The Use Of Probiotics in the Management of Diarrhea in Infants and Children Ana Abad-Jorge, MS, RD, CNSC Brandis Roman, RD...
Financial Disclosures <ul><li>We have no commercial relationships relevant to the topic being presented. </li></ul>
Learning Objectives <ul><li>Upon completion of this session, the learner will be able to: </li></ul><ul><ul><li>Identify s...
Introduction to Probiotics (4-7) <ul><li>Viable microorganisms </li></ul><ul><li>Exert beneficial effects on the host when...
Forms of Probiotics <ul><li>Treatment </li></ul><ul><ul><li>Tyndalized = heat-treated </li></ul></ul><ul><ul><li>Lyophiliz...
Acute Diarrhea <ul><li>Various etiologies </li></ul><ul><ul><li>Infectious – bacteria, viral, or parasites </li></ul></ul>...
Impact of Acute Diarrhea <ul><li>Impact on the health care system (2) </li></ul><ul><ul><li>>130,000 hospitalizations per ...
Can probiotics shorten the duration of acute diarrheal episodes to improve quality of life and reduce necessary hospitaliz...
General Limitations in the Current Literature <ul><li>Dietary intake </li></ul><ul><ul><li>Juice consumption </li></ul></u...
Rotavirus-related acute diarrhea <ul><li>VSL #3 (1) </li></ul><ul><ul><li>Improved total recovery rate, reduced stool freq...
Non-rotavirus-related acute diarrhea <ul><li>E. coli Nissle  1917 (3) </li></ul><ul><ul><li>Reduced time to diarrhea reduc...
Acute Diarrhea of Mixed/Unknown Etiology <ul><li>L. rhamnosus GG – studies have yielded mixed results </li></ul><ul><ul><l...
Acute Diarrhea of Mixed/Unknown Etiology, cont’d <ul><li>S. boulardii  – yeast probiotic </li></ul><ul><ul><li>Mixed resul...
Acute Diarrhea of Mixed/Unknown Etiology, cont’d <ul><li>Lactogemina blend </li></ul><ul><ul><li>Reduced duration of diarr...
Acute Diarrhea of Mixed/Unknown Etiology, cont’d <ul><li>B. clausii </li></ul><ul><ul><li>No reduction in diarrhea duratio...
Persistent Diarrhea of Mixed/Unknown Etiology <ul><li>L. rhamnosus  GG (17) </li></ul><ul><ul><li>Reduced frequency of dia...
Can probiotics, when given prophylactically, reduce the incidence of diarrhea?
Diarrhea of Mixed/Unknown Etiology <ul><li>CUPDAY milk formula containing  B. lactis  CNCM (18)  </li></ul><ul><ul><li>20%...
Diarrhea of Mixed/Unknown Etiology, cont’d <ul><li>Infant formula with  L. reuteri  SD2112 (20) </li></ul><ul><ul><li>Redu...
Commercial Availability of Probiotic Preparations That Have Been Studied in Infants and Children
Cost Comparison of Common Products Product cost information obtained from: a =  www.costlessvitamin.com b =  www.vsl3.com ...
References  <ul><li>See attached references list </li></ul><ul><li>All proprietary product information was obtained from t...
Learning Assessment Question #1 <ul><li>Which of the following is NOT a common limitation of the current literature in thi...
Learning Assessment Question #2 <ul><li>Which of the following probiotic products did NOT show positive results in reducin...
