Using probiotics in the paediatric population

Question 1

What are probiotics?

Answer 1

Live micro-organisms which can confer a health effect on the host when consumed in adequate amounts. They are non-pathogenic in the normal host, resist processing and are able to survive in the digestive tract.

Question 2

What are examples of probiotics?

Answer 2

1. Lactobacilli
2. Bifidobacteria
3. Saccharomyces

Question 3

What are prebiotics?

Answer 3

Nonviable food components which can confer a health benefit on the host by modulating intestinal microflora.

Question 4

What are examples of prebiotics?

Answer 4

Fructo- and galacto-oligosaccharides

Question 5

Which factors influence the composition of the infant gut microflora?

Answer 5

1. Type of delivery
2. Infant diet (breastmilk vs. formula)
3. Environment
4. GA
5. Presence of antibiotics

Question 6

Which flora types are higher in breastmilk infants?

Answer 6

Lactobacilli

Bifidobacteria

Question 7

When does the composition of a child’s intestinal microflora begin to resemble the adult flora?

Answer 7

Once solid food is introduced into the diet

Question 8

What are the role of gut microflora?

Answer 8

1. Gut’s barrier function by:
   a) competing with pathogenic bacteria
   b) increasing mucin secretion
   c) decreasing gut permeability
   d) modulating the gut’s immune function
2. Metabolize malabsorbed CHO into short-chain fatty acids (SCFA) which are preferential fuel for enterocyte, acidify colonic content and increase water absorption

Question 9

How do probiotics modify the gut microflora?

Answer 9

1. Lowering colonic pH through production of SCFA
2. Producing antimicrobial compounds and antitoxins
3. Competing with other bacteria for nutrients and adhesion receptors
4. Enhance gut barrier function
5. Role in immunomodulation

Question 10

What is antibiotic-associated diarrhea (AAD)?

Answer 10

≥3 loose stools/day for ≥2 days occurring up to two weeks after the initiation of antibiotics. AAD occurs in about 30% of patients

Question 11

What is the effectiveness of probiotics in preventing antibiotic-associated diarrhea (AAD)?

Answer 11

Probiotics: Saccharomyces boulardii and Lactobacillus rhamnosus GG (LGG) decrease incidence of AAD with per protocol results, but lack of compliance maybe an issue

Question 12

What is the effectiveness of probiotics in preventing Clostridium difficile?

Answer 12

No evidence to support using probiotics either to prevent or treat C difficile in children or adults, there might be a role for probiotics in preventing relapse in patients with recurrent C difficile infection

Question 13

What is the effectiveness of probiotics in treatment of acute infectious diarrhea in children?

Answer 13

Lactobacillus rhamnosus GG (LGG) most effective probiotic
Reduce: 1. duration of acute infectious viral diarrhea
2. efficacy is strain & dose-dependent

Most beneficial effects of probiotics more evident when treatment initiated <48h. Probiotics are not useful for treating bacterial diarrhea.

Question 14

What is the effectiveness of probiotics in preventing infectious diarrhea in children?

Answer 14

Effective probiotic strains: LGG, S. boulardii, Bifidobacterium bifidum, Lactobacillus casei, Bifidobacterium lactis, Lactobacillus reuteri –> acute diarrhea

Bifidobacterium breve, Streptococcus thermophilus –> dehydration

Modest effect:

1. preventing acute diarrhea
2. children who are not breastfed

Probiotic use may be considered in long-term facilities or for patients attending child care who have recurrent infections.

Question 15

What is the effectiveness of probiotics in irritable bowel syndrome (IBS)?

Answer 15

Strains: LGG, Escherichia coli, VSL#3

Preliminary data on improvement of some symptoms (abdominal distension, bloating, gassiness) with probiotics

Question 16

What is the effectiveness of probiotics in infantile colic?

Answer 16

Insufficient evidence to recommend for or against

Question 17

What is the effectiveness of probiotics in preventing NEC?

Answer 17

Strains: 1. Lactobacillus

2. Bifidobacterium infantus and bifidus
3. S thermophilus
4. Probiotics may help to prevent NEC.
5. Administering live microorganisms to preterm newborns should be approached with caution.
6. Along with breastfeeding promotion, probiotics can be considered for the prevention of NEC in preterm infants >1 kg who are at risk for NEC. There is currently no data for infants weighing <1000 g.

Question 18

What is the effectiveness of probiotics in preventing traveller’s diarrhea?

Answer 18

No conclusions and further trials required

Question 19

What is the effectiveness of probiotics in preventing infection?

Answer 19

1. Childhood respiratory illness
2. Antibiotic use
3. Absences from childcare due to illness

More study required

Question 20

What is the effectiveness of probiotics in preventing atopic and allergic disease?

Answer 20

Insufficient evidence to recommend. Further research is required.

Question 21

What are the side effects of probiotics?

Answer 21

1. Systemic or local infections
2. LCC and saccharomyces sepsis in critically ill, immunocompromised, occ. immunocompetent, and those with central venous access

Question 22

Which conditions are probiotics effective for?

Answer 22

Effective: ADD, acute infectious viral diarrhea, NEC

Some effect: colic, IBS?

Question 23

What are the CPS recommendations regrading probiotics?

Answer 23

1. Keeping in mind that the effect of probiotics is both strain- and disease-specific, physicians should consider recommending probiotics to:

a) prevent antibiotic-associated diarrhea.
b) shorten the duration of acute infectious viral diarrhea.
c) prevent necrotizing enterocolitis in preterm infants who are at risk of necrotizing enterocolitis.
d) decrease the symptoms of colic.
e) decrease some symptoms of irritable bowel syndrome.

2. Based on current evidence, the use of probiotics cannot yet be recommended for the treatment or prevention of atopic diseases.
3. Physicians should be aware of the small risks of invasive infections with using some strains of probiotics in immunocompromised patients, and more rarely in the healthy child.
4. Physicians should advocate for further research to define which strains and dose of probiotics should be used in specific conditions.

Question 24

What are the CPS recommendations for the government?

Answer 24

The federal government should require manufacturers of probiotics and products containing probiotics to provide high quality products with precise and informative labelling.