1. PROBIOTICS IN PEDIATRIC PRACTICE
Dr Sarath Gopalan
• Senior Consultant in Pediatric Gastroenterology,
Hepatology and Clinical Nutrition, PSRI Hospital, New
Delhi.
• Visiting Consultant in Pediatric Gastroenterology and
Hepatology, Indraprastha Apollo Hospital, New Delhi.
• Executive Director, Centre for Research on Nutrition
Support Systems, New Delhi.
• Deputy Director, Nutrition Foundation of India, New
Delhi.

2. Functions of gut flora
Fermentation of dietary waste and
endogenous mucins
Energy recovery through the generation of
short-chain fatty acids
Protection against colonization and invasion
by pathogens (barrier effect)
Development, stimulation and modulation of
the immune system

3. Gut flora
By the age of two years, the flora
established is practically definitive
Every individual tends to have a relatively
stable flora
Negative modification by antibiotics
Positive modification by probiotics

4. Probiotics
Probiotics are living microorganisms that
are consumed in order to obtain a beneficial
effect regardless of their intrinsic nutritional
value

5. Probiotics - criteria
Application in the living state
Resistance to gastric acid and bile
Ability to adhere to colonocytes
Ability to colonize the gut
Clinically proved favourable health-effect
Safety

6. Probiotics - effects
Involvement in production of essential nutrients
of the colonic mucosa
Beneficial effect on intestinal immunity
Recovery of the disturbed gut mucosal barrier
and prevention of microbial translocation
Elimination of toxins and eradication of
microbial pathogens

7. Probiotics - effects
Competitive inhibitor of bacterial
adhesion
Synthesis of compounds that inhibit or
destroy pathogens
Competitive consumption of nutrients
required for growth of pathogens

8. Probiotics and clinical usage
Benefits are of varying degree
dependent on :
Number of agents
The dose
Dosing patterns
The characteristics of the host
Underlying luminal microbial
environment of the host

9. Probiotics - uses
Traveler’s diarrhoea
Antibiotic-associated diarrhoea
Relapsing Clostridium difficile colitis
Infantile diarrhoea
Rotavirus enteritis
Inflammatory bowel disease
Irritable bowel syndrome
Colon cancer

10. Probiotics - uses
Peritonitis
Acute pancreatitis
Diarrhoea associated with HIV infection

11. Probiotic agents with clinical data
Lactobacillus GG
Lactobacillus acidophilus
Lactobacillus plantarum 299V
Lactobacillus casei Shirota
Bifidobacterium bifidum
Bifidobacterium longam
Streptococus thermophilus
Enterococcus faecium SF68
Saccharomyces boulardii
Bacillus clausii

12. Lactobacillus
Lactobacillus is part of lactic acid
bacteria - non pathogenic gram
positive bacteria that produce lactic
acid as a primary metabolic end
product
Vary greatly from one species to
another in genetic make up,
colonization and adherence patterns
Term “lactobacillus” is meaningless

13. Lactobacillus casei –
documented benefit
• Recurrence of superficial bladder cancer
(Urol Int 1992; 49:125-129, Urol Int
2002;68:273-280)
• Significant improvement in sodium
absorption in short bowel syndrome
(JPGN April 2001;32:506-508)

14. L. Casei Shirota - Constipation
IMPROVED FREQUENCY AND < GI SYMPTOMS
• Koebnick et al, Can J Gastroenterol 2003, Vol 17:11
• Bioscience Microflora 2006; 25 (2):39 – 48
• Chimielewska et al, World J Gastroenterol 2010; 16 (1) :
69 – 75
• Krammer HJ, Coloproctology 2011; 33:109-113

15. Bacillus clausii
•ACUTE DIARRHEA
•ANTIBIOTIC – ASSOCIATED DIARRHEA
•TRAVELLER’S DIARRHEA
EXAMPLE OF SINGLE STRAIN CONCEPT TO
JUSTIFY STRAIN SPECIFICITY

16. Saccharomyces boularidii (Sb)
Non pathogenic thermophyilic yeast
Reaches high levels in stools in 3 – 5
days
Undetectable by 2 - 6 days after
discontinuation

17. Sb - anti toxin effects
Prevention of cytotoxicity of toxins A and
B of C. difficile
Reduces toxins A receptor binding
Neutralisation of cholera toxin
Neutralisation of heat stable enterotoxin
of E. coli

18. Sb and C. difficile enteropathy
Prevention of recurrence
Surawicz
Prevention of recurrence in those who
failed to respond to vancomycin and
metronidazole
McFarland

19. Sb and antibiotic associated
diarrhoea (AAD)
Prophylactic use of Sb with beta
lactam resulted in reduction of AAD
McFarland
Sb reduces the incidence of AAD in
hospitalized patients
Surawicz
Efficiency in preventing AAD 56%
McFarland

