What is the evidence for using probiotics (live microorganisms) in children with viral gastroenteritis?

Evidence for Probiotics in Children with Viral Gastroenteritis

The American Gastroenterological Association (AGA) recommends against the use of probiotics for treating acute gastroenteritis in children in North America, based on high-quality studies showing no benefit. 1, 2

Current Evidence and Recommendations

North American vs. International Studies

• Recent high-quality North American studies show no benefit of probiotics in pediatric gastroenteritis:

  • Two large multicenter, randomized, double-blind, placebo-controlled trials in the US and Canada found no significant difference between placebo and probiotic groups in reducing moderate-to-severe gastroenteritis 1, 2
  • These trials tested L. rhamnosus ATCC 53103 (US study) and a combination of L. rhamnosus R0011 and L. helveticus R0052 (Canadian study) 1
  • A 2020 study examining virus-specific effects found no benefits from L. rhamnosus and L. helveticus in reducing clinical symptoms or viral clearance 3

• International studies show mixed results:

  • Most positive studies were conducted in India, Italy, Poland, Turkey, and Pakistan 1
  • Many of these studies had concerns regarding risk of bias 1
  • Regional differences in host genetics, diet, sanitation, and endemic pathogens may explain these discrepancies 2

Strain-Specific Evidence

• S. boulardii:

  • Most frequently studied (22 trials)
  • May reduce diarrhea duration by 28.77 hours and frequency of prolonged diarrhea, but with very low certainty of evidence 1
  • ESPGHAN Working Group gave it a strong recommendation despite low quality evidence 4

• L. rhamnosus ATCC 53103:

  • Evaluated in 19 trials
  • May reduce diarrhea duration by 23.13 hours and proportion of children with diarrhea lasting >4 days
  • Low certainty of evidence 1
  • ESPGHAN Working Group gave it a strong recommendation despite low quality evidence 4

• L. reuteri:

  • May reduce diarrhea duration by 24.36 hours
  • May reduce proportion of children with prolonged diarrhea
  • Low certainty of evidence 1
  • ESPGHAN gave weak recommendation with very low quality evidence 4

• Other probiotics:

  • L. acidophilus and B. bifidum combination may reduce diarrhea duration, but with low certainty of evidence 1
  • Heat-inactivated L. acidophilus LB received weak recommendation with very low quality evidence from ESPGHAN 4

Clinical Application

Decision Algorithm

1. Primary approach: Focus on oral rehydration therapy as the cornerstone of treatment for all children with acute gastroenteritis 2

2. Location-based decision:

   • In North America: Do not use probiotics for acute gastroenteritis in children (AGA recommendation) 1, 2
   • Outside North America: Consider regional evidence and local guidelines

3. If considering probiotics despite recommendations:

   • S. boulardii or L. rhamnosus GG have the strongest evidence, though still low quality 1, 4
   • Ensure early administration at adequate doses
   • Recognize that benefits may be modest (potential reduction in diarrhea duration by ~24 hours) 1

Important Caveats

• Strain specificity matters: Different probiotic strains have different effects; results from one strain cannot be generalized to others 5

• Potential confounding factors:

  • Rotavirus vaccination has changed the landscape of viral gastroenteritis pathogens 3
  • Dosage, duration of treatment, and quality of probiotics affect outcomes 5

• Risk-benefit consideration: While probiotics have generally good safety profiles, their limited efficacy in North American studies doesn't justify routine use 1, 2

• Different from prevention: Evidence for probiotics in preventing necrotizing enterocolitis in preterm infants is stronger and represents a different clinical scenario 2

• Zinc supplementation: In developing countries, zinc supplementation has shown significant benefits in reducing duration and severity of diarrhea, which may be more impactful than probiotics in those settings 6