Abstract:
A novel method for the prevention of infectious diarrhea or diarrhea caused by antibiotic therapy is disclosed. The method comprises the steps of 1) mixing a powder comprising viable cultures of the probiotic organisms Lactobacillus reuteri, Lactobacillus acidophilus and Bifidobacieriurn infantis with a liquid; and 2) enterally administering the mixture to a mammal or a human. In a preferred embodiment at least 10 6  CFU (colony forming units) of each probiotic organism is consumed per day. The invention also relates to pills or capsules containing the probiotic system (Lactobacillus reuteri, Lactobacillus acidophilus and Bifidobacterium infantis) in a freeze dried or lyophilized form. The invention also relates to a novel powdered nutritional formula for the prevention of diarrhea that comprises protein, fat, carbohydrates and the microorganisms Lactobacillus reuteri, Lactobacillus acidophilis and Bifidobacterium infantis. In a preferred embodiment the powdered nutritional formula is a nutritionally complete infant formula. A large clinical study has shown that the probiotic system according to the invention when provided in a non-fermented form is efficacious in the prevention of diarrhea. Also disclosed is a method for manufacturing the formula of the invention.

Description:
TECHNICAL FIELD 
     The present invention relates generally to a method of preventing diarrhea associated with infectious agents such as rotavirus, or diarrhea associated with antibiotic therapies. More specifically, this invention relates to a powdered infant nutritional that contains the probiotic organisms Lactobacillus reuteri, Lactobacillus acidophillus and Bifidobacterium infantis. Administration of at least 10 6  CFU of each probiotic organism in a 24 hour period has been shown to be effective in the prevention of diarrhea. 
     BACKGROUND ART 
     Diarrhea is one of the most common health problems in the world, and even in developed countries is one of the most common infectious diseases. Diarrhea is also one of the most common health problems during childhood. While it has been suggested to administer fermented milk products in the treatment of diarrhea (for example rotavirus associated diarrhea), the medical community continues to seek improved methods or products which would be useful in the prevention of the disease. 
     In recent years, rotavirus and other enteric viruses have been identified as a major cause of acute diarrhea in infants and young children attending daycare centers. There is an acute need, both domestically and in third world countries, for products and methods that would be effective in preventing infectious diarrhea and diarrhea associated with antibiotic therapy. 
     Probiotics are a class of microorganisms that are defined as live microbial organisms that beneficially affect the animal and human hosts. The beneficial effects include improvement of the microbial balance of the intestinal microflora or by improving the properties of the indigenous microflora. A better understanding of probiotics in man and animals can be found in the following publications. Fuller R: Probiotics in Man and Animals, J Appl. Bacteriol 1989;66:365-365-378 and Havenaar R, Brink B, Huis In&#39;t Veld JHJ: Selection of Strains for Probiotic Use. In Scientific Basis of the Probiotic Use, ed. R. Fuller, Chapman and Hall, London UK, 1992. 
     The known benefits of enteral administration of probiotic microorganisms include enhanced host defense to disease, improving colonization resistance of the harmful microflora and numerous other areas of health promotion. Probiotics have been suggested to play an important role in the formation or establishment of a well-balanced, indigenous, intestinal microflora in newborn children or adults receiving high doses of antibiotics. 
     Lactic acid bacteria and specific strains of Lactobacillus have been widely recommended for use as probiotics. See, for example, Gilliland SE: Health and Nutritional Benefits from Lactic Acid Bacteria. Micro Rev. 1990;87;175-188 and Gorbach SL: Lactic Acid Bacteria and Human Health. Annals of Med. 1990;22-37-41. Species of Streptococci, Enterococcus, and Bifidobacteria have also been suggested as being beneficial. One of the more recently studied probiotics is Lactobacillus reuteri. This ubiquitous microorganism resides in the gastrointestinal tract of humans and animals and produces a potent, broad spectrum antimicrobial substance called reuterin. The inhibition of growth of Escherichia, Salmonella, Shigella, Listeria, Campylobacter, Clostridium and species of Staphylococcus by reuterin has been reported. See for example, Axeisson L T, et al (1989), Production of a Broad Spectrum Antimicrobial Substance by Lactobacillus reuteri, Microbial Ecology in Health and Disease 2, 131-136. 
