1. Probiotics in the
Prevention of Neonatal
Necrotising Enterocolitis,
Sepsis & Mortality
Sourabh Dutta
Professor, Newborn Unit
PGIMER, Chandigarh

2. What is NEC?
• The most devastating intestinal disease in newborns
• Affects mostly preterms weighing <1500 g
• Divided into three stages I, II, III of increasing severity
• May result in intestinal perforation and death

3. Bacteria & NEC
GI mucosa is in a state of controlled inflammation
PATHOGEN COMMENSAL
MAMPs (microbe
associated molecular
patterns)
Pattern
recognition
receptors
(PRRs)
Toll-like
receptor 4
(TLR4)
 NF-κB
NucleusPro-inflammatory
cytokines
 I-κB
Anti-inflammatory
cytokines

4. Why does dysbiosis occur in
preterms?
• Vaginal colonization with Bifido & Lacto  as
pregnancy progresses
• Often delivered by LSCS
• Antenatal & postnatal antibiotic exposure
• Exposure to NICU flora
• Multiple procedures
– Tube feeding
– Suctioning
– Intubation
• Less human milk feeding

5. Theoretical basis for use of
probiotics to PREVENT NEC
• Aberrant gut colonization  NEC
• Probiotics
– Competitively inhibit growth of pathogens
– Increase mucosal immunity
– Prevent adherence of pathogens
– Shift balance to anti-inflammatory state

6. Cochrane meta-analysis
Khalid AlFaleh, Jasim Anabrees
• Probiotics for prevention of NEC in preterms
• Published 2014, up-to-date as of Oct 2013
• 24 eligible trials
• Variability in baseline risk of NEC, probiotic
regime, breast-feeding
• Prophylactic probiotic supplementation
– Reduced severe NEC [RR 0.43 (95% CI 0.33, 0.56),
20 studies, 5529 infants, I2 0%]
– Reduced mortality [RR 0.65 (95% CI 0.52, 0.81),
17 studies, 5112 infants, I2 0%]
– No reduction of sepsis [RR 0.91 (95% CI 0.8, 1.03),
19 studies, 5338 infants, I2 0%]

7. What does it take to change practice?
Intervention Outcome Effect size Number of
subjects in
meta-analysis
Natural surfactant
vs placebo,
Cochrane 2009
Mortality RR = 0.68 (0.57, 0.82) 1469
Hypothermia for
HIE.
Cochrane 2008
Mortality
Mortality or
NDI
RR = 0.74 (0.58, 0.94)
RR = 0.76 (0.65, 0.89)
638
506
Room air for
resuscitation.
Cochrane 2009
Mortality
HIE
RR = 0.71 (0.54, 0.94)
RR = 0.84 (0.65, 1.08)
1275
1124
Probiotics for
NEC.
Cochrane 2014
Mortality RR = 0.65 (0.52, 0.81) 5112
Evidence for probiotics has been there since 2009
and yet practice has not changed!!

8. Why is there still so much resistance to
introducing probiotics?
• Roger Soll; Beattie; Neu et al. Letters to Ed. Pediatrics, 2010
– Different strains, regimes
– Meta-analysis had no sub-group of ELBW babies
– Variety of milk (breast, formula) used
– No exclusively breast-fed sub-group
– Environmental cross-contamination of placebo group
– Safety not proven
– Long-term neuro-developmental sequelae not known
– Lack of US FDA approval
• Are these objections valid?