20. Sb - clinical uses
Nasogastric alimentation associated
diarrhoea
decrease in number of diarrhoeal
days
HIV associated diarrhoea
decrease in stool frequency

21. Sb - clinical uses
Crohn’s disease
decreased frequency of bowel
movements
Traveler’s diarrhoea
reduction in the incidence of
diarrhoea

22. Single probiotic or cocktail??!!
Rationale for using a probiotic “cocktail”- the
beneficial effects of different probiotic
agents may be additive – but is it really so?
Advantage of using a single strain – easy to
study the desired therapeutic effect and
interpret it as responsible for the observed
benefit.

23. Probiotic Supplementation in
Developing Countries of South Asia
• Issues Raised
2. Lack of sufficient evidence from South Asian countries
regarding possible benefit of probiotic supplementation in
humans.
3. It is likely that microbial colonization of the gut in
individuals from countries like India who are exposed to a
microbiologically hostile environment is considerably
different from those in the developed countries of the
West.
4. The possible benefit from a probiotic preparation is
dependent on specificity of the strain as well as host
23
response and these may differ in the two settings.

24. SUMMARY OF TRIALS(RCT)
S. CLINICAL SETTING PROBIOTIC STRAIN(S) PURPOSE RESULT
NO
1. Acute watery diarrhea L. acidophilus Treatment No benefit
2. Acute watery diarrhea L. rhamnosus GG Treatment No benefit
3. Persistent diarrhea L.rhamnosus GG Treatment Benefit
4. Acute diarrhea L .casei DN-11400, L. Treatment
bulgaricus, S. thermophilus,
Lactococcus lactis, +
Lactococcus lactis cremoris,
Leuconosta Benefit
mesenteroides cremoris Prevention
5. Morbidity B. Lactis(DR-10) Prevention Benefit
6. Neonatal sepsis L. plantarum Treatment Benefit
7. Ulcerative Colitis VSL#3 Treatment Benefit
8. Pediatric Irritable Bowel VSL#3 Treatment Benefit
Syndrome
9. Acute diarrhea L. casei Shirota Prevention Benefit
24

25. Guidelines for the treatment of gastroenteritis by ESPGHAN
Guarino & al. JPGN 2008;46:619-21
 “Probiotics may be an effective adjunct to the management of diarrhea.
However, because there is no evidence of efficacy for many preparations, we
suggest the use of Probiotic strains with proven efficacy and in appropriate
doses for the management of children with AGE as an adjunct to rehydration
therapy (II, B). The following Probiotics showed benefit in meta-analyses of
clinical trials: Lactobacillus GG (I, A) and S.boulardii (I, A).
 Evidence of lack of risk of antibiotic resistance transfer is required for
Probiotics proposed for clinical use (Vb, D).”
S. Boulardii is acknowledged
as an evidence-based probiotic
and recommended by the ESPGHAN

26. LASPGHAN Guidelines
(Latin American Society of Pediatric Gastroenterology ,Hepatology and Nutrition)
Only S.boulardii & L.GG
has been give 1A
grade level of evidence

27. PEDIATRIC CASE STUDIES – L. casei Shirota
N 3 YRS F
RECURRENT LOOSE STOOLS - FOR 18 MONTHS
Given antibiotics for 3 – 5 days on most occasions, loose
stools subsided, but frequent recurrence.
L. casei Shirota consumed once daily ( 65 ML) for 5
months ( irrespective of occurrence of loose stools) –
parents observed decreased frequency of episodes of loose
stools.

28. PEDIATRIC CASE STUDIES – (L.casei Shirota)- contd..
S 6 YRS M
PASSAGE OF HARD STOOLS WITH DIFFICULTY - 2 YRS
IRREGULAR STOOL FREQUENCY - 2 YRS
Had received lactulose and cremaffin intermittently – no significant benefit.
Then, received continuous medical treatment for 6 months as follows:-
• LACTULOSE 15 ML TWICE DAILY ( AFTER LUNCH & DINNER), MON – SAT, 6 DAYS /
WEEK.
• POLYETHLENE GLYCOL ½ PACKET ONCE WEEKLY (EVERY SUNDAY) DISSOLVED IN
TOTAL 1000 ML (600 ML BISLERI WATER + 400 ML MANGO FROOTI JUICE) OVER 3 HRS
FOR 2 MONTHS, THEN STOPPED.
• L. casei Shirota FOR 6 MONTHS AND STILL CONTINUING.
• DISTINCT CLINICAL IMPROVEMENT - REGULAR STOOL PASSAGE ( 1 -2 / DAY), EASY.

29. Thank You