First for India: Expert panel recommends probiotic strain Lactobacillus GG as adjuvant therapy for children with diarrhoea
However, they added that Saccharomyces boulardii had far less evidence of success.
The consensus also recommends a combination of probiotics as therapy for neonatal necrotising enterocolitis (NEC) to reduce its risk of moving to stage II and beyond, late-onset sepsis and mortality.
In contrast, the NCG does not condone probiotic use in treating acute dysentery, persistent diarrhoea, Clostridium difficile diarrhoea, and chronic diarrheal conditions, such as celiac disease, diarrhoea-predominant irritable bowel syndrome (IBS) and inflammatory bowel disease, in children.
The consensus was documented in a paper titled “Indian Academy of Pediatrics Consensus Guidelines for Probiotic Use in Childhood Diarrhea”.
The consensus is crucial because research has shown that diarrhoea accounts for approximately 11% of childhood deaths worldwide.
“Probiotics, when administered in adequate amounts, confer beneficial effects by replacing the pathogenic bacteria with favourable ones, interfering with pathogen attachment, inactivating toxins, having anti-secretory effects, reducing the loss of water and electrolytes from the gut, strengthening gut barrier integrity, releasing gut protective metabolites, and having loco-systemic immunomodulatory effects,” said the experts.
A team of experts named the NCG was first designated by the Indian Academy of Pediatrics (IAP). As they reviewed current literature on the role of probiotics in childhood diarrhoea, they considered several issues, such as the impact of probiotics on the overall outcomes, recommended strains to be utilised and compliance with international guidelines.
They deliberated upon 15 years of literature, ranging from existing guidelines and systematic reviews to meta-analyses and trials, from 2005 to 2020. The quality of the evidence was then assessed using the GRADE approach.
Their research highlighted four categories of illness – acute diarrhoea, necrotising enterocolitis (NEC), antibiotic-associated diarrhoea (AAD) and pouchitis – which were then explained through the lenses of the Indian context and international guidelines.
For example, in acute gastroenteritis, recommendations and guidelines came from North America and Europe, but heavy caseloads with more severity and mortality were managed by Asia, Africa and Latin America.
From the Indian experience, an RCT conducted by Sriparna Basu et al. (2009), for instance, showed a significant reduction in the duration of the diarrhoea, hospital stay and stool consistency with the help of LGG.
For neonatal NEC cases, the European Society of Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN) recommends LGG or a combination probiotic to halt the disease progression beyond stage two.
However, Indian research mostly used multi-strain probiotics and the supplementation was continued until the patient was discharged, reaching full feeds or specified duration of up to three weeks. Demographic issues like geography, gender, ethnicity and peripartum cultural practices also influenced study results.
Probiotics in India
In the context of India, research has shown that there were significant differences in some brand preparations and the next-gen probiotics. Some probiotics even contained new strains that were not part of the original label.
Several studies also compared the label concentrations and the in-vitro viable cell count on culture, indirectly confirming the bioavailability.
Combination probiotics like the VSL#3 also contain recommended versus marketed concentration issues.
Hence, the experts advised using probiotics carefully based on crucial factors, such as the rationale, type of species and strains, concentrations available, format, bioavailability and shelf life.
“Probiotics in India should be used judiciously after obtaining complete information regarding the strains present, shelf life and storage requirements.
“The decision to use a probiotic should be in line with scientific evidence, keeping in mind the cost-benefit ratio,” said the experts.
Source: Indian Pediatrics
“Indian Academy of Pediatrics Consensus Guidelines for Probiotic Use in Childhood Diarrhea”
Authors: Surender Kumar Yachha et al