|Year : 2015 | Volume
| Issue : 2 | Page : 508-513
Effects of supplementation with probiotics and prebiotics in infants with gastroenteritis
Fady M El-Gendy1, S Hasan1, Ghada S Shalan MBBCh 2
1 Department of Pediatrics, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Department of Pediatrics, Shebin El-Kom Teaching Hospital, Shebin El-Kom, Egypt
|Date of Submission||01-Jun-2014|
|Date of Acceptance||24-Aug-2014|
|Date of Web Publication||31-Aug-2015|
Ghada S Shalan
Source of Support: None, Conflict of Interest: None
The aim of the study was to investigate the effect of probiotics and prebiotics in infantile gastroenteritis.
Gastroenteritis is a major cause of childhood morbidity and mortality worldwide. Administration of probiotic microorganisms and prebiotic fibers has a role in the prevention of and remediation against a range of intestinal disorders.
Patients and methods
Sixty-five infants with acute gastroenteritis were randomized to receive either probiotic and prebiotic supplementation (supplementation group; n = 50) or no supplementation (nonintervention; n = 15).
Probiotics and prebiotics reduced the duration of vomiting to 3.4 ± 0.9 days in the supplementation group, compared with 4.9 ± 0.8 days in the nonintervention group (t = 5.44, P 0≤ 0.001).
Probiotics and prebiotics reduced the duration of fever to 2.9 ± 0.9 days in the supplementation group, compared with 3.9 ± 0.7 days in the nonintervention group (t = 3.93, P ≤ 0.001). The results showed that probiotics and prebiotics reduced the duration of hospital stay to 5.5 ± 1.9 days in the supplementation group, compared with7.0 ± 1.8 days in the nonintervention group (t = 2.61, P = 0.01).
Probiotics and prebiotics reduced the duration of diarrhea to 4.5 ± 1.4 days in the supplementation group, compared with 6.1 ± 1.4 days in the nonintervention group (t = 3.94, P ≤ 0.001).
Probiotic and prebiotic supplementation has a role in the treatment of gastroenteritis by decreasing the duration of vomiting, fever, diarrhea, and length of hospital stay.
Keywords: diarrhea, gastroenteritis, prebiotic, probiotic, vomiting
|How to cite this article:|
El-Gendy FM, Hasan S, Shalan GS. Effects of supplementation with probiotics and prebiotics in infants with gastroenteritis. Menoufia Med J 2015;28:508-13
|How to cite this URL:|
El-Gendy FM, Hasan S, Shalan GS. Effects of supplementation with probiotics and prebiotics in infants with gastroenteritis. Menoufia Med J [serial online] 2015 [cited 2021 Apr 19];28:508-13. Available from: http://www.mmj.eg.net/text.asp?2015/28/2/508/163910
| Introduction|| |
Acute gastroenteritis (AGE) is an inflammation of the intestine characterized by acute diarrhea, which may or may not be accompanied by nausea, vomiting, fever, or abdominal pain. Worldwide, diarrhea causes 1.4-2.5 million deaths per year in children under the age of 5 years  .
Despite the large numbers of microbes coexisting within the human body, humans, including infants and children, achieve a physiologic state of equilibrium known as health in the context of this microbial world. Probiotics, or beneficial microbes, may modulate immune responses, provide key nutrients, or suppress the proliferation and virulence of infectious agents  .
Prebiotics, which are not digested in the small intestine, enter the colon as intact large carbohydrates, which are then fermented by the resident bacteria to produce short-chain fatty acid  .
Clear criteria have been established for classifying a food ingredient as a prebiotic. These criteria are :
There are only two food ingredients that fulfill these criteria - inulin and trans-galacto-oligosaccharides  .
- Resistance to gastric acidity, to hydrolysis by mammalian enzymes, and to gastrointestinal absorption;
- Fermentation by intestinal microflora; and
- Selective stimulation of the growth and/or activity of those intestinal bacteria that contribute to health and well-being.
Probiotics are commercially available microorganisms that, when ingested as individual strains or in combinations, offer potential health benefits to the host. These agents are often concurrently administered with prebiotics and are referred to as synbiotics  .
This study will examine the evidence for the potential roles of probiotics and prebiotics in reducing the severity and duration of acute infantile gastroenteritis.
| Patients and methods|| |
Our study was a randomized control follow-up clinical trial conducted on 65 critically ill infants suffering from AGE who were admitted to the PICU in Menoufia University Hospital with severe dehydration and shock for intravenous fluid during the period from March 2013 to December 2013. The study was conducted after taking informed consent from parents of each studied patient.
- AGE: defined as acute onset of diarrhea with or without vomiting or fever  .
- Age not more than 2 years.
