized to evaluate the risk of bias, and the GRADE approach was employed to assess the credibility of the evidence concerning the efficacy of probiotics in treating constipation in older individuals.

RESULTS

A total of six RCTs involving 444 patients were included. Two studies were rated as low risk of bias. The meta-analysis findings revealed that probiotics, when compared to a placebo, led to an increase in stool frequency (MD = 1.02,95% CI [0.21, 2.07], p<0.05, very low quality), the probiotic group exhibited a notable impact on ameliorating symptoms associated with constipation (OR = 11.28, 95%CI [7.21, 17.64], p < 0.05, very low quality), no significant disparities were observed in terms of efforts to evacuate, manual maneuvers, and the incidence of adverse events (p>0.05).

CONCLUSION

The available evidence indicates a degree of uncertainty, ranging from low-to-very low, suggesting the efficacy of probiotics in augmenting bowel frequency and ameliorating constipation-related symptoms among elderly patients with constipation. Nevertheless, given the quality of the studies included, it is advisable to conduct further well-designed investigations with substantial sample sizes to substantiate the findings of this study.

Gastrointestinal Microbiome and Multiple Health Outcomes: Umbrella Review

In recent years, there has been growing concern about the impact of the gastrointestinal microbiome on human health outcomes. To clarify the evidence for a link between the gastrointestinal microbiome and a variety of health outcomes in humans, we conducted an all-encompassing review of meta-analyses and systematic reviews that included 195 meta-analyses containing 950 unique health outcomes. The gastrointestinal microbiome is related to mortality, gastrointestinal disease, immune and metabolic outcomes, neurological and psychiatric outcomes, maternal and infant outcomes, and other outcomes. Existing interventions for intestinal microbiota (such as probiotics, fecal microbiota transplant, etc.) are generally safe and beneficial to a variety of human health outcomes, but the quality of evidence is not high, and more detailed and well-designed randomized controlled trials are necessary.

Saccharomyces boulardii and Lactulose for Childhood Functional Constipation: A Multicenter Randomized Controlled Trial

Background/Aims

The effects of probiotics in children vary based on diseases and probiotic strains. We aim to investigate the effectiveness of Saccharomyces boulardii and lactulose for treating childhood functional constipation.

Methods

This open-label randomized controlled trial was conducted at 10 university hospitals in Korea. Children who were diagnosed with functional constipation were allocated to 3 groups (lactulose monotherapy, combination therapy, and S. boulardii monotherapy). The primary outcome was treatment success rate that was accordingly defined as ≥ 3 bowel movements without incontinence at week 12. The cumulative successful maintenance and drug maintenance rates without drug changes were calculated throughout the study period. We compared stool frequency, incontinence, consistency, and painful defecation at week 2 among the 3 groups.

Results

Overall, 187 children were assigned to the lactulose monotherapy (n = 69), combination therapy (n = 68), or S. boulardii monotherapy (n = 50) groups. The primary outcome was significantly higher in the lactulose monotherapy group (26.1%) or combination therapy group (41.2%) than in the S. boulardii monotherapy group (8.0%). The S. boulardii monotherapy group showed a significantly lower cumulative successful maintenance and drug maintenance rate than the other 2 groups. There were no significant intergroup differences in the frequency of defecation, incontinence, painful defecation, or stool consistency during the follow-up at week 2.

Conclusion

S. boulardii monotherapy was not superior to lactulose monotherapy or combination therapy and showed a higher drug change rate, supporting the current recommendation of probiotics in the treatment of childhood functional constipation.

MOLECULAR ASSESSMENT OF FECAL LACTOBACILLI POPULATIONS IN CHILDREN WITH FUNCTIONAL CONSTIPATION

BACKGROUND

Investigation of the gut-specific bacterial strains including lactobacilli is essential for understanding the bacterial etiology of constipation.

OBJECTIVE

This study aimed to compare the prevalence and quantity of intestinal lactobacilli in constipated children and healthy controls.

METHODS

Forty children fulfilling Rome IV criteria for functional constipation and 40 healthy controls were recruited. Fecal samples were analyzed using species-specific polymerase chain reaction followed by random amplified polymorphic DNA-PCR and quantitative real-time PCR.

RESULTS

Totally, seven different species of lactobacilli were detected. Out of 80 volunteers, 65 (81.3%) were culture and species-specific PCR positive from which 25 (38.46%) constipated children and 40 (61.54%) healthy subjects. The most prevalent species were L. paracasei 21 (32.3%) followed by L. plantarum 18 (27.7%) among both healthy and patient groups. Analysis of the RAPD dendrograms displayed that strains isolated from constipated and non-constipated children have similarity coefficients of more than 90%. The qPCR assays demonstrated constipated children had a lower amount of total lactobacilli population (per gram of feces) than healthy controls.