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The Use Of Probiotics In The Management Of Diarrhea In Infants And Children

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The Use Of Probiotics In The Management Of Diarrhea In Infants And Children

  1. 1. The Use Of Probiotics in the Management of Diarrhea in Infants and Children Ana Abad-Jorge, MS, RD, CNSC Brandis Roman, RD, CNSD Pediatric Nutrition Support Specialists University of Virginia Health System Charlottesville, VA February 3, 2009
  2. 2. Financial Disclosures <ul><li>We have no commercial relationships relevant to the topic being presented. </li></ul>
  3. 3. Learning Objectives <ul><li>Upon completion of this session, the learner will be able to: </li></ul><ul><ul><li>Identify specific strains or combinations of probiotics that may be useful in managing diarrhea in infants in children. </li></ul></ul><ul><ul><li>Identify strains that might be useful in managing infectious vs. non-infectious diarrhea. </li></ul></ul><ul><ul><li>Identify the commercial availability of probiotic strains. </li></ul></ul>
  4. 4. Introduction to Probiotics (4-7) <ul><li>Viable microorganisms </li></ul><ul><li>Exert beneficial effects on the host when consumed in adequate amounts </li></ul><ul><li>Survive gastric, biliary, and pancreatic digestion to adhere to the gut epithelium </li></ul><ul><li>Alter intestinal microflora </li></ul>
  5. 5. Forms of Probiotics <ul><li>Treatment </li></ul><ul><ul><li>Tyndalized = heat-treated </li></ul></ul><ul><ul><li>Lyophilized = freeze-dried </li></ul></ul><ul><ul><li>Live cells </li></ul></ul><ul><li>Method of administration </li></ul><ul><ul><li>Capsules </li></ul></ul><ul><ul><li>Powder </li></ul></ul><ul><ul><li>In food products (yogurt, infant formula, milk) </li></ul></ul>
  6. 6. Acute Diarrhea <ul><li>Various etiologies </li></ul><ul><ul><li>Infectious – bacteria, viral, or parasites </li></ul></ul><ul><ul><ul><li>Most common is rotavirus (2) </li></ul></ul></ul><ul><ul><li>Non-infectious – excess juice, lactose intolerance, antibiotic-associated </li></ul></ul><ul><li>Definition </li></ul><ul><ul><li>Varies from study to study </li></ul></ul><ul><ul><li>Most studies define as loose/liquid stools that have not persisted for more than 48-72 hours </li></ul></ul>
  7. 7. Impact of Acute Diarrhea <ul><li>Impact on the health care system (2) </li></ul><ul><ul><li>>130,000 hospitalizations per year for acute diarrhea </li></ul></ul><ul><ul><li>Mean stay is 3.2 days and costs >$3600 </li></ul></ul>
  8. 8. Can probiotics shorten the duration of acute diarrheal episodes to improve quality of life and reduce necessary hospitalizations?
  9. 9. General Limitations in the Current Literature <ul><li>Dietary intake </li></ul><ul><ul><li>Juice consumption </li></ul></ul><ul><ul><li>Infant formula type – lactose content, intact protein, osmolarity </li></ul></ul><ul><ul><li>Fiber intake </li></ul></ul><ul><ul><li>Prebiotics/probiotics from solid foods </li></ul></ul><ul><ul><li>Breastfeeding </li></ul></ul><ul><li>Recency of antibiotic use </li></ul><ul><li>Researchers not checking probiotic viability </li></ul>
  10. 10. Rotavirus-related acute diarrhea <ul><li>VSL #3 (1) </li></ul><ul><ul><li>Improved total recovery rate, reduced stool frequency on days 2, 3 and 4 of treatment </li></ul></ul><ul><li>Bifilac (2) </li></ul><ul><ul><li>Reduced duration of diarrhea in treatment group; reduced stool frequency on days 2-7 of treatment </li></ul></ul><ul><li>L. rhamnosus GG (9) </li></ul><ul><ul><li>Reduced duration of diarrhea </li></ul></ul><ul><li>L. rhamnosus 573L/1, 573L/2, 573L/3 (10) </li></ul><ul><ul><li>Reduced duration of diarrhea </li></ul></ul><ul><li>L. paracasei ST11 (15) </li></ul><ul><ul><li>No reduction in diarrhea duration, stool frequency, or diarrhea resolution rates </li></ul></ul>
  11. 11. Non-rotavirus-related acute diarrhea <ul><li>E. coli Nissle 1917 (3) </li></ul><ul><ul><li>Reduced time to diarrhea reduction </li></ul></ul><ul><li>L. acidophilus LB (4) </li></ul><ul><ul><li>Reduced duration of diarrhea </li></ul></ul><ul><li>L. rhamnosus GG (9) </li></ul><ul><ul><li>Reduced duration of diarrhea </li></ul></ul><ul><li>L. paracasei ST11 (15) </li></ul><ul><ul><li>Reduced stool frequency on all study days, improved diarrhea cessation rate, but no significant reduction in diarrhea duration </li></ul></ul>