     Of the intestinal lactic acid bacteria (LAB), L. reuteri is considered a major species. Due to the inability of microbiologists to distinguish L. reuteri from Lactobacillus fermenyum (L. fermetum) in the past, many researchers believe that a large percentage of LAB classified as L. fermentum in older literature, in reality, are strains of L. reuteri. 
     L. reuteri is a dominant heterofermentative Lactobacillus species residing in the gastrointestinal tract of healthy humans and most animals. Like other lactobacilli, L. reuteri produces acidic metabolic end-products which have considerable antimicrobial activity. It has been recently discovered that metabolism of glycerol by L. reuteri can result in excretion of a metabolic intermediate, 3-hydroxpropionaldehyde, or reuterin. See Axelsson, &#34;Production of a Broad Spectrum Antimicrobial Substance by Lactobacillus reuteri,&#34; Microbial Ecology in Health and Disease, 2:131-136, 1989. Reuterin has been shown to have antimicrobial activity against a variety of organisms including Gram-positive and Gram-negative bacteria, yeast, molds and protozoa. See Chung, et al., &#34;In Vitro Studies on Reuterin Synthesis by Lactobacillus reuteri,&#34; Microbial Ecology in Health and Disease, 2:137-144, 1989. It is suspected that the antimicrobial activity of reuterin contributes to the survival of L. reuteri within the gastrointestinal ecosystem. 
     Likewise, L. acidophilus is a normal inhabitant of the human gastrointestinal tract and is a Gram-positive rod widely used in the dairy industry. L. acidophilus is a homofermentative species, fermenting mainly hexose sugar, yielding predominantly lactic acid (85-95%). The use of L. acidophilus predates the 20th century. Bifidobacterium infantis is a Gram-positive, strictly anaerobic, fermentative rod. Bifidobacterium infantis is the predominant form of Bifidobacterium in breast fed infant feces. 
     Cultures of these organisms are commercially available and are usually supplied as powders. The cultures are alive but in a dormant state which is achieved by a process known as lyophilization (freeze-drying). BioGaia Biologics, Inc. of Raleigh, N.C. promotes and markets a cultured sweet milk and a fermented milk known as BRA milk™. The cultured sweet milk is made by adding to 1% pasteurized and vitaminized low fat milk a Lactobacillus reuteri, Bifidobacterium infantis, Lactobacillus acidophilus culture mixture just before filling cartons. The fermented BRA milk is similar to the cultured sweet milk except that the organisms are allowed to ferment the milk. 
     The feeding of Bifidobacterium bifidum and Streptococcus thermophilus to infants in hospitals is reported by Savedra, J. et al. in The Lancet, Vol. 344, Oct. 15, 1994. The feeding of these two specific organisms was shown to reduce episodes of diarrhea disease over a control (no organisms). 6.9% of the B. bifidum and S. thermophilus fed infants experienced diarrhea, while 31% of the control group experienced diarrhoeal disease. 
     U.S. Pat. No. 5,021,245 relates to an infant formula containing a soy polysaccharide fiber source. More specifically, this patent is directed to an infant formula used for the treatment of infantile colic. All of the data and teachings of U.S. Pat. No. 5,021,245 are incorporated herein by reference. 
     U.S. Pat. No. 5,234,702 relates to a powdered nutritional product which uses a specific antioxidant system to prevent the degradation of the lipid fraction. More specifically, this patent discloses an antioxidant system made up of ascorbyl palmitate, beta carotene and/or mixed tocopherols, and citrate. All of the data and teachings of U.S. Pat. No. 5,234,702 are incorporated herein by reference. 
     U.S. Pat. No. 5,492,899 discloses an improved enteral nutritional formula containing ribonucleotide equivalents. This patent suggests that such a formula enhances the immune system and alleviates diarrhea. The teachings and data of U.S. Pat. No. 5,492,899 are incorporated herein by reference. 
