Probiotics in very preterm infants - how do you do (now)?

[Stefan Johansson]

The awaited probiotics UK-trial is now published, and the results are showing that a single bacteria (Bifidobacterium breve BBG-001 in very preterm infants) does not reduce the risk of NEC, late-onset sepsis, or mortality. http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(15)01027-2/abstract

In short, a negative trial of good quality methodologically.

However, the results contrasts against the ProPrems trial, similarly powered and well-designed, but the probiotics in that trial included a 3-strain preparation: http://pediatrics.aappublications.org/content/early/2013/11/12/peds.2013-1339

Another upcoming paper in Acta Paediatrica from Berlin on a 2-strain probiotics also showed benefits: http://onlinelibrary.wiley.com/doi/10.1111/apa.13280/abstract

My question to you how you interpret all these findings, also in the light of the Cochrane review from last year, which expressed strong conclusions that probiotics should be offered to preterm infants. (here: http://www.ncbi.nlm.nih.gov/pubmed/24723255)

Do you, or don't you use probiotics? Why?

Please share your own experiences. If you use probiotics, please also share what type of probiotics you use.

[geeth]

At present we do not use probiotics. Why all these trials use different products and in different doses? 

[R. Hentschel]

I totally agree with you that a mixture of strains is required to get a protective effect - this is obviously also the result of metaanalyses. We have used Lactobacillus acidophilus and Bifidobacterium infantis as a commercially available preparation for several years now and my impression is that NEC has declined since then.

[Stefan Johansson]

We got an interesting comment from @AllThingsNeonatal after the announcement on "Home" - I quote it

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I think what this shows is that this particular strain of probiotics is ineffective.  Herein lies the problem with the huge glut of info on probiotics and that is the wide variation in products that have used.  I suspect probiotics will not help all premature infants but rather a subset which we have yet to identify.  Add to this that so few centres are comparing the same bacteria and it is no wonder the results are inconsistent.

Based on the work being done here in Manitoba on the infant microbiome (see work by Meghan Azad) it is clear that not only do the bacterial genus and species matter but whether they are active and to what extent that influences health.  I am not sure how we will ever settle the probiotic discussion but it may become entirely moot as we expand donor breast milk programs which I think is the better way to go.

[r.dippenaar]

Probiotics will always a contentious subject and I personally agree with the comments above, but also of interest is from the available literature aside from less than a handful of isolated cases in relation to the global footprint of probiotic use within the Neonatal ICU's it at least appears to do no harm. We have used probiotics extensively from 2007. Our preferred choice has been Lactobacilli Reuteri in a commercially available preparation and this choice was largely based on availability and quality assurance of product in South Africa. We have not had a single case of necrotising enterocolitis in 6 years representing 1200 infants for that period. Attributing this to a single intervention would be a unreasonable as aggressive conversion to exclusive breast milk should rather be credited. Attached is an interesting article describing lactobacillus in breastmilk world wide.  

Ricky Dippenaar

HumanBreastMilkLactobacillus.pdf

[Amirmasoud Borghei]

extensive data show probiotic decrease incidence severe nec and mrtality but fda no approved .........nelson textbook 20 edition

[Amirmasoud Borghei]

Prophylactic Probiotics for Preterm Infants: A Systematic Review and Meta-Analysis of Observational Studies

http://www.karger.com/Article/Pdf/441274