Re: ESPGHAN Commentary and Education That Probiotics Substantially Reduce All‐cause Mortality and Necrotizing Enterocolitis in Preterm Infants

Abstract

To the Editor: We congratulate Professor Goudoever and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition Committee on Nutrition on their commentary published in the January 2010 issue (1). However, the committee only had access to articles published by early 2007 when the commentary was drafted. Their conclusion that present data do not permit recommending the routine use of probiotics in preterm infants did not take into account (1) the Cochrane Review in 2008, which found that probiotics reduced all-cause mortality and necrotizing enterocolitis (NEC) by more than half (2), with no increase in sepsis, and recommended a change in practice with regard to starting probiotics in preterm infants >1000 g birth weight, or (2) subsequent randomized controlled trials (RCTs) (3–8). A meta-analysis of 11 RCTs in 2032 preterm infants in April 2009 (3) showed that probiotics reduced all-cause mortality (P < 0.00001) and NEC (P < 0.00001) by more than half, confirming an earlier systematic review (4). We suggest that readers consider the evidence from 11 published RCTs (2–8), which suggest that probiotics substantially reduce all-cause mortality and NEC in preterm infants. Given that evidence, requiring that safety and efficacy be established in RCTs of each probiotic versus placebo would now be ethically problematic. A more appropriate strategy would be to undertake RCTs with multiple treatment arms of different probiotic regimens with no placebo. One commentator asks, “Do we, knowing what we now know, have the right to deny parents the option of giving a probiotic if that is what they would like? (9)”.