9. Is this objection valid?...
• “Various strains used. Cannot be
combined in meta-analysis as a single
therapeutic agent.”
– But if this argument were correct, Cochrane
reviews on antibiotics for colo-rectal ca
surgery, beta-blockers, contraceptives etc
would all have to be disregarded!
– Despite heterogeneity of probiotic regimes,
homogeneity of outcome supports contention
that probiotics as a class are effective

10. Cochrane meta-analysis
Subgroup analysis of strains
Severe NEC
Mortality
Either use
Lactobacillus or
mixture including
Lactobacillus
RR

11. Is this objection valid?
Cochrane meta-analysis
Subgroup analysis of ELBW babies
outcome participants RR [95% CI]
Severe NEC 575 0.76 [0.37, 1.58]
mortality 1199 0.94 [0.58, 1.53]
Comment to Cochrane review
Probiotics ought to work in ELBW because 25% of
pooled population expected to be ELBW if
distribution is normal

12. Cochrane meta-analysis
Subgroup analysis of ELBW babies
outcome participants RR [95% CI]
Severe NEC 575 0.76 [0.37, 1.58]
mortality 1199 0.94 [0.58, 1.53]
Comment to Cochrane review
Probiotics ought to work in ELBW because 25% of
pooled population expected to be ELBW if
distribution is normal

13. Is this objection valid?...
• “Safety of probiotics not known. May cause
sepsis due to probiotic strains.”
– Not a single case of probiotic induced sepsis
documented in 2761 infants in probiotic arm of
Cochrane 2014 meta-analysis
– 5 case reports of neonatal probiotic septicemia
• Only 1 confirmed to be probiotic strain by molecular typing*
Study Organism grown Patient
Jenke 2012 B longum & B infantis 600 g, proplylactic L acidophilus & B infantis
Ohishi 2010 B breve Term, probiotic therapy postop Omphalocele
Guenther 2010 E coli Nissle 1917 935 g, probiotic therapy post diarrhea
Kunz 2004 Lactobacillus GG 36 w, probiotic therapy post-op short gut*
34 w, probiotic therapy post-op short gut

14. Is this objection valid?...
• “Effect on long-term neuro-development?”
– NEC itself is a major cause of impaired
neuro-development in VLBW
– If you are dead, what more impairment of
neuro-development can you possibly have?
– Difficult to imagine that probiotics would cause
so much NDI as to nullify the benefit caused
by NEC reduction!
– NDI on follow-up (Kitajima et al)
• RR = 1.02 (0.15, 6.94)

15. Is this objection valid?...
• “Not all trials are of good quality”
– Sub-group analysis of high quality studies
(Cochrane, 2014)
– Sub-group analysis of 4 high quality studies
(Guthman et al, Klin Padiatr, 2010)
• RR = 0.36 (0.20, 0.66)
Outcome Studies Participants RR [95% CI]
Severe NEC 11 4473 0.43 [0.31, 0.59]
Mortality 10 4386 0.71 [0.55, 0.91]

16. Is this objection valid?
“US FDA does not approve.
Not enough trials done in USA”
Study Country Study Country
Reuman 1986 US (n=45) Manzoni 2009 Italy
Millar 1993 UK Rouge 2009 France
Kitajima 1997 Japan Samanta 2009 India
Dani 2002 Italy Sari 2010 Turkey
Costalos 2003 Italy Mihatsch 2010 Germany
Li 2004 Japan Romeo 2011a Italy
Lin 2005 Taiwan Romeo 2011b Italy
Bin-Nun 2005 Israel Rojas 2012 Colombia
Manzoni 2006 Italy Al-Hosni 2012 USA
Mohan 2006 Germany Demirel 2013 Turkey
Stratiki 2007 Greece Fernandez 2013 Mexico
Lin 2008 Taiwan ProPrems 2013 Australia, NZ

17. Do we endlessly wait for the “best regime”?
• Head-to-head comparisons to find which is best regime
would require > 20 RCT’s!!
– Not less than another 10 years
– Enormous expense
• More pragmatic approach
– Use a mixture of probiotics including Lactobacillus
– 1 billion cells 12 hourly
– Start with the first feed
– Give for about six weeks or until discharge
– Never use probiotics as therapy after a GI problem
– In you are very concerned about safety in ELBW babies, discuss
with parents that there is one reported case of possible probiotic
septicemia when used prophylactically and take consent

18. You eat this
frequently…
No, these
are not
noodles…
This is an
electron
microscopic
picture of
YOGURT
Lactobacillus bulgaricus
Streptococcus thermophilus
Why deprive our
neonates of this?