In a child with acute gastroenteritis, do Probiotics reduce the duration and severity of diarrhoea?
Date First Published:
November 9, 2003
Last Updated:
November 10, 2003
Report by:
S.Venkatesh Karthik and N.D.Nelhan, SpR in paediatrics, Consultant Paediatrician (Wrexham Maelor Hospital, Wrexham North Wales)
Search checked by:
S.Venkatesh Karthik, Wrexham Maelor Hospital, Wrexham North Wales
Three-Part Question:
In a [child admitted with acute gastroenteritis], does [the use of Probiotics] reduce the [duration of hospital stay, frequency and severity of diarrhoea]?
Clinical Scenario:
You are a Paediatric Registrar on duty. The S.H.O asks you to review a child recently returning from Spain, presenting with acute gastroenteritis. The mother shows you a prescription indicating treatment with a Probiotic preparation started by the doctor abroad and wonders about whether you would continue with the same. The S.H.O also quotes some studies supportive of this intervention. You have some time and go off to search for evidence in this regard.
Search Strategy:
Secondary Sources- Cochrane Database: Topic registered but no reports.
Primary Sources- MEDLINE [1966-Sept'2003];
Primary Sources- MEDLINE [1966-Sept'2003];
Search Details:
Search Terms-
"Acute Gastroenteritis"/ "Infectious Diarrhoea" AND/OR "Probiotics"/ "Lactobacillus"; Limits: English; Human; Child<18 years.
"Acute Gastroenteritis"/ "Infectious Diarrhoea" AND/OR "Probiotics"/ "Lactobacillus"; Limits: English; Human; Child<18 years.
Outcome:
There were 28 reported RCT's of Lactobacillus treatment of Infectious diarrhoea/Acute gastroenteritis in this period of which 11 were included in the systematic review carried out earlier in 2002. There have been two further RCT's carried out since then, that also meet the criteria laid down for the earlier review. See Table 1 below.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Probiotics in the treatment and prevention of Acute Infectious Diarrhea in Infants and Children: A Systematic Review of Published Randomized, Double-Blind, Placebo-Controlled Trials. Szajewska H and Mrukowicz JZ. 2001 Poland | Systematic review of 13 double-blinded RCT's including 3 prevention trials comparing the use of probiotics versus placebo in the treatment and prevention of acute infectious diarrhoea in infants and children | Systematic review(Level 1a) | (1) Risk of diarrhoea lasting for greater than 3 days (2) Number of watery stools per day and duration of hospitalisation (3) Prevention trials: Incidence rates of diarrhoea | (1) Pooled estimate relative risk of diarrhoea lasting >3 days was 0.43(95% CI 0.34-0.53; p< 0.0001; significant) (2) Reduction in the duration of diarrhoea with probiotics(versus placebo)- Pooled weighted mean difference was -20.1 hours (95% CI WERE -26.1 to -14.2 hours) | Diverse range of probiotics employed which makes exact comparison of outcomes difficult. Stool output(Volume) not measured Significant methodological and statistical heterogeneity across studies |
| Lactobacillus Therapy for Acute Infectious Diarrhea in Children: A Meta-analysis. Van Niel CW. Feudtner C. Garrison MM. Christakis DA. 2002 U.S.A | Nine RCT's over a 27 year period comparing the use of Lactobacillus versus placebo for the treatment of infectious diarrhoea in children. Only adequately blinded studies were included. | Systematic review(Level 1a) | (1) Duration(in days) of diarrhoea (2) Frequency(number of stools per day) | (1) Significant reduction in diarrhoea duration of 0.7 days(95% CI 0.3 to 1.2 days) in subjects given Lactobacillus compared to placebo (2) Summary point estimate for frequency of stools(only in 3 studies) was 1.6/day fewer in the intervention group(95% CI 0.7-2.6 fewer stools) | Not all studies reported variance in measurement of diarrhoea duration and frequency Heterogeneity of treatment effects across studies (Most were children with mild-to-moderately severe dehydration) seen. |
| Effect of probiotic Lactobacillus strains in young children hospitalized with acute diarrhoea. Rosenfeldt V. Michaelsen KF. Jakobsen M et al. 2002 Denmark | 69 children hospitalised for acute diarrhoea randomised to receive probiotic Lactobacillus strains or placebo | RCT(Level 1b) | (1) Duration(in hours) of diarrhoea (2) Length of hospital stay( in hours) (3)Absence of Rotaviral antigen in stools at the end of the 5-day intervention period | (1) Lactobacillus intervention reduced diarrhoea duration(82 versus 101 hours;p=0.07;not significant) (2) Length of hospitalisation reduced by 48% in intervention group(3.5 versus 1.7 days; p=0.03; significant) (3) Rotaviral antigen found in 12% 9vs 46% in placebo group;p=0.02; not significant) | Frequency and stool volume were not measured |