CONCLUSION

Our findings showed that the mere existence of various species of Lactobacillus in the gut does not enough to prevent some gastrointestinal disorders such as functional constipation, and their quantity plays a more important role.

Probiotics and Functional Gastrointestinal Disorders in Pediatric Age: A Narrative Review

Assessment and management of pain are essential components of pediatric care. Pain in pediatric age is characterized by relevant health and socio-economic consequences due to parental concern, medicalization, and long-term physical and psychological impact in children. Pathophysiological mechanisms of nociception include several pathways in which also individual perception and gut-brain axis seem to be involved. In this narrative review, we analyze the rational and the current clinical findings of probiotic use in the management of functional gastrointestinal disorders (FGID) in pediatric age, with special focus on infantile colic, irritable bowel syndrome, constipation, and gastroesophageal reflux. Some specific probiotics showed a significant reduction in crying and fussing compared to placebo in breastfed infants with colic, although their exact mechanism of action in this disorder remains poorly understood. In irritable bowel syndrome, a limited number of studies showed that specific strains of probiotics can improve abdominal pain/discomfort and bloating/gassiness, although data are still scarce. As for constipation, whilst some strains appear to reduce the number of hard stools in constipated children, the evidence is not adequate to support the use of probiotics in the management of functional constipation. Similarly, although some probiotic strains could promote gastric emptying with a potential improvement of functional symptoms related to gastroesophageal reflux, current evidence is insufficient to provide any specific recommendation for the prevention or treatment of gastroesophageal reflux. In conclusion, probiotics have been proposed as part of management of pain in functional gastrointestinal disorders in pediatric age, but mechanisms are still poorly understood and evidence to guide clinical practice is currently inadequate.

Probiotics Regulating Inflammation via NLRP3 Inflammasome Modulation: A Potential Therapeutic Approach for COVID-19

Inflammasomes are cytoplasmic multiprotein complexes formed by the host's immune system as a response to microbial infection and cellular damage. Many studies have revealed various regulators of NOD-, LRR-, and pyrin domain-containing protein 3 (NLRP3) inflammasome activation, while it has been recently shown that NLRP3 is implicated in COVID-19 pathogenesis. At the same time, probiotics counteract the inflammatory process and modulate cytokine release, thus influencing both innate and adaptive immune systems. Herein, we review the immunomodulatory potential of probiotics on the assembly of NLRP3 inflammasome, as well as the pathophysiological mechanisms supporting the use of probiotic bacteria for SARS-CoV-2 infection management, presenting evidence from preclinical studies of the last decade: in vivo, ex vivo, and mixed trials. Data show that probiotics intake is related to NLRP3 inflammasome attenuation and lower levels of inflammation markers, highlighting the beneficial effects of probiotics on inflammatory conditions. Currently, none of the ongoing clinical trials evaluating the effectiveness of probiotics intake in humans with COVID-19 has been completed. However, evidence from preclinical studies indicates that probiotics may block virus invasion and replication through their metabolites, bacteriocins, and their ability to block Angiotensin-Converting Enzyme 2 (ACE2), and by stimulating the immune response through NLRP3 inflammasome regulation. In this review, the beneficial effects of probiotics in the inflammatory process through NLRP3 inflammasome attenuation are presented. Furthermore, probiotics may target SARS-CoV-2 both by blocking virus invasion and replication and by stimulating the immune response through NLRP3 inflammasome regulation. Heterogeneity of the results-due to, among others, different bacterial strains and their metabolites, forms, dosage, and experimental designs-indicates the need for more extensive research.

Comparison of Publication of Pediatric Probiotic vs Antibiotic Trials Registered on ClinicalTrials.gov

IMPORTANCE

The published evidence in support of probiotic use is conflicting, which may be a result of selective publication of probiotic trials.

OBJECTIVES

To compare the proportion of registered trials that evaluate pediatric probiotics vs those that evaluate antibiotics that are published and to identify study-related factors associated with publication status.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study evaluated eligible trials registered in ClinicalTrials.gov, an online clinical trials registry, from July 1, 2005, to June 30, 2016. Eligible studies included participants younger than 18 years, evaluated a probiotic or 1 of the 5 most commonly prescribed antibiotics in children and adolescents, and randomized study participants. All searches were updated and finalized as of September 9, 2020.

EXPOSURES

Probiotic or antibiotic.

MAIN OUTCOMES AND MEASURES

The primary outcome was study publication status. In addition, exposure status (probiotic vs antibiotic), trial result, and funding source were assessed for independent association with publication status. Whether study design elements, publication journal impact factor, and the interval from study completion to publication differed by exposure status were also evaluated.