- Critically ill infants suffering from gastroenteritis only (dehydrated, shocked, electrolyte disturbance) and admitted to the PICU for the same.
Infants were randomly assigned (according to supervisors' opinion) by means of sealed envelopes into two groups: group 1 (the supplementation group) and group 2 (nonintervention group).
- Having congenital anomalies.
- Having inherited metabolic disorders.
Group 1 comprised 50 infants (22 boys and 28 girls) with AGE who received probiotic and prebiotic supplementation. Their mean age was 12.2 ± 7.3 months and mean weight was 8.1 ± 3.2 kg.
The probiotic was contained in sachets, each containing 10 billion lyophilized heat-killed Lactobacillus acidophilus LB. The dose was one sachet twice daily added to water or yoghurt (by ryle if unable to drink or if there was abdominal distension) starting from the first day of admission until discharge from hospital. The prebiotic was in the form of formula containing galacto-oligosaccharide (Hero Baby Nutradefense), given from the first day of admission until discharge from hospital instead of their usual formula (this group was chosen as the artificial feeder group). The infants were regularly evaluated clinically, and laboratory tests were carried out.
Group 2 comprised 15 infants (seven boys and eight girls) of matched age and sex, suffering from gastroenteritis, who did not receive probiotic or prebiotic supplementation and continued to take their regular formula. They served as controls and their mean age was 13.9 ± 6.7 months and mean weight was 9.6 ± 2.4 kg.
On admission, all infants were subjected to clinical history, including personal, present, past, family, and nutritional history, a thorough clinical examination (abdominal girth, tolerability of oral intake), and laboratory investigations including complete blood count, electrolytes, blood and stool cultures, serum albumin and total protein, and arterial blood gas (ABG).
The probiotic group received a standard dose of Lactobacillus LB and were followed up for signs of dehydration and for evaluation of growth parameters (rate of weight gain) until the end of the study.
The duration of follow-up was the whole duration of stay in the PICU.
Data were presented as mean ± SD (X ± SD) or %. The means of two groups were compared using the Student t-test and the Mann-Whitney U-test.
The χ2 -test was used to find the association between qualitative variables. Linear correlation and regression were used to test the correlation between the measured parameters and the studied groups.
Data were tabulated and statistically analyzed with the statistical package for the social sciences (SPSS, version 10; SPSS Inc., Chicago, Illinois, USA). P values less than 0.05 were considered significant  .
| Results|| |
Among the enrolled children 23 had mild dehydration and had been admitted to the PICU because of persistent vomiting not controlled by antiemetics, warranting more investigation for suspicious causes, although their severity of diarrhea had reduced; 20 had moderate dehydration and were receiving intravenous fluids; and seven were severely dehydrated and were undergoing shock treatment.
Baseline demographic data of the studied groups and clinical data were recorded, such as number of episodes of vomiting/day, stool volume/day, weight before and after rehydration, and severity of dehydration.
No statistically significant difference was found as regards stool frequency, vital signs (heart rate (HR) and respiratory rate (RR)), and signs of dehydration in the supplemental group when compared with the nonsupplemental group; however, the frequency of vomiting was more in the nonsupplemental group when compared with the supplemental group at the time of admission (t = 3.28, P = 0.002) [Table 1].
|Table 1 Comparison of clinical data of the studied groups at the time of admission|
Click here to view
The duration of diarrhea, vomiting, and fever was highly statistically significantly shorter in the supplemental group when compared with the nonsupplemental group [Table 2].
|Table 2 Comparison of duration of vomiting, diarrhea, and fever of the studied groups during their stay in the hospital|
Click here to view
No statistically significant difference was found between the groups as regards white blood cell count, K level, albumin level, total proteins, alanine aminotransferase and aspartate aminotransferase levels, platelet count, red blood cell count, and creatinine level and statistically significant difference was found as regards hemoglobin level and Na level and a highly statistically significant difference as regards blood urea nitrogen (BUN) level at the time of admission.
The frequency of stools and number of episodes of vomiting at the time of discharge was highly statistically significantly lower in the supplemental group when compared with the nonsupplemental group [Table 3].
|Table 3 Comparison of clinical data of the studied groups at the time of discharge|
Click here to view
There was a nonstatistically significant difference between the groups as regards hemoglobin, Na, K level, alanine aminotransferase and aspartate aminotransferase level, platelet count, and creatinine level and a statistically significant difference as regards serum albumin level, total proteins, and BUN and a highly statistically significant difference as regards white blood cell and red blood cell counts at the time of discharge, which was more in the supplemental group when compared with the nonsupplemental group.
The length of hospital stay was statistically significantly shorter in the supplemental group when compared with the nonsupplemental group [Table 4].
|Table 4 Comparison of length of stay in the hospital between the studied groups|
Click here to view
There was no statistically significant difference as regards stool cultures in the studied groups [Table 5].
