Dr. J. N. Khargharia*
MD (PED), DCH
Sr. Pediatrician, Jorhat *
Probiotics by definition, are the live micro organisms which when administered in adequate amount, confer a health benefit on the host. But there is no clear and definite answer regarding "adequate amount". It is generally accepted that the number of cells of organisms (probiotics) required for successful implantation is one billion per day and in case of lactobacillus to be clinically effective the bacterial count required should be 108-9 (1).
Probiotics are naturally found in Yoghurts and fermented foods. Now a days it is available as tablets, caps, and powders and also in liquid forms. Basically they are acid excreting bacteria like Lactobacillus acidophilus, streptococci, bifidobacteria etc. Yeasts and other fungi are also used.
Mechanism of action
Till now the exact mechanism of action by which probiotics exert therapeutic and or protective effect are not clearly understood. But several mechanisms have been postulated like production of inhibitory substances against pathogenic organisms e.g., Organic acids like by hydrogen peroxide and Bacteriocin-"s", blocking of the adhesion sites, degradation of toxin receptors on the intestinal mucosa (e.g. Sacc. Boulardii protects the host against CI. Difficile intestinal infection by degradation of toxin receptors). Competition for nutrients and immunomodulators.
Probiotics and Child health
The G.I. system of a newborn is sterile in utero. But acquired microbes like Lactobacillus, Bifidobacteria, L. Ramnosus, L Paracasei, etc. by swallowing the vaginal fluid during delivery and from the surrounding environment including breast milk. But unfortunately caesarian babies are deprived from this first dose of probiotics resulting in frequent G.I. disturbances.
Breast feeding and Probiotics
Breast milk contains some specific anti-infective proteins like immunoglobulin A, Lacto ferritin, lysozyme, lactic acids and Oligosaccharides which is a Probiotics modulatory factor. Moreover researchers have isolated an antibacterial carbohydrate called Reuterin from breast milk, which helps to prevent infection in the infants G.I. tract.
The primary forms of probiotics that first colonize the baby's GI tract are bifidobacteria with lesser amount of L. rhamnosus, paracasei and L, salivarius. Breast milk assists in gradually establishing the organism Lactobacillus bifidus in the baby's intestine. This organism helps in digestion of sugar.
Probiotics and Pediatric Diarrheal Diseases
Diarrhea is still a major cause of mortality and morbidity in India. Probiotics and prebiotics have been found to be very effective as therapeutic as well as preventive measure. In acute infective diarrhea, especially Rotavirus diarrhea, Probiotics in combination with ORS, reduce the duration of diarrhea and also prevent recurrence of diarrheas. (3)
Probiotics and Antibiotic-induced Diarrhea
Diarrhea is one of the common side effects of antimicrobial therapy. Pathogenesis of antibiotic associated diarrhea is not understood but undoubtedly it is related to quantitative and qualitative changes in the intestinal flora (4).
Many studies have shown that Lactobacillus species, Bifidobacteria species and Sacc. Boullardii, have got beneficial effects in preventing and treating antibiotic associated diarrhea (5).
Probiotics and Lactose Intolerance
Lactose intolerance in children is a common condition which may be due to congenital deficiency of the enzyme, β-galactosidase or acquired due to decrease in the enzyme Lactase resulting from g.i., infection or antibiotic use, disrupting the normal bacterial flora which helps in fermentation of Lactose in the intestine. This results in indigestion of Lactose and cause osmotic diarrhea. The baby will have intolerance to milk and milk products and present with abdominal bloating, abdominal cramps, and diarrhea after consuming milk and milk products.
It has been shown that when Lactase positive strain of bacteria like Lactobacillus, Bifidobacteria and streptococcus are used in pasteurized milk and its products, the digestibility of Lactose improves (6).
The possible mechanism is the Lactase activity of the bacteria digest Lactose in the product, once it reaches the intestine and reduce Lactose in the dairy products through fermentation.
Probiotics and Infantile Candidiasis
Candida infection is common in infants and children which can cause oral thrush and candida diaper dermatitis. Older children getting steroid inhaler may also develop oral thrush. The baby will have a white patch or film on the tongue inner surface of cheek and roof of the mouth. It may be mistaken for milk coating, which can be easily scraped off but thrush cannot be removed so easily.
Thrush causes discomfort and sucking difficulties for the baby and some times it may be transferred to the nursing mother's nipple and cause her to develop an itchy burning rash. This can be treated with antifungal drugs. Probiotics are a better option. They correct the bacterial imbalance by bringing the internal ecosystem back into balance.
