Overview of Probiotics Use in the Pediatric Population

Probiotics are live microorganisms that restore normal flora in the gut and have beneficial effects in the host in which they live. These nonpathogenic bacteria often come from food sources such as cultured milk. Various indications for the use of probiotics have been analyzed in both adults and children. Even though there are not any standard guidelines for indications of probiotics in children, their use has been studied for the treatment of different disease states and conditions that significantly affect a child’s overall health status. Major indications of probiotics in the pediatric population include the treatment of acute infectious diarrhea and the prevention of Clostridium difficile–associated diarrhea (CDAD) and antibiotic-associated diarrhea (AAD), treatment of pain and symptoms related to irritable bowel syndrome (IBS), and prevention of ventilator-associated pneumonia (VAP). With probiotics showing possible benefit in these indications, other types of potential areas of use continue to be identified and researched. Although the exact mechanism of action of probiotics and how they provide benefits in children is not well understood, there are proposed ways that these microorganisms work in the flora of the gastrointestinal tract. Probiotics may increase the immune system response and cause suppression of bacterial growth. Additionally, the presence of probiotics provides a competitive environment for bacteria to actually grow and may extend the action of an antibiotic on a pathogen. Probiotics contribute to the improvement of the intestinal barrier function and provide some changes to the inflammatory response of the intestines by preventing cytokine-induced damage to the epithelial membrane. Probiotics may modulate pain perception as well by causing less visceral hypersensitivity and inducing opioid receptors in the abdomen, especially in patients with IBS. There are not any documented drug interactions with probiotics, other than the possibility of increasing vitamin B levels. As for adverse events, probiotics should be used with caution in patients who are immunocompromised and at high risk of opportunistic infections, and in those with badly damaged gastrointestinal tracts, such as individuals who have short bowel syndrome. An area of concern when using probiotics is the microorganism transporting from the gut to the bloodstream and possibly causing bacteremia with lactobacillus or fungemia with saccharomyces in neonates or children with inadequate immune systems. Probiotics include many microorganisms but are often part of the genera Lactobacillus, Bifidobacterium, and Streptococcus. The main ones used in research so far are Lactobacillus rhamnosus GG (LGG), Bifidobacterium lactis, and Streptococcus thermophilus, with LGG appearing to be the most common. Others mentioned are Lactobacillus plantarum 299, Lactobacillus casei rhamnosus, Lactobacillus reuteri, Lactobacillus acidophilus, Lactobacillus bulgaricus, Bifidobacterium breve, and nonpathogenic Escherichia coli. Also, a probiotic that is a yeast, Saccharomyces boulardii, has been used in studies. Standard dosing for each individual probiotic does not presently exist. Dosing schedules for the diverse indications of probiotics used in various studies and meta-analyses are listed in Table 1.