Probiotics

Pediatrics in Review is happy to present a new series. It is difficult to define complementary and alternative medicine, but one perspective would be to include methods of treating or preventing disease or improving wellness that have arisen from sources of experience and research different from those traditionally taught in most medical schools and that have not been incorporated into current practice by traditional practitioners. Many of these therapies have arisen from the background of herbal use.The series was proposed by Dr Sunita Vohra, Director of the Complementary and Alternative Research and Education Program at the University of Alberta, Canada, and the initial articles will be written by Dr Vohra and her colleagues in cooperation with the Provisional Section on Contemporary, Holistic, and Integrative Medicine of the American Academy of Pediatrics (AAP SCHIM).Dr Kathi Kemper, a member of the AAP who is a leading educator in the realm of holistic and alternative medicine and who has been involved in establishing this series, urges colleagues to focus not on the tradition from which any therapy emerges, but on whether the therapy has been studied and proven. It is in the spirit of examining these therapies, which might appear unfamiliar and unusual, with a scientific eye and an open mind that we present these articles, starting with a discussion of probiotics. Significant numbers of our patients are using alternative therapies, usually on their own, and it is important for us to educate ourselves as to what is known about them.—LFNIncreasing evidence supports the use of probiotics to treat and prevent gastrointestinal (GI) disorders. The rationale behind probiotics usage is their ability to normalize microbial flora.Probiotics are nonpathogenic microbes, usually of the lactic acid-producing variety, that are used to improve or normalize the balance of gut microflora. They are available as dietary supplements or in food products (eg, yogurt) as live active culture. A variety of probiotic supplements are available, but LactobacillusGG, Bifidobacterium, and Saccharomyces sp have been studied most extensively. Increasing evidence supports the use of probiotics to prevent and treat various GI disorders such as irritable bowel syndrome, inflammatory bowel disease, acute gastroenteritis, and antibiotic-related diarrhea.Although probiotic preparations are used commonly worldwide, specific use data for children are unavailable.A number of systematic reviews (TableT1) have evaluated the use of probiotic supplements to treat diarrhea. Additionally, numerous randomized, controlled trials have examined their use in constipation, irritable bowel syndrome, Crohn disease, ulcerative colitis, atopy and eczema, Helicobacter pylori colonization and eradication, pancreatitis, cirrhosis, radiation-induced diarrhea, necrotizing enterocolitis, prophylaxis against bacterial sepsis, and urinary tract infections in preterm infants. (6)(7) More data are necessary before probiotics can be recommended as primary therapeutic agents for these disorders.Common empiric uses that have not yet been studied formally include acne, canker sores, colon cancer, heart disease, nonalcoholic fatty liver, and thrush.Clinical trials have not revealed major adverse effects of probiotics in healthy individuals, and long-term consumption also appears to be safe and well tolerated. However, there are case reports of aggravation of existing symptoms, septicemia, pneumonia, and meningitis in severely debilitated, immunocompromised children and in neonates. (8) The safest forms of probiotic bacteria are found in fermented foods, including buttermilk, yogurt, kefir, and sauerkraut. However, supplemental forms usually provide higher doses of probiotic bacteria.Some probiotics (L acidophilus, Lactobacillus GG, Saccharomyces sp) have been found safe for use in children if administered in appropriate doses. Usage has been evaluated in randomized, controlled trials for children as young as 1 month of age.Information is insufficient to recommend safe probiotic supplement usage by women who are pregnant or lactating. Usage of probiotic-containing foods in this population generally is considered safe.Probiotics are believed to modulate immune activity via differential activation of epithelial and immune cell receptors. Postulated mechanisms of action include inhibition of adhesion and invasion by enteroinvasive species into enteric cells, colonization of the gut, enhancement of epithelial cytoprotection, and destruction of receptor sites for toxins.The investigated dosages range from 1 million to 300 billion colony-forming units per day. Probiotic supplements usually are administered as capsules or powder. There is significant discrepancy in the literature as to appropriate doses in children, and the dose varies according to probiotic. Moreover, variations are significant between and within products because production generally is not standardized. Stability is an issue with most probiotic preparations; some may require refrigeration and others (such as S boulardii, which is a yeast product) may not. Patients should be instructed to consider this when selecting a product. Some products can be sprinkled on food or dissolved in beverages, which aids in administration to children. However, because some probiotics are sensitive to gastric acid and bile, they should be administered on an empty stomach. This property is product-specific, and patients should refer to the labeling instructions. Treatment often is initiated at the same time as antibiotic therapy to prevent antibiotic-associated diarrhea. The duration of treatment varies from 1 to 4 weeks following resolution of symptoms.

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