RESULTS

A total of 401 unique trials (265 probiotic and 136 antibiotic) met eligibility criteria. A greater proportion of antibiotic compared with probiotic studies were published (83 [61.0%] vs 119 [44.9%]; difference, 16.1% [95% CI, 5.8%-25.9%]). After adjustment for funding source, blinding, and purpose, studies evaluating an antibiotic were more likely to be published (odds ratio, 2.1 [95% CI, 1.3-3.4]). No other covariates included in the model were independently associated with publication status. Antibiotic trials, compared with probiotic trials, were more likely to have a therapeutic purpose (114 [83.8%] vs 117 [44.2%]; difference, 39.6% [95% CI, 31.1%-48.3%]) and to be multicenter (46 [33.8%] vs 46 [17.4%]; difference, 16.5% [95% CI, 7.5%-25.7%]). The median impact factor of the journals in which the studies were published was higher for the antibiotic trials (7.2 [IQR, 2.8-20.5] vs 3.0 [IQR, 2.3-4.2]; P < .001). The median number of days to publication did not differ between the probiotic and antibiotic trials (683 [IQR, 441-1036] vs 801 [IQR, 550-1183]; P = .24).

CONCLUSIONS AND RELEVANCE

The findings of this cross-sectional study suggest that probiotic studies are less likely to be published than antibiotic trials. No other study characteristics were associated with publication status. This finding raises concerns regarding the results of meta-analyses of probiotic trials.

Probiotics in Pediatrics. A Review and Practical Guide

The potential benefit of the administration of probiotics in children has been studied in many settings globally. Probiotics products contain viable micro-organisms that confer a health benefit on the host. Beneficial effects of selected probiotic strains for the management or prevention of selected pediatric conditions have been demonstrated. The purpose of this paper is to provide an overview of current available evidence on the efficacy of specific probiotics in selected conditions to guide pediatricians in decision-making on the therapeutic or prophylactic use of probiotic strains in children. Evidence to support the use of certain probiotics in selected pediatric conditions is often available. In addition, the administration of probiotics is associated with a low risk of adverse events and is generally well tolerated. The best documented efficacy of certain probiotics is for treatment of infectious gastroenteritis, and prevention of antibiotic-associated, Clostridioides difficile-associated and nosocomial diarrhea. Unfortunately, due to study heterogeneity and in some cases high risk of bias in published studies, a broad consensus is lacking for specific probiotic strains, doses and treatment regimens for some pediatric indications. The current available evidence thus limits the systematic administration of probiotics. The most recent meta-analyses and reviews highlight the need for more well-designed, properly powered, strain-specific and dedicated-dose response studies.

Multi-Strain Probiotics: Synergy among Isolates Enhances Biological Activities

The use of probiotics for health benefits is becoming popular because of the quest for safer products with protective and therapeutic effects against diseases and infectious agents. The emergence and spread of antimicrobial resistance among pathogens had prompted restrictions over the non-therapeutic use of antibiotics for prophylaxis and growth promotion, especially in animal husbandry. While single-strain probiotics are beneficial to health, multi-strain probiotics might be more helpful because of synergy and additive effects among the individual isolates. This article documents the mechanisms by which multi-strain probiotics exert their effects in managing infectious and non-infectious diseases, inhibiting antibiotic-resistant pathogens and health improvement. The administration of multi-strain probiotics was revealed to effectively alleviate bowel tract conditions, such as irritable bowel syndrome, inhibition of pathogens and modulation of the immune system and gut microbiota. Finally, while most of the current research focuses on comparing the effects of multi-strain and single-strain probiotics, there is a dearth of information on the molecular mechanisms of synergy among multi-strain probiotics isolates. This forms a basis for future research in the development of multi-strain probiotics for enhanced health benefits.

The effect of different dietary structure on gastrointestinal dysfunction in children with cerebral palsy and epilepsy based on gut microbiota

BACKGROUND

Gastrointestinal (GI) difficulties are very common among children with cerebral palsy (CP) and comorbid epilepsy. GI function is influenced by dietary structure on gut microbiota. The aim of this study was to compare gut microbiota differences in two dietary groups of this population and examine whether such differences are related to GI dysfunction.

METHODS

Forty children with CP and epilepsy were recruited from a social welfare center, including 23 consuming a fluid diet (liquid diet group) and 17 consuming a normal diet (general diet group). Bacterial DNA was extracted from feces, the V3-V4 region of the 16S rRNA gene was amplified from the DNA, and high-throughput sequencing of the amplified sequences was performed. Microbe prevalence levels were compared on multiple phylogenic levels.

