Efficacy of Lactobacillus Therapy for Acute Diarrhea

Abstract

Source: Van Niel CW, Feudtner C, Garrison MM, et al. Lactobacillus therapy for acute infectious diarrhea in children: a meta-analysis. Pediatrics. 2002;109:678–684.A number of studies in various settings have suggested that Lactobacillus may both prevent and treat diarrhea (see AAP Grand Rounds, March 2000;3:28–29 and June 2001;5:58–59). Van Niel and colleagues at the University of Washington in Seattle conducted a meta-analysis of all randomized, blinded, controlled studies comparing Lactobacillus with placebo for the treatment of children with acute infectious diarrhea. Nine studies of primarily hospitalized patients between 1 and 37 months of age met the criteria. Some studies included diarrhea from bacteria, viruses, and diarrhea of unidentified etiology, and others were limited to rotavirus diarrhea alone. Seven studies involving 575 children had data on duration of diarrhea and 3 studies involving 122 children had data on daily number of stools on day 2 of admission. Comparing children who received Lactobacillus treatment versus those who received placebo, summary point estimates from the meta-analysis indicate a significant reduction in diarrhea duration of .7 days (95% CI, .3–1.2) and 1.6 fewer stools (95% CI, .7–2.6) on day 2 of treatment. No publication bias was detected. Differences between various Lactobacillus strains could not be inferred but a dose-response relationship was detected. The beneficial effect of Lactobacillus was noted in all forms of infectious diarrhea studied and not limited to any specific subset. In all included studies, adverse reactions were comparable between the 2 groups. The authors conclude by observing that a commercially available Lactobacillus product costing $10 could on average save about 1–2 diapers and 17 hours caring for a sick child with diarrhea.Interest in and use of complementary-alternative medical (CAM) therapies have markedly increased in recent years.1 (See also Complementary Medicine in Inflammatory Bowel Disease in this issue AAP Grand Rounds.) Probiotics, living organisms which potentially promote health, have been utilized to prevent and treat numerous human afflictions from gastrointestinal and respiratory infections to allergies;2 however, the data from controlled trials to support their efficacy remains scant. This meta-analysis lends strong and timely support regarding the safety and efficacy of Lactobacillus as a therapeutic modality for a major cause of morbidity and mortality in children throughout the world, infectious diarrhea. How Lactobacillus works is unclear. Postulated mechanisms include enhancing an immune response, elaborating an antimicrobial substance, or altering the intestinal microbial balance. Although the cost of commercially available Lactobacillus preparations may not yet be covered by all third party payors, the saving of hours of work missed will surely balance the expenditure. We agree with the authors’ conclusion that Lactobacillus can be recommended for therapy of children with infectious diarrhea.Some physicians persist in recommending ineffective medications such as cough medicines with codeine or dextromethorphan3,4 or antihistamine-decongestant combinations for upper respiratory infection 5 or otitis.6 Why we are dragging our feet on Lactobacillus remains puzzling. Perhaps it is in part because some view it as an “alternative therapy,” or perhaps because this commercial product has not been widely promoted.The utility of dietary sources of Lactobacillus (eg, acidophilus milks, live culture yogurts) in ameliorating or preventing diarrhea is uncertain. Since most supermarket yogurt is pasteurized, a yogurt a day is unlikely to replace the proverbial apple. Nonetheless, we believe that Lactobacillus therapy of acute infectious diarrhea should be considered as part of routine therapy for this condition.