Swab the baby's mouth with a cotton swab dipped in a solution of probiotic powder with water or mother's milk once daily and sprinkle the same solution over the mother's nipple if it is affected by candida yeast. She should also take a probiotic supplement daily. She should also be on an anti yeast diet by eliminating all sugars and refined carbohydrates. Mushrooms should also be cut off from the anti-yeast diet. In case of bottle fed babies after each feeding the nipple or pacifiers should be boiled.
Candida diaper dermatitis is an intensely red rash with small extensions on the edge. Prolonged exposure to urine or faeces is a major cause of diaper rash. Topical antifungal drugs are to be applied over the rash.
Topical as well as oral probiotics are an alternative measure for its control prompt changing of soiled diapers and keeping the buttocks dry after each cleaning is also necessary.
Probiotics & Necrotizing Enterocolitis
Enterocolitis is a rare but fatal condition in the newborn. Researchers developed a laboratory model of Necrotizing Enterocolitis and found that the probiotic Bifidobacteria Infantis, significantly reduced the likelihood of its development (7).
Probiotics and Atopic Dermatitis
Infants and children are more susceptible to eczema, 90% of those who suffer from eczema are below the age of five. Atopic children are also more prone to develop asthma. Cortisone is the main stream of treatment but long-term use leads to suppression of body's own production of important hormone-cortisol.
So multiple research had been done for an alternative way of treating atopy and eczema by using probiotics. Oral administration of probiotics had been shown to result in altered immunity at distant mucosal sites including respiratory tract, the skin etc., specific strains of Bifidobacterium and Lactobacillus appear to be promising in the treatment and prevention of eczema in infants and children. These results are due to altered immunity-rather than altered colonization (8).
Probiotic and HIV
Children with HIV infection have recurrent episodes of diarrhea. They are more prone to develop over growth of pathogenic bacteria and are unable to absorb adequate amount of food. In most of the cases the etiology of diarrhea is not clear. So there is no effective treatment so far. In two separate studies 33 HIV patients with Chronic diarrhea were treated with Sacc. Boulardii (9-10). In these double blind studies 56% of the patients receiving Sacc. Boulardii had resolution of diarrhea compared to 9% of patients receiving placebo. In another study of 17 children with HIV, some received L. plantaruin 299V and others received a placebo. In probiotic group, there were more improvements in height and weight than the placebo group. Some improvement in immune response has also been observed in some children and in one subject immune factors were completely normalized after probiotic therapy no adverse effect was noted.
Probiotics seem to have tile potentiality of treating and preventing various pediatric diseases. Various clinical trials have found robust evidences in the prevention and treatment of antibiotic associated diarrhea and diarrhea of various etiology including lactose intolerance in children.
Inappropriate use of antibiotics and alarming increase of bacterial resistance and the recent trends of ecological methods of preventing infection, makes the biotherapy (probiotic) a subject of research specially in inflammatory disease control, treatment and prevention of allergies, immunity stimulation etc. in children.
Regarding safety of probiotics, from the present study reports it call be said that it is safe. But still information is limited. So in future good randomized studies are needed to define the safety of probiotics.
- Japan Health Food Association - "Standards for Lactic acid bacteria in foods".
- Senderds ME - "Consideration for use of probiotic Bacteria to, modulate human Health". J. Nutrition 2000:130;384S-390S (2 S suppl).
- Isolourie E, et al - "Probiotic : Effect on Immunity - Am. J. clin. Nutr. 2001:73 (suppl:444S-SOS)
- Rolf RD. "The role of probiotic cultures in the control of gastro intestinal Health". J. Nutr. 2000:30;396S-402S.
- GOTZV et al - Prophylaxis against Ampicillin associated diarrhea with a Lactobacillus preparation. Am. J. Hosp. Pharm 1979:36;754-57.
- Pettoello MM et al - Lactose mal absorption in children with symptomatic giardia LambLia infection : feasibility of yoghurt supplementation. J. Pediat. Gastroentero 1989:9;295-30.
- Caplan MS et al - Neonatal necrotizing entero colitis ; Possible vote of probiotic supplements. J. pediatr. Gastroenterol Nutr. 2000 (3 suppl) 2:S 18-22.
- Fedorak RN et al - Probiotics and prebiotics in gastrointestinal disorders. Current opinion gasteroenterology 2004:20;149-55.
- Born Petal - The Saccharomyces Boulardii therapy of HIV associated diarrhea (letter), Disc Med wocharschr -1993:188;765.
- Saint Marc et al - Efficacy of S. Boulardii in the treatment of diarrhea in AIDS - Ann Med Intern 1991:142;64-65.
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