RESULTS

Gut microbial populations differed substantially between the liquid diet group and general diet group. The only two phyla that differed significantly between the two groups were Bacteroidetes (p = 0.034) and Actinobacteria (p = 0.013). Regarding representation of genera, Prevotella species were selectively predominant in the general diet group (25.849% vs. 3.612% in the liquid diet group, p < 0.001), while Bifidobacterium species were selectively predominant in the liquid diet group (24.929% vs. 12.947% in the general diet group, p = 0.013). The gut microbiota of children in the general diet group contained more butyric acid-producing microbiota which was also common in healthy people (e.g. Lachnoclostridium, Dorea, Ruminococcus, Faecalibacterium, Roseburia, and Coprococcus). The gut microbiota of children in liquid diet group however, were rich in symbiotic pathogenic bacteria (e.g. Collinsella, Alistipes, and Eggerthella).

CONCLUSION

The gut microbiota of children with CP and epilepsy consuming a liquid diet had elevated levels of symbiotic pathogens and diminished intestinal barrier protection bacteria, relative to a general diet group. These differences in bacterial microbiota were associated with GI dysfunction symptoms.

Paediatric constipation for general paediatricians: Review using a case-based and evidence-based approach

Constipation is a common problem in childhood. The most common type of constipation is functional, accounting for 90-95% of all cases. The aim of this review is to provide clinical scenarios with treatment using evidence-based information, and management strategies and a clinical algorithm to guide the management of constipation in children. Recent guidelines and online information sites are detailed. Clinical red flags and organic causes of constipation are included. Four clinical scenarios are presented: case (1) 4-month-old child with constipation since birth and likely Hirschsprung disease; case (2) 6-month-old infant with infant dyschezia; case (3) 4-year old with functional constipation; and; case (4) 9-year old with treatment resistant constipation. Children with functional constipation need a thorough history and physical exam to rule out the presence of any 'red flags' but do not require laboratory investigations. Management includes education and demystification, disimpaction followed by maintenance therapy with oral laxatives, dietary counselling and toilet training. Treatment options differ between infants and children. Disimpaction and maintenance regimens for common laxatives are presented. On treatment failure or on suspicion of organic disease the patient should be referred for further evaluation. The radionuclide intestinal transit study (scintigraphy) is a useful modality for evaluation and planning of management in treatment-resistant children. Treatment options for treatment-resistant patients are presented. High-level evidence (meta-analyses) for pharmalogical and non-pharmalogical treatment modalities are reviewed and an algorithm for assessment and treatment are presented.

Medications for constipation in 2020

PURPOSE OF REVIEW

Chronic constipation is a common problem that substantially impacts the quality of life of patients and families, healthcare professionals, and resources. The purpose of this review is to discuss the medications that are available for management of chronic constipation, including medications that have been approved by the FDA for adults, other been studied in pediatrics now, and might become available within the upcoming years.

RECENT FINDINGS

Recent developments in the evaluation of childhood constipation are providing a better understanding into defecation disorders in children and not only new therapies are becoming available, including medications, but also other therapies, such as biofeedback for treatment of functional defecation disorders, electrical stimulation, and surgeries. The aim of this article is to provide an update on the medications that are available for management of chronic constipation, especially with the development and study of newer medications, such as Linaclotide and Lubiprostone with promising results in both adult and pediatric patients.

SUMMARY

This review will help us identify and have a better understanding regarding what medications are available for use and the indications, so that we can better manage patients with chronic constipation. VIDEO ABSTRACT.

Treatment of childhood constipation: a synthesis of systematic reviews and meta-analyses

Introduction: Constipation occurs in many children and can become chronic. Many grow out of it but for one third, it continues into adulthood. For most patients, there is no identifiable organic disorder and it is classified as functional constipation.Areas covered: In 2016, treatment of childhood constipation was extensively reviewed by Rome IV. This review covers meta-analyses and evidence for treatment of paediatric constipation since 2016 and new emerging treatments.Expert opinion: Since 2016, meta-analyses conclude 1) fibre should be included in a normal diet, but further supplementation does not improve constipation; 2) probiotics may increase stool frequency in children, but evidence from larger RCTs is needed; 3) comparing laxatives, polyethylene glycol (PEG) is superior to placebo, lactulose and milk of magnesia, and 4) appendix stomas are effective and should be considered before surgery. Emerging areas of study include food intolerance, electrical stimulation and faecal microbiota transplant. For research, outcome measures need standardising to allow comparison between studies and allow meta-analyses. To assist this, validated GI instruments have been developed by Rome IV and PedsQl.

Lactobacillus reuteri DSM 17938 and Magnesium Oxide in Children with Functional Chronic Constipation: A Double-Blind and Randomized Clinical Trial

OBJECTIVE

Chronic functional constipation is a frequent condition. The aim of the study was to evaluate the efficacy of the probiotic Lactobacillus (L.) reuteri DSM 17938 and magnesium oxide (MgO) for relieving chronic functional constipation in children.

