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Probiotics in Pediatrics

Article  in  The Indian Journal of Pediatrics · February 2015

DOI: 10.1007/s12098-015-1719-1 · Source: PubMed

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Indian J Pediatr (May 2015) 82(5):399–400
DOI 10.1007/s12098-015-1719-1
EDITORIAL COMMENTARY
Probiotics in Pediatrics
Meenakshi Bothra & Shinjini Bhatnagar
Received: 29 January 2015 / Accepted: 29 January 2015 / Published online: 19 February 2015
# Dr. K C Chaudhuri Foundation 2015
Probiotics refer to the live microorganisms which, when
ingested in an adequate amount, provide health benefit to the
host. Most of the probiotics are bacteria, while Saccharomyces
boulardii is a yeast [1]. The postulated mechanisms by which
probiotics exert their beneficial effects include improvement
in host barrier function, competitive inhibition of pathogenic
bacteria, strengthening of tight junctions between enterocytes,
promoting maturation of the intestinal brush border membrane
and stimulation of production of secretory IgA.
There has been substantial evidence in the recent past to
suggest some beneficial effects of probiotics in the treatment
of acute diarrhea in children. The recent Cochrane review on
the use of probiotics for treating acute infectious diarrhea,
which included 63 trials (56 in infants and children), reported
shortened duration of diarrhea by 25 h (95 % CI 15.9 to
33.6 h), decrease in the risk of diarrhea lasting four or more
days by 59 % and one fewer loose stool on day 2 after the
initiation of probiotic [2]. In another more recent systematic
review in children, which included 8 randomized controlled
trials (RCTs), probiotics were found to reduce the duration of
community-acquired acute diarrhea by 14.0 % (95 % CI: 3.8–
24.2 %) and stool frequency on the second day of treatment by
M. Bothra (*)
Department of Pediatrics, All India Institute of Medical Sciences,
Ansari Nagar, New Delhi 110029, India
e-mail: meenakshibothra@gmail.com
S. Bhatnagar
Pediatric Biology Centre, Translational Health Science and
Technology Institute, Gurgaon, India
13.1 % (95 % CI: 0.8–25.3 %) [3]. These data need to be
interpreted with caution as most of the studies were not from
LMIC (low middle income countries) and there was marked
variability across the studies, such as use of different strains,
variable doses, and different breast feeding and dietary prac-
tices. Additionally, these studies did not evaluate the effects of
probiotics with the concurrent use of zinc, which is currently
the accepted adjunct to ORS in the treatment of diarrhea.
Most of the earlier studies that evaluated the effect of
probiotics in the prevention of acute diarrhea were once again
from developed countries and the effects were dependent on
the host and the particular strain used [4]. The only large RCT
evaluating the effect of probiotics on prevention of diarrhea in
India was in an urban slum that found a protective efficacy of
14 % (95 % CI 4–23%) in 3758 children, followed for a period
of 24 wk. However, one must note that the 95 % CI was very
wide [5].
The RCT by Hegar et al., published in this edition of the
journal, tested the efficacy of a combination of Lactobacillus
rhamnosus R0011 1.9 × 109 & Lactobacillus acidophilus
R0052 0.1×109 colony forming units/day in 112 children
aged 6–36 mo with acute infectious diarrhea and moderate
dehydration in Jakarta, Indonesia [6]. This study is important
as it has evaluated therapeutic efficacy of probiotics in child-
hood diarrhea in the setting of a developing country and also
where the study subjects were given zinc in addition to ORS
as standard therapy. In earlier studies, zinc was not a part of
standard treatment regime in the study subjects. The study
reported a reduction in the median duration of diarrhea
[61.5 h (range 21–166) vs. 68.5 h (range 13–165)] and the
median daily frequency of defecation (5.0 vs. 5.5) in the pro-
biotic supplemented group as compared to the control group,
but these differences were not statistically significant. The
400
lack of significant difference may be because of the small
sample size of the study. The authors have argued that the
negative results in their study could also have been due to
the interaction between zinc and probiotics. However, it is
important to evaluate the effects of probiotics along with zinc,
as the latter is standard of care in the treatment of diarrhea, both
globally and within our country. Some of the limitations of this
study, as acknowledged by the investigators themselves, in-
clude possibility of recall bias, non-compliance to therapy,
and inability to perform an independent quality analysis of
the tested probiotic product. It may also be difficult to compare
the result of this study with the earlier studies because the
definitions of diarrhea (based on the Bristol criteria) and severe
dehydration (capillary refill time >4 s) used are different from
the conventionally used WHO definitions by other groups.
While most of the preventive and therapeutic effects of
probiotics have been evaluated in diseases involving the gastro-
intestinal tract, their use has also been evaluated in other infec-
tions and allergic disorders. Therapeutic benefits have been re-
ported in severe necrotizing enterocolitis (Bells stage II or more)
(RR 0.35, 95 % CI 0.24 to 0.52), but not with nosocomial sepsis
(RR 0.90, 95 % CI 0.76 to 1.07) [7, 8]. A Cochrane review
found insufficient evidence for the use of probiotics in the pre-
vention or treatment of atopic dermatitis, but another Cochrane
meta-analysis of 10 clinical trials found that probiotics were
more beneficial than placebo in reducing the rate of acute upper
respiratory tract infection and frequency of antibiotic use, but
did not decrease the duration of each episode [9, 10].
Due to the heterogeneous and lack of convincing evidence
on the use of probiotics in childhood diseases particularly
diarrhea, larger, well planned, multicentric studies are required
with different probiotic preparations, in varying dose ranges in
developing countries. Data from studies done in the west can-
not be extrapolated to children in our settings where the infec-
tion rates, the gut microbiome, breast feeding practices and the
dietary patterns are very different. The standard of care for the
treatment of acute diarrhea in children remains oral rehydra-
tion solution (ORS), zinc and continued oral feeding, as rec-
ommended by WHO as well as the IAP [11].
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Indian J Pediatr (May 2015) 82(5):399–400
Conflict of Interest None.
Source of Funding None.
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