Probiotics and prebiotics in paediatric medicine: What are clinicians recommending?
That's the view of US-based paediatrician Dr Michael Cabana, who delivered a review of the evidence at the International Scientific Association of Probiotics and Prebiotics (ISAPP) conference in Singapore.
He argued that there was an increasing clinical use of probiotics, but less so of prebiotics, and sought to evaluate their effectiveness for a number of paediatric conditions.
1) The use of probiotics to treat acute viral gastroenteritis
For these cases, Dr Cabana said there was good evidence that probiotic strains were effective, but claimed the clinical impact could be limited.
He said an analysis of 63 trials featuring 8,014 patients showed that probiotics caused no adverse effects and shortened the duration of diarrhoea.
"A range of meta-analyses show the reduction in disease time is 25 hours. As a clinician, you have to ask if it is worthwhile. In some cases, it will be. In others, maybe not," he said.
2) Otitis media: Should probiotics be prescribed alongside antibiotics?
Dr Cabana said there was a strong case to recommend a probiotic alongside a 10-day course of amoxicillin when treating otitis media in order to reduce diarrhoea.
"The evidence here is strong I know it won't work every time, but there is a good chance it will."
However, he cautioned that as the complexity and duration of a regime increased, patient adherence would decrease.
"If the regimen is four times a day, you may well get a negative dose response. There is the science, and then there is the art."
3) Should breastfed children take probiotics to reduce disease risk when starting day care?
In this setting, Dr Cabana said he would not recommend such a strategy, but he would not object to parents initiating it.
He cited research that showed daily administration of probiotics did not correspond to fewer days of absence, lower or upper respiratory tract infections, or diarrhoea.
He added that some childcare studies did show positive effects on children who had received minimal or no breastfeeding.
4) Should probiotics be used to alleviate colic?
The literature focusing on probiotics and colic has developed rapidly in recent years, said Dr Cabana.
"Overall, the results suggest there is a positive benefit, with one study recording a negative impact."
However, a meta-analysis sponsored by ISAPP found that the one negative study had assessed older children, who also tended to consume more formula.
"I think it works best for breastfed infants, who are not on other gastrointestinal medications and who start to take probiotics at an earlier age."
He added there was not yet sufficient evidence to recommend probiotics for healthy infants in order to prevent future colic.
5) Should probiotics be used to prevent atopic dermatitis?
In this regard, Dr Cabana said the evidence was conflicting. He referred to a 2001 study, which showed there was a benefit, but a 2008 trial showed it did not make a difference.
One possible reason for the variation could have been the duration of breastfeeding. In the former, the mean duration was 6.5 months, and in the latter, it was 9.2 months.
"At the moment, the evidence is mixed. We have seen it have pre- and post-natal success in Finland, but not in Germany. We also had a negative result in post-natal use in San Francisco.”
Why is probiotic research in paediatrics so challenging?
Dr Cabana said his review of the evidence had reinforced why paediatric probiotic research was so difficult.
He said there were challenges around dependency, noting that research on colic depended on parents maintaining adequate diaries of incidences of crying. Moreover, they could also change their minds about taking part in treatment or trials.
The development of trials can be tricky, not least because there is a higher scrutiny when it comes to safety for studies on children, and it can also be difficult to compare interventions against a placebo.
"For example, we couldn't use a placebo when assessing diarrhoea. We would have to use lactulose because it is a low-cost and widely available treatment."
There is also the issue of a delayed payoff and the difficulty of measuring long-term benefits of interventions, as well as the limited number of potential subjects.
Additionally, he argued that demographic issues often meant there were under-served communities not featured in studies.
"There is a need for study materials that are linguistically and culturally appropriate," he added.