STUDY DESIGN

A prospective, double-blind, placebo-controlled, randomized, and parallel-group trial was conducted in five pediatric outpatient clinics in Japan. Sixty patients who were more than six months old and under six years of age with a diagnosis of functional constipation according to Rome IV criteria were randomly divided into three groups: group A (n = 20) received L. reuteri DSM 17938 and lactose hydrate as a placebo of MgO; group B (n = 19) received L. reuteri DSM 17938 and MgO; and group C (n = 21) received a placebo of L. reuteri DSM 17938 and MgO.

RESULTS

All three groups exhibited significant improvement in defecation frequency in the fourth week compared with the baseline condition (group A: p < 0.05; group B: p < 0.05; group C: p < 0.05). The MgO group and combination group showed a significant decrease in stool consistency, but the L. reuteri DSM 17938 group did not (group A: p = 0.079; group B: p < 0.05; group C: p < 0.05). MgO significantly suppressed the presence of the genus Dialister. Defecation frequency negatively correlated with the frequency of Clostridiales-belonging bacteria among the gut microbiome.

CONCLUSIONS

L. rueteri DSM 17938 and MgO were both effective in the management of functional constipation in young children. MgO caused an imbalance in the gastrointestinal microbiome, which was not the case in the probiotic group.

Meta-analysis of randomized controlled trials of the effects of probiotics on functional constipation in adults

BACKGROUND & AIMS

Clinical trials have reported controversial results regarding the effectiveness of probiotics in alleviating functional constipation in adults. We reviewed relevant randomized controlled trials to elucidate the effectiveness of probiotics on constipation symptoms in adults with functional constipation.

METHODS

We searched Medline, the Cochrane Library, Web of Science, and Google Scholar for relevant articles published up to April 2019. The primary outcomes of interest were stool frequency, gut transit time (GTT), stool consistency, and bloating. Two authors independently performed the study selection, risk-of-bias assessment, and data extraction. The outcome data were extracted from each included study and synthesized using weighted mean differences (WMDs) or standardized mean differences (SMDs). Pooled data synthesis was performed using a random-effects model.

RESULTS

In total, 2327 relevant studies were identified, 15 of which were found to be eligible randomized controlled trials and were included in the meta-analysis. Pooling of the extracted data demonstrated that probiotic consumption significantly reduced the whole GTT by 13.75 h [95% confidence interval (CI): -21.93 to -5.56 h] and increased the stool frequency by 0.98 (95% CI: 0.36 to 1.60) bowel movements per week. This increase was significant with the consumption of multispecies probiotics [at least two bacteria; WMD: 1.22 (95% CI: 0.50 to 1.94) bowel movements per week] but not with the consumption of Bifidobacterium lactis [WMD: 1.34 (95% CI: -0.27 to 2.94) bowel movements per week] or B. longum [WMD: -0.02 (95% CI: -0.56 to 0.53) bowel movements per week] alone. Multispecies probiotics (WMD: 1.37; 95% CI: 0.72 to 2.01), but not single-species probiotics (WMD: 1.18; 95% CI: -0.59 to 2.96), improved stool consistency (WMD: 1.30; 95% CI: 0.22 to 2.38). Similarly, multispecies probiotics (at least two bacteria; WMD: -0.49; 95% CI: -0.85 to -0.13), but not single-species probiotics (WMD: -0.24; 95% CI: -0.55 to 0.07), significantly decreased bloating. Performance bias were high, whereas detection bias was unclear because of inadequate reporting.

CONCLUSION

Consumption of probiotics, in particular, multispecies probiotics, may substantially reduce the GTT, increase the stool frequency, and improve the stool consistency. Thus, probiotics can be regarded as safe and natural agents for alleviation of functional constipation in adults.

Management of functional constipation in children and adults

Functional constipation is common in children and adults worldwide. Functional constipation shows similarities in children and adults, but important differences also exist regarding epidemiology, symptomatology, pathophysiology, diagnostic workup and therapeutic management. In children, the approach focuses on the behavioural nature of the disorder and the initial therapeutic steps involve toilet training and laxatives. In adults, management focuses on excluding an underlying cause and differentiating between different subtypes of functional constipation - normal transit, slow transit or an evacuation disorder - which has important therapeutic consequences. Treatment of adult functional constipation involves lifestyle interventions, pelvic floor interventions (in the presence of a rectal evacuation disorder) and pharmacological therapy. When conventional treatments fail, children and adults are considered to have intractable functional constipation, a troublesome and distressing condition. Intractable constipation is managed with a stepwise approach and in rare cases requires surgical interventions such as antegrade continence enemas in children or colectomy procedures for adults. New drugs, including prokinetic and prosecretory agents, and surgical strategies, such as sacral nerve stimulation, have the potential to improve the management of children and adults with intractable functional constipation.