There was a nonstatistically significant difference in weight gain between the studied groups during hospital stay [Table 6].
|Table 6 Comparison of weight gain during stay in the hospital between the studied groups|
Click here to view
There was no statistically significant difference in clinical outcome between the studied groups [Table 7].
Two children died in the intervention group:
- One child died from complications due to hemolytic uremic syndrome.
- One child died from complications due to disseminated intravascular coagulation (DIC).
| Discussion|| |
We aimed to study the effect of probiotic and prebiotic supplementation in acute infantile gastroenteritis.
In our study there was no statistically significant difference as regards frequency of stool, vital signs (HR and RR), and signs of dehydration in the supplemental group at the time of admission when compared with the nonsupplemental group. However, the frequency of vomiting was higher in the nonsupplemental group when compared with the supplemental group at the time of admission.
The results showed that there was a highly statistically significant difference between the two groups with regard to the frequency of stool (motions/day), with a mean of 1.32 ± 0.61 in the supplemental group compared with 2.63 ± 1.25 in the nonsupplemental group. There was also a highly statistically significant difference in the number of episodes of vomiting (times/day), which was lesser in the supplemental group when compared with the nonsupplemental group at the time of discharge. The mean in the supplemental group was 0.78 ± 0.23 and that in the nonsupplemental group was 1.72 ± 0.68.
These results agree with those from a trial conducted by a research team from the Aldo Moro University of Baro in Italy in which 554 infants were analyzed with probiotic supplementation during attacks of AGE between September 2010 and October 2012. The infants were all randomized to receive either a probiotic supplement containing Lactobacillus reuteri DSM 17938 bacteria or placebo. The researchers found that the children who received the probiotic supplement had a lower average number of episodes of vomiting and crying rate each day, compared with the placebo group  .
However, our results were in contrast to those from a double-blind randomized control trial conducted on 78 children who received either standard antibiotic treatment plus a food supplement containing 108 colony forming units of Bifidobacterium longum PL03, Lactobacillus rhamnosus KL535A, and Lactobacillus plantarum PL02 (n = 0¼40) or placebo (n = ¼38) twice daily for the duration of antibiotic treatment. The probiotic-treated patients had a similar rate of diarrhea as those receiving placebo  .
We also found a statistically significant difference as regards signs of dehydration between the studied groups at the time of discharge, which was lesser in the supplemental group when compared with the nonsupplemental group.
In a double-blind, placebo-controlled trial 87 children (age ranged from 2 months to 6 years) with infectious diarrhea were administered Lakcid L at a dose of 1.2 × 10 10 colony forming units or placebo, twice daily, for 5 days.
The mean duration of diarrhea in the treated group was 84 ± 56 h and that in the placebo group was 96 ± 72 h (P = 0.36). The duration of parenteral rehydration was 15 ± 14 versus 38 ± 33 h (P = 0.006). Gut colonization by administered strains was 80 and 41% at 5 and 14 days, respectively  .
In our study there was a highly statistically significant difference as regards duration of vomiting, which was shorter in the supplemental group (mean 3.4 ± 0.9) when compared with the nonsupplemental group (mean 4.9 ± 0.8). There was also a highly statistically significant difference as regards the duration of diarrhea, which was shorter in the supplemental group (4.5 ± 1.4) when compared with the nonsupplemental group (6.1 ± 1.4). In our study there was a highly statistically significant difference as regards duration of fever, with a mean of 2.9 ± 0.9 in the supplemental group and 3.9 ± 0.7 in the nonsupplemental group.
These results agreed with the study by Grandy et al.  , which was a prospective, double-blind, randomized protocol conducted on children aged 1-23 months who had been hospitalized for acute diarrhea. These children were randomized to one of three groups: group GC received oral rehydration solution (ORS) and a placebo; group GB received ORS plus Saccharomyces boulardii; and group GARLB received ORS plus the combined probiotic product L. acidophilus, L. rhamnosus, B. longum, and S. boulardii. Placebo and probiotic products had similar color and taste. When the merged intervention groups were compared with the control, the total duration of diarrhea, fever, and vomiting was significantly shorter  .
In contrast, the study by Albano et al.  on probiotics in the management of children with acute diarrhea found that most of the preparations tested had no effect on the duration of diarrhea.
Our results were also in contrast to the results of a study conducted in some hospitals comparing nitazoxanide with probiotics, none of which detected shorter duration of fever during attacks of gastroenteritis  .
Our study also revealed that weight gain (g/day) was higher in the supplemental group (although nonsignificant) (17.7 ± 18.2) when compared with the nonsupplemental group (9.2 ± 8.8).