     One major aspect that all of the prior art fails to appreciate is the discovery that fermented dairy products, such as yogurts which contain various probiotic agents, present the consuming individual with numerous byproducts that are associated with the fermentation. One aspect of the present invention is the realization that unfermented administration of the probiotic system will be effective in preventing diarrhea. In this regard, pills or capsules containing the probiotic system according to this invention or direct administration of the probiotic powder to the individual is one embodiment of the present invention. Rehydration of the probiotic powder would occur in the patient&#39;s stomach and not allow for the fermentation byproducts to form. Thus, the present invention provides an enterally administerable product containing Lacyobacillus reuteri, Lactobacillus acidophilus and Bifidobacterium infantis in an amount which is effective to inhibit diarrhea associated with infectious agents and antibiotic therapy. 
     DISCLOSURE OF THE INVENTION 
     There is disclosed a method for the prevention of infectious diarrhea or diarrhea associated with antibiotic therapy in a human, said method comprising the steps of 1) mixing of a powder containing Lactobacillus reuteri, Lactobacillus acidophilus and Bifidobacterium infantis with a liquid and 2) enterally administering an effective amount of said liquid mixture to said human. More specifically the method should result in the administration of at least 10 6  CFU of Lactobacillus reuteri, 10 6  Lactobacillus acidophilus and 10 6  CFU Bifidobacterium infantis per day. 
     Also disclosed is a nutritional product in powdered form comprising protein, fat, carbohydrates, minerals, vitamins, trace elements and a probiotic system, said probiotic system comprising Lactobacillus reuteri, Lactobacillus acidophilus and Bifidobacterium infantis. In a specific embodiment the powdered nutritional product contains at least 10 5  CFU Lactobacillus reuteri per gram, 10 4  CFU Lactobacillus acidophilus per gram and 10 4  CFU Bifidobacterium infantis per gram. 
     The infectious diarrhea to be prevented by the present invention may be caused by any known organism that those skilled in this art would understand to cause infectious diarrhea. Such organisms include, but are not limited to: rotavirus, C. difficle, Salmonella, Shigella, Campylobacter, E. coli, Proteus, Pseudomonas, Clostridium, enteric Adenovirus, Ameoba, Staphylococcus, Ova and intestinal parasites such as Giardia Lamblia. The method and composition of the present invention is also efficacious in preventing diarrhea associated with antibiotic therapies. Those skilled in the art appreciate that antibiotic therapy for the treatment for numerous disorders and diseases results in the destruction of the intestinal microflora. This destruction of the intestinal microflora by the antibiotic results in the proliferation of pathological microorganisms. This effect of antibiotic associated diarrhea is well known in the art and readily appreciated by those skilled in this art. 
     The method according to this invention can also be accomplished through the administration of a powder per se or in the form of a capsule, pill or tablet which incorporates the proper level and types of probiotics disclosed herein. Also contemplated within the scope of this invention is the administration of the probiotic system in a nutritional product. This nutritional product may be, for example, powdered milk, a commercially available infant formula or powdered nutritional supplements. Thus, one aspect of this invention includes the mixing of the probiotics system with a preformed liquid nutritional product (i.e. milk or commercial infant formula). The present invention also contemplates a powdered nutritional product which may be a complete nutritional product or a nutritional supplement comprising vitamins and minerals in conjunction with the probiotic system of this invention. Thus, this invention includes powdered infant formula containing the three probiotic organisms at levels which would deliver the minimum colony forming units (CFU&#39;s) during a typical day of fecding. 
     More specifically, a powdered infant formula according to this invention would supply about 3.5×10 8  CFU of the probiotic blend per day. The infant formula would contain about 4×10 6  CFU of the probiotic blend per gram of formula. If one assumes that about 600 mL of formula is consumed per day, then about 7×  7  CFU of L. reuteri is consumed per day if the formula is fortified at 8×10  5  CFU of L. reuteri per gram of powdered formula. 
     Also contemplated in this invention is the use of the probiotic system in a nutritional supplement to prevent diarrhea. For example, Gain® nutritional beverage sold by Abbott Laboratories, is fortified with from 1.75 to 8.75×10 6  CFU per gram of each organism. If 240 mL of the probiotic supplement is consumed per day, then 1.4 to 7.0×10 8  CFU of the probiotic system is delivered to the patient per day. 