Review: Probiotics in dermatology

Probiotics are live microbial organisms that are beneficial to the host health when they are administered in adequate amounts. Since its introduction, the concept of probiotics has stimulated much interest and scientific research. Modulation of intestinal microbiota with probiotics is used as a therapeutic modality in many disease conditions. The role of probiotics in dermatological diseases like atopic dermatitis, acne, vaginal infections etc. is not yet established inspite of several studies on the same. As probiotics provide a safe and well-tolerated therapeutic modality in this era of antibiotic resistance and adverse effects, it becomes essential for us to validate the efficacy of its therapeutic supplementation. Herein, an attempt is made to review the current evidence from literature.

GUT MICROBIOTA AND THE USE OF PROBIOTICS IN CONSTIPATION IN CHILDREN AND ADOLESCENTS: SYSTEMATIC REVIEW

Objective:

To perform a systematic review of literature data on gut microbiota and the efficacy of probiotics for the treatment of constipation in children and adolescents.

Data source:

The research was performed in the PubMed, the Scientific Electronic Library Online (SciELO) and the Latin American and Caribbean Health Sciences Literature (LILACS) databases in English, Portuguese and Spanish. All original articles that mentioned the evaluation of the gut microbiota or the use of probiotics in children with constipation in their title and abstract were selected.

Data synthesis:

559 articles were found, 47 of which were selected for reading. From these, 12 articles were included; they studied children and adolescents divided into two categories: a gut microbiota evaluation (n=4) and an evaluation of the use of probiotics in constipation therapy (n=8). The four papers that analyzed fecal microbiota used different laboratory methodologies. No typical pattern of gut microbiota was found. Regarding treatment, eight clinical trials with heterogeneous methodologies were found. Fifteen strains of probiotics were evaluated and only one was analyzed in more than one article. Irregular beneficial effects of probiotics have been demonstrated in some manifestations of constipation (bowel frequency or consistency of stool or abdominal pain or pain during a bowel movement or flatulence). In one clinical trial, a complete control of constipation without the use of laxatives was obtained.

Conclusions:

There is no specific pattern of fecal microbiota abnormalities in constipation. Despite the probiotics’ positive effects on certain characteristics of the intestinal habitat, there is still no evidence to recommend it in the treatment of constipation in pediatrics.

Prophylactic use of probiotics for gastrointestinal disorders in children

The gastrointestinal microbiome is a hot topic in clinical research. Beneficial effects of selected probiotics in the prevention of gastrointestinal disorders are mainly restricted to acute gastroenteritis, antibiotic-associated diarrhoea, infantile colic, and necrotising enterocolitis. However, no broad consensus exists to recommend the use of probiotics in the prevention of these conditions, mainly because of the different design of the studies done so far, resulting in little evidence for specific strains, dosages, and indications. More well designed studies are needed before recommendations can be proposed. At this stage, the evidence is insufficient to recommend the routine use of probiotics in infants and children for the prevention of gastrointestinal disorders.

When poorly conducted systematic reviews and meta-analyses can mislead: a critical appraisal and update of systematic reviews and meta-analyses examining the effects of probiotics in the treatment of functional constipation in children

BACKGROUND

Recent systematic reviews and meta-analyses on the efficacy of probiotics in the treatment of functional constipation in children have yielded conflicting results.

OBJECTIVES

The aim of this study was to critically review and update the evidence in this field by mapping all the steps involved against those reported in previous reviews, in an attempt to understand the nature of their conflicting results.

METHODS

Four literature databases, trial registries, and citations were searched through December 1, 2018. We included randomized controlled trials (RCTs) that assessed the effects of probiotics compared with placebo or treatment as usual on defecation frequency [bowel movements (BMs)/wk] or treatment success rates in children with functional constipation. Independent reviewers extracted the data and assessed risk of bias in each RCT. Data were pooled with (inverse variance) random-effects models.

RESULTS

We identified 17 RCTs, of which 14 and 11 provided sufficient data to enable meta-analysis of the effects of probiotics compared with control on defecation frequency (n = 965) or treatment success (n = 835), respectively. When compared to (any) control intervention, probiotics did not significantly increase defecation frequency [weighted mean difference (WMD): 0.28 BMs/wk; 95% CI: -0.12, 0.69; P = 0.165] but were more efficacious in achieving treatment success (RR: 1.24; 95% CI: 1.03, 1.50; P = 0.024). These effects did not differ by type of control (i.e., active or inactive) intervention. However, in analyses confined to the RCTs that were free of high risk of bias (only 5), probiotics did not confer any beneficial effects on defecation frequency (WMD: -0.55 BMs/wk; 95% CI: -1.37, 0.26; P = 0.185) and achievement of treatment success (RR: 1.01; 95% CI: 0.90, 1.13; P = 0.873), compared with control interventions.