| Limitations of Probiotic Therapy in Acute, Severe Dehydrating Diarrhea. Costa-Ribeiro H. Ribeiro TC. Mattos AP et al. 2003 U.S.A | 124 male children under 2 years of age admitted with moderate dehydration randomised to recieve either Lactobacillus or placebo | RCT(Level 1b) | (1) 24 hour estimation of stool output(Volume) (2) Duration(in hours) of diarrhoea (3) Proportion of children requiring Intravenous rehydration | (1) No significant reduction in duration of diarrhoea(38.27±3.78 versus 39.09± 4.60 hours; p=0.59) (2) No significant reduction in stool output/kilogram body weight(139.74 ± 171.16 versus 184.63 ± 274.13 ml/kg; p=0.81) | Greater proportion of moderate to severely dehydrated as well as very young children. Children with severe malnutrition and bloody diarrhoea were excluded. |
Author Commentary:
Acute diarrhoeal illnesses are a leading cause of childhood morbidity and mortality in young children, especially in the developing world. Oral Probiotic therapy supplementing oral rehydration treatment has in the recent years been suggested to have a substantial therapeutic potential for reducing the severity and duration of diarrhoea. Numerous bacteria have been identified of possible benefit of which Lactobacillus GG has been most extensively studied. The systematic review by Van Niel et al found that treatment with Lactobacillus brought about a significant reduction in the duration of diarrhoea as well as stool frequency. Szajewska et al however, in their review, studied trials employing a diverse range of Probiotics in relation to not only their therapeutic value in established diarrhoeal illness but also their potential value as a preventive in reducing the incidence of diarrhoea. Though these two reviews favour Probiotics as a valuable intervention, the trials included in both show a great degree of diversity in terms of the subjects involved, nature of the illness and its severity. More importantly, these reviews have not addressed the effect of Probiotics on Stool output [Volume]. The World Health Organization (WHO) recommends that the main criterion to assess the potential benefit of any planned intervention in acute gastroenteritis should be quantifiable in terms of its effect on reducing stool volume. Costa-Ribeiro et al in their recent study found that Lactobacillus GG therapy did not bring about a statistically significant reduction in either the stool output or duration of diarrhoea. It should however be noted that many subjects in their study had moderate to severe dehydration often requiring intravenous fluids and all were under two years of age. They concluded that any potential benefits accruing from Probiotics might be limited to children with prolonged diarrhoea and possibly in high-risk populations. No significant adverse effects were reported. Further large-scale controlled trials particularly focussing on an ambulatory child population are essential to identify the exact benefits of these agents.
Bottom Line:
Probiotics are a useful adjuvant along with rehydration therapy in Acute Gastroenteritis.
Their role in prevention of diarrhoeal illness and children treated as outpatients is still not established.
Cost-effectiveness particularly in developing nations is an important and unresolved issue
Their role in prevention of diarrhoeal illness and children treated as outpatients is still not established.
Cost-effectiveness particularly in developing nations is an important and unresolved issue
References:
- Szajewska H and Mrukowicz JZ.. Probiotics in the treatment and prevention of Acute Infectious Diarrhea in Infants and Children: A Systematic Review of Published Randomized, Double-Blind, Placebo-Controlled Trials.
- Van Niel CW. Feudtner C. Garrison MM. Christakis DA.. Lactobacillus Therapy for Acute Infectious Diarrhea in Children: A Meta-analysis.
- Rosenfeldt V. Michaelsen KF. Jakobsen M et al.. Effect of probiotic Lactobacillus strains in young children hospitalized with acute diarrhoea.
- Costa-Ribeiro H. Ribeiro TC. Mattos AP et al.. Limitations of Probiotic Therapy in Acute, Severe Dehydrating Diarrhea.