     There is further disclosed a method for the prevention of infectious diarrhea or diarrhea caused by antibiotic therapy in a human, said method comprising administering to said human in powdered, tablet, pill or capsule form at least 10 5  CFU Lactobacillus reuteri, at least 10 4  CFU Lactobacillus acidophilus and at least 10 4  CFU Bifidobacterium infantis per day 
     There is also disclosed, a method for the production of a powdered nutritional product containing a probiotic system, said method comprising dry blending a powdered probiotic system comprising Lactobacillus reuteri, Lactobacillus acidophilus and Bifidobacterium infantis with said powdered nutritional product. 
     One important realization that distinguishes this invention from the prior art is that the inclusion of a viable probiotic into a liquid nutritional product substantially prior to consumption will result in a fermented product. Thus, it is important that the probiotic system not be allowed to actively or substantially ferment the liquid product prior to ingestion by a human. 
     Those skilled in this area of technology will appreciate that for the method of the present invention, to accomplish the prevention of diarrhea, host specific microorganisms should be used. 
     DETAILED DESCRIPTION OF THE INVENTION 
     A clinical study was designed to investigate the ability of enteral administration of the probiotic system of this invention (Lactobacillus reuteri, Lactobacillus acidophilus and Bifidobacterium infantis) to prevent infectious diarrhea and diarrhea associated with antibiotic therapy. The study was conducted by adding flavor packets containing the probiotic system of the invention to a base milk just prior to consumption. Thus, the organisms did not have the opportunity to ferment the milk. This feature of administration of the probiotic system in an essentially non-cultured and non-fermented environment is an aspect of the prevention of diarrhea. Example I sets forth the manufacture of the probiotic containing packets and Example II describes the clinical study. The invention will be better understood in view of the following examples, which are illustrative only and should not be construed as limiting the invention. 
    
    
     EXAMPLE I 
     Manufacture of Probiotic System 
     The Bifidobacterium infantis used in this experiment is a human isolate and has been deposited with the American Type Culture Center--No. 27920. The Lactobacillus reuteri is also a human isolate and is described in U.S. Pat. No. 5,439,678. The Lactobacillus acidophilus used herein is a Gram-positive rod well known in the dairy industry. Each organism was grown separately in appropriate media and under conditions which favored viability. The fermentation patterns for each organism are known in the art and have been described previously. For Lactobacillus for example, see Silva M, et al: Antimicrobial substance from a human lactobacillus stain. Antimicrobe Agents Chemother 31:1231-1233, 1987. For cultivating strains of L. reuteri, U.S. Pat. No. 5,439,678 should be reviewed. All of the data and teachings of U.S. Pat. No. 5,439,678 are incorporated herein by reference. After fermentation and isolation using techniques known in the industry, the organisms were combined along with a carrier/cryoprotectant (whey protein concentrate) and freeze dried. Other carriers/cryoprotectants such as lactose or maltodextrin can be used. The cultures were combined using dry blending techniques and the resulting inventive culture mixture had the following concentrations: 
     Lactobacillus reuteri at about 5×10 10  CFU/g. 
     Lactobacillis acidophilus at about 5×10 10  CFU/g. 
     Bifidobacterium infatis at about 6-7×10 10  CFU/g. 
     This three part culture was manufactured and supplied by BioGala Biologics, Inc., Raleigh, N.C. and is commercially available from BioGaia Biologics. 
     The flavor packets for the clinical study, including a control (no probiotic system), were manufactured by dry blending the inventive culture mixture described above with sucrose and cocoa powder for the chocolate flavor pouch/packet or sucrose, dextrose and vanilla flavor for the vanilla pouch/packet using a 1.5 cubic foot V-blender to accomplish the blending. The control pouches did not contain the inventive culture mixture. 
     The packets were 3&#34;×3&#34; foil pouches containing 2.5 g. of the flavor system with or without the inventive probiotic system. Each clinical product was dry blended separately, and the preparations were stored under refrigeration until the required number of pouches had been filled and sealed, and labeled with clinical labels. The control pouches contained no detectable Lactobacillus reuteri or Bifidobacterium infantis. Completed pouches were stored refrigerated until being shipped to the clinical site in Mexico City. The flavor packets were kept refrigerated until distributed to the children&#39;s homes on a weekly basis. 
