ProBiotics for AGE

ProBiotic

Probiotics for Acute Gastroenteritis (AGE)

We are all very familiar with the battle that is waged daily in pediatric emergency departments everywhere: the battle against dehydration due to vomiting and diarrhea!  We are well versed in the determination of degrees of dehydration (mild, moderate, and severe) and are well aware of the benefits of Oral Rehydration Therapy.  But while we may have gained the strategic high-ground over vomiting with the nearly ubiquitous use of Ondansetron, let us not forget that the diarrhea can be quite problematic and often leads to greater overall volume loss than emesis {Recall, you should replace ~10 ml/kg per diarrheal stool compared to ~2 ml/kg of emesis}.

What can be done to help win the battle on this front?  Perhaps employing some microbiologic armies to do our dirty work on the intestinal front can help!

 

Diarrhea certainly isn’t a friend: Probiotics can be an ally.

  • Probiotics = microbial cell preparations or components of microbial cells that have a beneficial effect on the health of the host.
  • Basic concept = probiotics compete for available nutrients and binding sites while making the gut contents acidic and producing a variety of chemicals as well as increasing specific and non-specific immune responses all leading to decreased ability for the pathogen to cause injury.
  • Because AGE is a self-limited condition, the tolerance for medication adverse reactions is minimal, which has lead to most anti-diarrheal medications not being advocated for in children.
  • Several studies, however, have shown probiotics to be effective and safe:
    • What each study uses to define diarrhea is one area of potential weakness for all of these studies, but results seem to be consistent.
    • Probiotics are found to be effective in limiting viral diarrhea duration.  (Guandalini Clin Gastroenterol 2008)
    • Systematic Review of 63 studies (8014 participants) showed a significant reduction of duration of diarrhea by a mean of 24.76 hrs and a reduction of stool frequency on day #2. (Allen Cochrane Database of Systematic Reviews 2010)
    • NO ADVERSE EVENTS WERE ATTRIBUTED TO PROBIOTCS.

     

    • But which probiotic should be prescribed?
      • More research is needed to guide the use of particular probiotic
      • Previous studies favor:
        • Lactobacillus strain GG
        • Lactobacillus acidophilus and Lactobacillus bifidus
        • Lactobacillus acidophilus LB strain (killed)
        • Lactobacillus reuteri
        • Enterococcus LAB strain SF68
        • There is a dose dependent relationship
          • Minimal effective dose reported to be 10 Billion colony-forming units (Van Niel. Pediatrics 2002)
          • One regimen (advocated by Cincinnati Children’s BESt) is:
            • Lactobacillus rhamnosus GG 10 billion CFU per Day.
              • A Commercial Product is available in the US for ~$19.
            • Start as soon as possible… and continue for 5-7 days.
  • Do NOT use probiotics for patients with:
    • Immunocompromised conditions
    • Short-Gut Syndrome
    • Prematurity
    • Cardiac Surgical diseases

 

  1. Guandalini S. Probiotics for children with diarrhea: an update. J. Clin Gastroenterol 2008;42(Suppl. 2): S53-7.
  2. Allen SJ, Martinez EG, Gregorio GV, Dans LF. Probiotics for treating acute infectious diarrhoea. Cochrane Database of Systematic Reviews 2010, Issue 11. Art. No.: CD003048. DOI: 10.1002/14651858.CD003048.pub3
  3. Van Niel CW, Feudtner C, Garrison MM, Christakis DA. Lactobacillus Therapy for Acute Infectious Diarrhea in Children:  A Meta-Analysis.  2002.  Pediatrics 109; 678-684.

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