Late initiation of probiotic therapy for acute pediatric gastroenteritis may account for null results

Francisco Guarner, MD, PhD, University Hospital Vall d’Hebron, Barcelona, Spain; Michael Cabana, MD, MPH, University of California, San Francisco, CA, USA; and Mary Ellen Sanders, PhD, International Scientific Association for Probiotics and Prebiotics, Centennial, CO, USA. 

Schnadower et al (1) and Freedman et al (2) conclude that probiotics given to children who presented to emergency departments with gastroenteritis are not effective; however, these new well-conducted trials used probiotics in children who were symptomatic much longer than when current recommendations suggest initiating therapy.  Both studies recruited children that were symptomatic for up to 72 hours or more at time of randomization. Half the cohort of Freedman (2) had diarrhea for 43 hours at randomization. In the study by Schnadower, (1) children were symptomatic at randomization for a median of 53 hours. It is not surprising that probiotic intervention at this late stage was not successful, since most children were close to spontaneous remission. Acute gastroenteritis in high-income countries is usually benign and after 48 hours typically remits spontaneously. These new studies should not change current recommendations (3,4,5) to use probiotics early after onset of pediatric gastroenteritis in conjunction with oral rehydration, consistent with previous beneficial trials.

 

1. Schnadower D, Tarr PI, Casper TC, et al. Lactobacillus rhamnosus GG versus placebo for acute gastroenteritis in children. N Engl J Med. 2018; 379(21):2002-2014.
2. Freedman SB, Williamson-Urquhart S, Farion KJ, et al. Multicenter trial of a combination probiotic for children with gastroenteritis. N Engl J Med. 2018;379(21):2015-2026.
3. Allen SJ, Martinez EG, Gregorio GV, Dans LF. Probiotics for treating acute infectious diarrhoea. Cochrane Database Syst Rev. 2010 Nov 10;(11):CD003048.
4. Szajewska H, Guarino A, Hojsak I, et al. Use of probiotics for management of acute gastroenteritis: a position paper by the ESPGHAN Working Group for Probiotics and Prebiotics. J Pediatr Gastroenterol Nutr. 2014;58(4):531-9.
5. Lo Vecchio A, Dias JA, Berkley JA, et al. Comparison of recommendations in clinical practice guidelines for acute gastroenteritis in children. J Pediatr Gastroenterol Nutr. 2016;63(2):226-35.