CONCLUSIONS

The current evidence thus does not support the use of probiotics as a single or coadjuvant therapy for treatment of functional constipation in children and refutes recently published reviews reporting favorable effects of probiotics. Conflicting findings of previous reviews resulted from methodologic errors, highlighting the susceptibility of evidence synthesis to oversights in study selection, quality assessments, and data extraction and collation. This review was registered at PROSPERO as CRD42019119109.

Impact of Low-dose Ionising Radiation on the Composition of the Gut Microbiota of Mice

BACKGROUND

Although the importance of the gut microbiota in the maintenance of human health has been well established, little is known about the impact of low-dose ionising radiation (exposure to a dose of less than 0.5 Gy of low linear energy transfer radiation such as γ- or X-rays [LDR]) on the composition and functional role of the gut microbiota. The aim of the present study was to investigate and compare the composition of the gut microbiota in mice exposed to LDR.

METHODS AND MATERIALS

Male BALB/c mice were exposed to low-dose Co60 radiation. Faecal samples taken prior to and after irradiation were used for high-throughput sequencing of 16S rRNA gene sequence amplicons.

RESULTS

We observed substantial changes in the composition of the gut microbiota, including alpha diversity and beta diversity, in mice exposed to LDR compared to the non-radiated control group. Moreover, at the genus level, the abundance of Clostridium, Helicobacter and Oscilibacter increased, and those of Bacteroides and Barnesiella decreased, in a time-dependent manner in the radiated groups compared to the non-radiated control group. The functional metabolic pathway analysis indicated that Bacteroides spp. and members of the other genera that were found are predicted to play roles in bacterial toxin production, DNA repair, and Type II diabetes. Furthermore, these alterations in the gut microbiota were accompanied by changes in the abundance of multiple metabolites, which were predicted to be involved in multiple signalling pathways, including glucagon, central carbon metabolism, and type II diabetes.

CONCLUSIONS

The possibility of microbiota-mediated pathophysiology resulting from LDR may be an as yet unrecognised hazard that merits further experimental examination. This study provides a conceptual and analytical foundation for further research into the chronic effects of LDR on human health, and points to potential novel targets for intervention to prevent the adverse effects of radiation.

Effectiveness and safety of lactobacilli in children with functional constipation: Study protocol for a meta-analysis and systematic review

BACKGROUND

Constipation is one of the most common diseases in children and it is also a significant healthcare burden, more than many other common childhood diseases. For some children, 1st-line treatment cannot relieve their constipation and their constipation symptoms maybe continue to adolescence. So, alternative treatment options such as lactobacilli are needed. However, the effectiveness and safety of lactobacilli is still unclear. To investigate this question, we conduct a systematic review and meta-analysis.

METHODS

The protocol followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols. Three main databases (PubMed, Embase, and the Cochrane Library) will be searched to December 20, 2018 for randomized controlled trials investigating the effects and safety of lactobacilli for constipation in children with no language restrictions. In addition, a manual search of the references of relevant published studies will also be considered.Two independent reviewers will conduct studies selection, data extraction, and risk of bias assessment. The primary outcome is defecation frequency, treatment success (bowl movement >3 times per week). The 2nd outcome is stool consistency, incidence of abdominal pain, patients using laxatives, and adverse events.

RESULTS

The results will provide useful information about the effect and safety of lactobacilli for constipation in children.

CONCLUSION

The findings of this study will be published in a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42019125913.

Increased Functional Foods' Consumption and Mediterranean Diet Adherence May Have a Protective Effect in the Appearance of Gastrointestinal Diseases: A Case⁻Control Study

Background: Epidemiological studies have suggested a possible correlation between nutritional factors and gastrointestinal diseases. Methods: A case–control study was designed in order to investigate if functional foods consumption and Mediterranean diet adherence have a positive effect in ulcerative colitis, Crohn’s disease, irritable bowel syndrome, and gastroesophageal reflux disease. In total, 142 patients (cases) and 147 gender-matched healthy people (controls) participated in the study. Functional food consumption was screened by using a Food Frequency Questionnaire based on the NHANES study, while Mediterranean diet adoption was evaluated by a 14-item Med Diet Assessment tool based on the PREDIMED study. The statistical analysis was performed with SPSS-22. Results: In the previous 2–3 years, the controls had more frequently consumed some categories (probiotics, prebiotics-enriched, and low-fat foods) and some kinds of functional foods (mountain tea, berries, pomegranate, oats, mastics, turmeric, soybeans, and raisins) compared to the cases (p < 0.05). Healthy people were more adherent to the Mediterranean diet than patients (p < 0.05). A multifactor analysis showed that the augmented score of the Mediterranean diet and the augmented consumption of categories and kinds of functional foods were protective factors in the appearance of gastrointestinal diseases. Conclusions: More studies should be conducted in order to further investigate the possible association between specific food components and gastrointestinal diseases’ pathophysiology.