     The chocolate flavor packet containing the probiotic system of the present invention had 1.6×10 7  CFU L. reuteri per g; 1.9×10 7  CFU L. acidophilus per g; and 2.3×10 7  CFU B. itfantis per g in the 2.5 g flavor packet. For the vanilla flavor packets manufactured with the probiotic system according to this invention, the cultures were present at 6.35×10 6  CFU per g for L. reuteri; at 2.2×10 7  CFU per g for L. acidophihus; and 1.5×10 7  CFU per g for B. infantis. The probiotic group consumed approximately 1×10 7  to 4×10 7  CFU L. reuteri per mL in each 4-oz serving, or 10×10 9  to 5×10 9  CFU of L. reuteri per day. The total daily dose of all three cultures in the probiotic blend for children consuming the probiotic Study Feeding was approximately 2.5×10 8  CFU per mL or 3.0×10 10  CFU per day. 
     EXAMPLE II 
     Clinical Study 
     The following clinical study was conducted under protocol number CP-AG08 and the results were reported in a final report issued Sep. 29, 1995. 
     258 children living in Mexico City, Mexico were invited to join the clinical study. These children were 12 to 36 months of age and had a history of ingesting cow&#39;s milk or cow&#39;s-milk-based infant formula as part of their daily diet. Children were excluded that had a history of allergy to cow&#39;s milk; were being breast fed; had clinical evidence of chronic gastroenteritis; had clinical evidence of chronic or severe renal, liver or gastrointestinal tract function; were on immunosuppressive therapy; had taken an investigational drug within 30 days prior to enrollment or were involved in another clinical study. 
     Parents or legal guardians of the study subjects signed an informed consent approved by the Institutional Review Board for the Department of Infectious Diseases at the National Institute of Nutrition in Mexico City, Mexico. The investigators, staff, and parents responsible for care of the children remained blinded to the type of feedings administered to the children. The parents or legal guardians also agreed to provide the Study Feeding (base milk plus flavor packet) twice daily during the 16 week study and agreed not to give yogurt or other cultured products during the clinical trial. 
     The children were randomized to receive one of two Study Feedings (control vs. experimental) in a blinded, parallel, 16 week feeding trail. Randomization was stratified by age and gender. The study consisted of an entry baseline evaluation phase and the 16 week feeding phase. All children were placed under active surveillance for diarrhea during the study. At least seven days prior to beginning the trial (baseline evaluation phase) each child consumed the base study milk which was whole milk packaged in single-serving Tetra Paks (240 ml) obtained from a commercial manufacturer in Mexico City. 
     Parents were instructed on how to complete the monthly visit evaluation forms, how to collect fecal samples, how to mix the base study milk with the flavor packets and what to do when their child developed diarrhea. 
     The Study Feeding Phase began the first day the base study milk plus clinically labeled flavor packet was given and continued through day 112 or until the study ended or the child exited the study. Parents received clinically labeled color coded chocolate and vanilla flavor packets each week to mix with the base milk. Each flavor packet was mixed with 120 mL of base milk. Daily intake was recorded by the parents on worksheets. 
     Parents were allowed to store the packets unopened at room temperature during the week. 120 mL of base milk plus one flavor pouch was fed in the morning and another 120 mL of base milk plus flavor pouch was fed in the evening. Once mixed, the Study Feeding was consumed; any beverage not consumed within 5 hrs. was discarded. The amount of beverage consumed was recorded for each feeding. Stool samples were taken and stool characteristics were evaluated at entry and on Study Days 28, 56, 84 and 112. Diaries were used to record the child&#39;s stool patterns and tolerance. 
     Antibiotic use was assessed and recorded weekly by study social workers during interviews with parents. Information of the drug name, dates of use and reason for use were also recorded. The children were actively observed for diarrhea. Diarrhea was defined as an acute change in stool pattern with three or more watery/liquid stools in a 24 hr period or two or more stools than normal which were looser than normal consistency or if a child had a watery or pasty stool with blood, diarrhea was considered present. 