This result agrees with that obtained in a national, open, randomized, controlled intervention trial in Pakistan. The intervention consisted of a 2-h course based on the guidelines for management of AGE and supplementation with probiotics. The baseline features of the children were similar in groups A (n = 617) and B (n = 692). The duration of diarrhea was shorter in group A (intention-to-treat: 83.3 vs. 90.9 h; P < 0.001). Weight gain was marginally but statistically significantly higher in children treated according to the guidelines (per-protocol analysis: +16.5 vs. −13.5 g; P < 0.05)  .
According to the results, we found that there was a significantly shorter length of hospital stay in the supplemental group (mean 5.5 ± 1.9) when compared with the nonsupplemental group (7.0 ± 1.8).
This agrees with the results of a large randomized controlled multicenter trial on 287 children with diarrhea. The children were administered oral rehydration salts enhanced with L. rhamnosus GG or a placebo. There was a significant reduction in the duration of diarrhea and decreased hospital stay in the probiotic group  .
In our study there was a nonsignificant statistical difference between intake of probiotic and prebiotic and clinical outcome.
This agrees with the observation made in a study conducted in the ICU of Scarborough Hospital in the UK on 45 critically ill patients who were randomized to receive L. plantarum 299v and compared with 45 controls. The rate of infective complications and clinical outcomes were unchanged; however, CRP and IL-6 levels and endotoxin exposure tended to be lower in the probiotic group, just failing to reach statistical significance  .
Despite the accumulation of studies with positive results, the practical use of probiotics in gastroenteritis is still limited, probably (at least partly) because available products (or formulations or doses) have not been properly assessed. Thus, efforts should be made to perform clinical studies with available products, formulations, and doses  .
| Conclusion|| |
Probiotic and prebiotic supplementation has a role in the treatment of AGE, decreasing the duration of vomiting, fever, diarrhea, and length of stay in the hospital.
| Acknowledgements|| |
Conflicts of interest
There are no conflicts of interest.
| References|| |
Kosek M, Bern C, Guerrant RL. The global burden of diarrheal disease as estimated from studies published between 1992 and 2000. Bull World Health Organ 2003; 81
Malek MA, Curns AT, Holman RC, et al.
Diarrhea- and rota virus-associated hospitalizations among children less than 5 years of age United States, 1997 and 2000. Pediatrics 2006; 17
Hsieh MH, Versalovic J. The human microbiome and probiotics: implications for pediatrics, Curr Probl Pediatr Adolesc Health Care 2008; 38
Kolida S, Tuohy K, Gibson GR. Prebiotic effects of inulin and oligofructose. Br J Nutr 2002; 87S193-S197.
Bengmark S. Synbiotics and mucosal barrier in critically ill patients. Curr Opin Gastroenterol 2005; 21
Verhagen P, Moore D, Manges A, Quach C. Nosocomial rotavirus gastroenteritis in a Canadian pediatric hospital: incidence, disease burden and patients affected. J Hosp Infect 2011; 79
Noursis MJ. Statistical package for social sciences (SPSS),
base 10.0 for windows user, s guide. Chicago, IL: SPSS Inc.; 1997.
Indrio F, Di Mauro A, Riezzo G, Civardi E, Intini C, Corvaglia L, et al
. Prophylactic use of a probiotic in the prevention of colic, regurgitation, and functional constipation: a randomized clinical trial. JAMA Pediatr 2014; 168
Szajewska H, Hoekstra JH, Sandhu BK. Management of acute gastroenteritis in Europe and the impact of new recommendations: a multicenter study. J Pediatr Gastroenterol Nutr 2008; 30
Grandy G, Medina M, Soria R, Terán CG, Araya M. Probiotics in the treatment of acute rotavirus diarrhea. A randomized, double-blind, controlled trial using two different probiotic preparations in Bolivian children. BMC Infect Dis 2010; 10
Albano F, Lo Vecchio A, Guarino A. The applicability and efficacy of guidelines for the management of acute gastroenteritis in outpatient children: a field-randomized trial on primary care pediatricians. J Pediatr 2010; 156
Nitazoxanide VS, Terán C, Terán-Escalera C, Villarroel P. Nitazoxanide vs. probiotics for the treatment of acute rotavirus diarrhea in children: a randomized, single-blind, controlled trial in Bolivian children. Int J Infect Dis 2009; 13
Guandalini S. Probiotics for children with diarrhea: an update. J Clin Gastroenterol 2008: 42
Deitch EA. Nutrition and the gut mucosal barrier. Curr Opin Gastroenterol 1993; 85-91.
Alvarez-Olmos, MI, Oberhelman, RA. Probiotic agents and infectious diseases: a modern perspective on a traditional therapy. Clin Infect Dis 2001; 32
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]