Effectiveness of Probiotics in Children With Functional Abdominal Pain Disorders and Functional Constipation: A Systematic Review

OBJECTIVE

The objective of this study was to investigate the effect of probiotics on functional abdominal pain disorders (FAPD) and functional constipation (FC).

METHODS

A systematic review was conducted, searching PubMed and Cochrane databases from inception to January 2018 for randomized controlled trials (RCTs) investigating the efficacy of probiotics in children aged 4 to 18 years with FAPD or children aged 0 to 18 years with FC.

RESULTS

A total of 657 citations were identified. Finally, 11 RCTs for FAPD and 6 RCTs for FC were included. Some evidence exists for Lactobacillus rhamnosus GG (n=3) in reducing frequency and intensity of abdominal pain in children with irritable bowel syndrome. There is no evidence to recommend L. reuteri DSM 17938 (n=5), a mix of Bifidobacterium infantis, Bifidobacterium breve and Bifidobacterium longum (n=1), Bifidobacterium lactis (n=1) or VSL#3 (n=1) for children with FAPD. No evidence exists to support the use of Lactobacillus casei rhamnosus LCR35 (n=1), B. lactis DN173 010 (n=1), B. longum (n=1), L. reuteri DSM 17938 (n=1), a mix of B. infantis, B. breve and B. longum (n=1), or Protexin mix (n=1) for children with FC. In general, studies had an unclear or high risk of bias.

CONCLUSIONS

Insufficient evidence exists for the use of probiotics in FAPD and FC, only L. rhamnosus GG seems to reduce frequency and intensity of abdominal pain but only in children with irritable bowel syndrome. A better understanding of differences in gut microbiota in health and disease might lead to better probiotic strategies to treat disease.

Constipation Management in Pediatric Primary Care

Constipation is a common and often difficult to manage problem encountered in outpatient primary care. Although we give our patients many different modalities to treat constipation (eg, diet changes, behavior modification, probiotics, medication), there is little evidence to support any of these modalities. We also tend to order unnecessary tests during the diagnostic process. This article tries to clarify the diagnostic process and provide a clear treatment path to be used for functional constipation. [Pediatr Ann. 2018;47(5):e180-e184.].

Probiotics for the Treatment of Atopic Dermatitis in Children: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Objective: Atopic dermatitis (AD) is a prevalent, burdensome, and psychologically important pediatric concern. Probiotics have been suggested as a treatment for AD. Some reports have explored this topic; however, the utility of probiotics for AD remains to be firmly established.

Methods: To assess the effects of probiotics on AD in children, the PubMed/Medline, Cochrane Library Scopus, and OVID databases were searched for reports published in the English language.

Results: Thirteen studies were identified. Significantly higher SCORAD values favoring probiotics over controls were observed (mean difference [MD], −3.07; 95% confidence interval [CI], −6.12 to −0.03; P < 0.001). The reported efficacy of probiotics in children < 1 year old was −1.03 (95%CI, −7.05 to 4.99) and that in children 1–18 years old was −4.50 (95%CI, −7.45 to −1.54; P < 0.001). Subgroup analyses showed that in Europe, SCORAD revealed no effect of probiotics, whereas significantly lower SCORAD values were reported in Asia (MD, −5.39; 95%CI, −8.91 to −1.87). Lactobacillus rhamnosus GG (MD, 3.29; 95%CI, −0.30 to 6.88; P = 0.07) and Lactobacillus plantarum (MD, −0.70; 95%CI, −2.30 to 0.90; P = 0.39) showed no significant effect on SCORAD values in children with AD. However, Lactobacillus fermentum (MD, −11.42; 95%CI, −13.81 to −9.04), Lactobacillus salivarius (MD, −7.21; 95%CI, −9.63 to −4.78), and a mixture of different strains (MD, −3.52; 95%CI, −5.61 to −1.44) showed significant effects on SCORAD values in children with AD.

Conclusions: Our meta-analysis indicated that the research to date has not robustly shown that probiotics are beneficial for children with AD. However, caution is needed when generalizing our results, as the populations evaluated were heterogeneous. Randomized controlled trials with larger samples and greater power are necessary to identify the species, dose, and treatment duration of probiotics that are most efficacious for treating AD in children.