     Parents contacted the investigators when a child passed the first diarrhea stool. Records regarding number of stools and consistency were taken. Stool samples were also taken. The Study Feeding was continued during the diarrhea episode unless it interfered with the medical management of the illness. Diarrhea was tracked until the stool pattern (number and consistency) returned to normal for the child. 
     Also important was antibiotic use associated with any diarrhea episodes. Antibiotic associated diarrhea was defined as an episode of diarrhea that developed during antibiotic therapy or within 14 days after an antibiotic was stopped for which there was no enteric pathogens other than C. difficile (as detected by presence of C. difficile toxin) identified in the stool specimen collected during the episode. 
     Diarrhea stool samples were collected for evaluation of rotavirus and enteric adenovirus; for enteric pathogens; for Clostridium difficile toxin; and, selected parasites. 
     Statistical Methods 
     For continuous outcomes (percent watery stools, percent watery/loose stools, mean rank stool consistency, average number of stools per day, percent feedings, average number of feedings per day, average daily intake which were measured at several visits), repeated measures analysis of variance was employed. Values at Day 28, Day 56, Day 84 and Day 112 were responses. 
     The number of cases of diarrhea was analyzed by the marginal approach to multivariate survival analysis. Time to the first episode of diarrhea was analyzed by the Cox regression with the robust estimator of the variance. A multivariate Cox regression was performed comparing the number of episodes of diarrhea in the feeding groups. This analysis counts all episodes of diarrhea, including repeated episodes. The marginal approach of Lin, Wei and Weisfield was used to analyze the data. The generalized estimating equations technique is used due to the fact that some individuals have repeat episodes. We assume that the effect of the probiotic feeding is the same for first and for repeat episodes. A Cox regression analysis was also perforned for first episodes, ignoring repeat episodes. Analysis was also done for first episodes and for all episodes that occurred ≧8 days of study feeding. 
     RESULTS 
     Study Entrance Data 
     Two hundred fifty eight children received randomization numbers and signed informed consent to enter the study, 129 subjects in each group. The entry age ranged from 12.2 months to 36.9 months for the control group (median=23.2 months) and from 12.0 to 36.6 months for the probiotic group (median=24.0 months). The mean age of children randomized was similar across both groups. For the 243 children that entered the study and received the Study Feeding, the mean age in the control group was 24.0±0.7 months, and 24.1±0.6 months for the probiotic group. No statistically significant differences were seen in entry data for sex, age, and prior serious illness. All 243 subjects receiving the Study Feeding were placed under diarrhea surveillance (120 children in the control group and 123 children in the probiotic group). 
     Study Feeding Phase 
     Mean days on Study Feeding were 94.8±2.5 days for the control group and 95.9±2.6 days for subjects receiving the probiotic feeding. Median days on the study (111.0 days), and number of days on Study Feeding for the 75th percentile (111.0 days) and 25th percentile (97.0 days) were the same for both groups. Length of feeding for subjects who successfully completed the study ranged from 88 to 120 days. Study feeding for subjects in the control group ranged from 88 to 120 days, and from 97 to 111 days for the probiotic group. 
     The Study Feeding consisted of two 4-oz (about 120mL) feedings of whole milk (base milk) with added flavor packet, constituting only a minor portion of the daily caloric intake for the child. Subjects were allowed to consume regular milk in addition to the Study Feeding, and ice cream, solid foods, cheeses, juices and/or cereals were also permitted. The only restrictions were on the consumption of yogurts and other cultured products, and on the consumption of other probiotic-containing products. 
     Study Feeding Intake 
     Average daily intake was consistent for both groups (control vs. experimental) among the children consuming the Study Feeding. Intake was noted daily for all children participating in the study and total daily intake was recorded on study records. 
     Episodes of Diarrhea 
     Emphasis was given to the analysis of diarrhea episodes on Study Day 8 or later, thus subjects on the Study Feeding less than eight days were excluded. Of the 243 subjects who received the Study Feeding, four exited the study within the first seven days, all in the probiotic group. This gave 239 subjects with diarrhea surveillance beyond Study Day 7, with 120 subjects in the control group and 119 in the probiotic group. 