  12. 12. Acute Diarrhea of Mixed/Unknown Etiology <ul><li>L. rhamnosus GG – studies have yielded mixed results </li></ul><ul><ul><li>No reduction in daily stool frequency (5) </li></ul></ul><ul><ul><li>Reduction (6, 9) vs. no reduction in duration of diarrhea (5, 7, 8) </li></ul></ul><ul><ul><li>Reduction (7) vs. no reduction (8) in daily stool output, but reduced daily stool output volume (7) </li></ul></ul><ul><ul><li>All studies were done in infants/toddlers, and varied from 5-7 days in length </li></ul></ul><ul><ul><li>Studies with higher doses seemed to have more favorable results in terms of reduction of diarrhea </li></ul></ul><ul><li>L. rhamnosus 573L/1, 573L/2, 573L/3 (10) </li></ul><ul><ul><li>No reduction in duration of diarrhea </li></ul></ul>
  13. 13. Acute Diarrhea of Mixed/Unknown Etiology, cont’d <ul><li>S. boulardii – yeast probiotic </li></ul><ul><ul><li>Mixed results: </li></ul></ul><ul><ul><ul><li>Two studies in infants and older children showed reduced duration of diarrhea (11, 12) </li></ul></ul></ul><ul><ul><ul><li>One study in infants and toddlers (<36 months old) showed no reduction in diarrhea duration (6) </li></ul></ul></ul>
  14. 14. Acute Diarrhea of Mixed/Unknown Etiology, cont’d <ul><li>Lactogemina blend </li></ul><ul><ul><li>Reduced duration of diarrhea (6) </li></ul></ul><ul><li>L. bulgaris and S. thermophilus </li></ul><ul><ul><li>Reduced stool frequency (13) </li></ul></ul>
  15. 15. Acute Diarrhea of Mixed/Unknown Etiology, cont’d <ul><li>B. clausii </li></ul><ul><ul><li>No reduction in diarrhea duration </li></ul></ul><ul><li>E. faecium </li></ul><ul><ul><li>No reduction in duration of diarrhea (6) </li></ul></ul><ul><li>L. acidophilus </li></ul><ul><ul><li>No reduction in diarrhea duration (14) </li></ul></ul><ul><li>B. lactis Bb12 and S. thermophilus TH4 </li></ul><ul><ul><li>No reduction in diarrhea duration in a at two different dosage amounts(16) </li></ul></ul>
  16. 16. Persistent Diarrhea of Mixed/Unknown Etiology <ul><li>L. rhamnosus GG (17) </li></ul><ul><ul><li>Reduced frequency of diarrhea at days 4-7 of treatment </li></ul></ul><ul><ul><li>Reduced average duration of diarrhea in all patients </li></ul></ul><ul><ul><li>Reduced average duration of diarrhea in patients with confirmed C. difficile </li></ul></ul>
  17. 17. Can probiotics, when given prophylactically, reduce the incidence of diarrhea?
  18. 18. Diarrhea of Mixed/Unknown Etiology <ul><li>CUPDAY milk formula containing B. lactis CNCM (18) </li></ul><ul><ul><li>20% reduction in rate of diarrhea (adjusted risk ratio =0.82) </li></ul></ul><ul><li>Infant formulas with B. lactis Bb12 </li></ul><ul><ul><li>Weizman, et al (20) found reduced days with diarrhea and reduced episodes of diarrhea </li></ul></ul><ul><ul><li>Chouraqui, et al (21) found reduced relative risk (0.54) of diarrhea and reduced days with diarrhea </li></ul></ul>
  19. 19. Diarrhea of Mixed/Unknown Etiology, cont’d <ul><li>Infant formula with L. reuteri SD2112 (20) </li></ul><ul><ul><li>Reduced episodes of diarrhea and reduced days with diarrhea </li></ul></ul><ul><li>Infant formula with B. longum and L. rhamnosus LPR (19) </li></ul><ul><ul><li>Reduced incidence of diarrhea in the post-treatment observational period (after probiotics were stopped) but not during the treatment period </li></ul></ul>
  20. 20. Commercial Availability of Probiotic Preparations That Have Been Studied in Infants and Children
  21. 21. Cost Comparison of Common Products Product cost information obtained from: a = www.costlessvitamin.com b = www.vsl3.com c = www.culturelle.com Product Name Probiotic Type Amount of Probiotic per Dose Cost per Dose Manufacturer Recommended Pediatric Dose Florastor ® for Kids S. Boulardii 250 mg per sachet $0.95 a 1 sachet daily VSL #3 ® Proprietary blend 450 billion live bacteria $2.65 b Dosage depending on weight/age Culturelle ® Lacto-bacillus GG 10 billion live bacteria $0.67 c 1 capsule daily
  22. 22. References <ul><li>See attached references list </li></ul><ul><li>All proprietary product information was obtained from the manufacturer’s website. </li></ul>
  23. 23. Learning Assessment Question #1 <ul><li>Which of the following is NOT a common limitation of the current literature in this area? </li></ul><ul><ul><li>a) lack of control for dietary intake </li></ul></ul><ul><ul><li>b) lack of control for other sources of probiotics, including milk </li></ul></ul><ul><ul><li>c) many studies do not assess the viability of the probiotic bacteria used in the study drug </li></ul></ul><ul><ul><li>d) every study uses the same definition of “diarrhea” </li></ul></ul>
  24. 24. Learning Assessment Question #2 <ul><li>Which of the following probiotic products did NOT show positive results in reducing the duration of diarrhea in infants and children? </li></ul><ul><ul><li>a) S. boulardii </li></ul></ul><ul><ul><li>b) E. faecium SF68 </li></ul></ul><ul><ul><li>c) L. rhamnosus GG </li></ul></ul><ul><ul><li>d) E. coli Nissle 1917 </li></ul></ul>

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