     There was a statistically significant difference between reported episodes of diarrhea occurring ≧8 days on Study Feeding for the two groups (Table 1). Among the 120 subjects in the control group with ≧8 days on Study Feeding, there were 51 reported episodes of diarrhea (0.425 episodes per subject). For the probiotic group, 33 episodes of diarrhea were reported (0.277 episodes per child) after at least 7 days on Study Feeding. Statistical evaluation by the marginal Cox Regression Analysis with robust, GEE estimate of the variance for the number of diarrhea episodes in the feeding groups was p=0.0385. The relative risk of diarrhea for a child receiving the probiotic feeding relative to the control feeding gives a point estimate of 0.592. 
     
                       TABLE I______________________________________Incidence of Diarrhea Episodes AsReported By Frequency By Group ≧ 8 Days on Study Feeding    Control     Probiotic   Total______________________________________No Episode  77      (64.2%)  90    (75.6%)                                    167One Episode 37      (30.8%)  25    (21.0%)                                    62Two Episodes       5       (4.2%)   4     (3.4%)                                    9Three Episodes       0                0           0Four Episodes       1       (0.8%)   0           1TOTAL       120              119         239p = 0.0385______________________________________ 
    
     Diarrhea Stool Samples 
     There were a total of 106 episodes of diarrhea tracked during the clinical trial. Of these, 84 episodes occurred ≧8 days on Study Feeding. Rotavirus ELISA was positive in a total of 12 stool samples and for nine diarrhea samples collected for subjects with an episode ≧8 days on Study Feeding (Table II). 
     
                       TABLE II______________________________________Incidence of Rotavirus (RV) Positive Diarrhea Stool SamplesFor Episodes and ≧8 Days After Study Feeding, By Group             Control                   Probiotic______________________________________No. RV + Stool Samples               9       3No. RV + Stool Samples ≧8               7/107   2/107Days on Study Feeding forSubjects at Risk______________________________________ 
    
     Antibiotic Associated Diarrhea 
     Six episodes of antibiotic-associated diarrhea that developed during antibiotic therapy or within 14 days after an antibiotic was stopped, and for which no enteric pathogen was identified in a diarrhea stool, were identified, all in the control group (Table III). 
     
                       TABLE III______________________________________Incidence of Antibiotic Associated Diarrhea ForEpisodes ≧8 Days AfterStudy Feeding, By Group for Subjects at Risk              Control                    Probiotic______________________________________Antibiotic Associated Diarrhea                6/120   0/119≧8 Days on Study Feeding forSubjects at Risk______________________________________ 
    
     Severity and Duration 
     There were no statistically significant differences in the severity scores of diarrhea for episodes that occurred after ≧8 days on Study Feeding. 
     Antibiotic Use 
     No statistically significant differences were seen in frequency of antibiotic use reported between the two feeding groups. Over 70% of the subjects in both groups took an antibiotic at least once during the Study Feeding Phase. 
     Conclusions 
     The Study Feeding, whole milk with a flavor packet added, was well received by the children participating in the study. Data indicate that use of the flavor packets containing the probiotic system according to this invention and added to milk at point of consumption, was effective in preventing the onset of infectious diarrhea or diarrhea caused by antibiotic therapy. Through the work of the inventors it has been shown that the probiotic system of the present invention is efficacious and has been determined to be safe. This large clinical trial was designed to evaluate the disclosed and claimed probiotic system to determine if it is effective in reducing the incidence and severity of infectious and antibiotic diarrhea. This study has demonstrated that children consuming the inventive probiotic-containing beverage were at a reduced risk of diarrhea compared to children receiving the control beverage. Differences were statistically significant and support the efficacy of the present invention in reducing the incidence of diarrhea in children when taken as part of the daily diet. 
     INDUSTRIAL APPLICABILITY 
     The results from the clinical study demonstrate that method and formula of this invention is effective in the prevention of diarrhea. The medical community is constantly searching for methods and products that will benefit the infant and the adult. The present invention can clearly fill that need. In addition, the products useful in the method claimed herein utilizes conventional equipment and may be readily accomplished. 
     While the methods and products herein described constitute a preferred embodiment of this invention; it is to be understood that the invention is not limited to the precise method or formulation and that changes may be made therein without departing from the scope of the invention which is defined in the appended claims.