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Probiotics to help manage occasional diarrhea in infants and children

 - Lactobacillus rhamnosus, LGG® and acute, antibiotic-associated & hospital-acquired diarrhea 

Young child diarrhea and the role of some probiotic strains
Infant health Diarrhea Microbiome LGG®
6 Min read

Supplementation with probiotic products, such as those containing Lactobacillus rhamnosusLGG® (hereafter referred to by its trademark LGG®) strain, has been associated with alleviation of the symptoms of acute,1, 2 antibiotic-associated,3, 4 and hospital-acquired diarrhea.5

Fact

Due to its effectiveness, the LGG® strain is recommended by organizations and expert groups worldwide for management of diarrhea

Factors to consider


Acute diarrhea
- 10 billion CFU/day (colony forming units) of LGG® for 5-7 days

Antibiotic-associated diarrhea - 10-20 billion CFU/day of LGG®. Commence LGG® the same day as starting the antibiotics, resume for a week longer than the antibiotics, consume the probiotic product a few hours after intake of antibiotics

Hospital-acquired diarrhea - 10 billion CFU/day of LGG® for the length of the hospital stay

High incidence rate

Diarrhea, whether acute, antibiotic-associated or hospital-acquired, is a major health burden, with a particularly high incidence rate in infants and young children.6 Globally, each child under three years of age will have at least one episode of acute diarrhea each year.6

Dysbiosis and diarrhea

Simply, diarrhea is an altered movement of ions and water. When healthy and balanced, the gastrointestinal tract has the capacity to absorb fluids and electrolytes.7 This is facilitated by beneficial bacteria blocking the actions of pathogenic bacteria, and thus helping to maintain a healthy gastrointestinal tract. However, when infected by pathogenic bacteria or diarrhea-causing virus such as rotavirus, the mucosa is compromised and either there is an excessive secretion or an impaired absorption of fluid and electrolytes across the intestinal epithelium.8

Evidence supports the beneficial impact of some probiotic strains at helping to maintain a healthy gastrointestinal tract, via a number of mechanisms.9,10 Lactobacillus rhamnosus, LGG® is one such strain; it has been associated with beneficial effects such as enhancing the integrity of the intestinal epithelial barrier,11,12 modulating immune responses13,14 and inhibition of pathogens.15,16

Acute diarrhea

Diarrhea is a common consequence of gastrointestinal infections that are caused by a wide range of pathogens, including bacteria and viruses, with rotavirus being the primary cause.17 Acute diarrhea is defined as loose or watery stools at least three times per day, or more frequently than is normal for a particular individual,18 and typically lasting < 7 days and no longer than 14 days.19 The incidence rate ranges from 0.5 – 1.9 episodes each year in children under 3 years of age.18

To rebalance fluid and electrolytes, rehydration when possible is key.19 Further, some probiotic strains have been associated with helping to support a healthy gastrointestinal tract, for instance, shorter duration of1, 2 and more rapid improvement in symptoms has been observed1 when supplementing with the LGG® strain.

These results have been observed in children with acute diarrhea in children when supplemented with 10 billion CFU/day of the LGG® strain for 5-7 days.19

Young child with diarrhea

Antibiotic-associated diarrhea

Occurring in up to one third of all patients treated with antibiotics, antibiotic-associated diarrhea (AAD) is common and challenging and is observed in both outpatient clinics and hospital settings.21 It is diarrhea that occurs in relation to antibiotic treatment, with the exclusion of any other etiologies.22 Almost any oral and intravenous antibiotic treatment can cause AAD. However, the risk of AAD is higher when aminopenicillins are used (with or without the addition of clavulanate, cephalosporins, or clindamycin) and, in general, the risk is higher with any antibiotic that is active against anaerobes.23

Since AAD does not necessarily occur immediately, and may instead occur a few weeks or months after treatment, caution is needed in order to differentiate AAD from an episode of infectious gastroenteritis.22 AAD typically presents as mild diarrhea, but it can also present as fulminant pseudomembranous colitis.24 Usually, no specific pathogen is identified, however, in the most severe case of AAD, or when in association with chronic conditions such as cancer and inflammatory bowel disease, the cause is frequently Clostridium difficile.24

By destroying not only the pathological but also the beneficial microbes and the competitive exclusion mechanism (one method by which microbiota eliminate pathological microbes), AAD may be caused by a disruption to the gut microbiota and an overgrowth of pathogens.21, 22, 25 Some probiotic strains have been associated with reducing the occurrence of AAD. Specifically, supplementation with the LGG® strain has been associated with a reduction in the occurrence of antibiotic-associated diarrhea in children.3, 4

Results from clinical studies3, 4 suggest that to optimize the potential effect of the LGG® strain, supplementation at 10-20 billion CFU/day of the LGG® strain26 should be initiated on the same day as starting antibiotic treatment, resumed for a week longer than the antibiotic treatment, and the probiotic product consumed a few hours after taking the antibiotics.

Infant being examined for stomach problems

Hospital-acquired diarrhea

Also known as nosocomial and healthcare-associated infections, hospital-acquired infections develop > 48 hours after hospital admission, and are therefore not present or incubating at the point of hospital admission.26 Depending on factors such as time of year and the ward, the incidence of hospital-acquired infections in children in developed countries is high, ranging from 5.1% - 11.6%,27 with gastrointestinal infection accounting for the majority of infections.28,29,30 The costs associated with hospital-acquired infections are significant, by prolonging length of hospital stay, worsening treatment outcomes, and increasing microbial antibiotic resistance.5


Probiotic products have been associated with alleviating the symptoms of occasional diarrhea resulting from  hospital-acquired infection. In one study, children admitted to pediatric facilities exhibited reduced incidence of hospital-acquired gastrointestinal and respiratory tract infection when supplemented with the LGG® strain at 10 billion CFU/day for the length of the hospital stay
5,31

 

LGG® is a registered trademark of Chr. Hansen A/S.


The article is provided for informational purposes regarding probiotics and is not meant to suggest that any substance referenced in the article is intended to diagnose, cure, mitigate, treat, or prevent any disease.

Our Chr. Hansen probiotic strains

At Chr. Hansen, our strains are backed by science. All of our probiotic strains are supported by clinical documentation. Learn more about the beneficial effects our strains have on different health areas.

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Reference list

1. Aggarwal S, et al. Lactobacillus GG for treatment of acute childhood diarrhoea: an open labelled, randomized controlled trial. Indian J Med Res. 2014;139(3):379-85. (PubMed)
2. Isolauri E, et al. A human Lactobacillus strain (Lactobacillus casei sp strain GG) promotes recovery from acute diarrhea in children. Pediatrics. 1991;88(1):90-7. (PubMed)
3. Arvola T, et al. Prophylactic Lactobacillus GG reduces antibiotic-associated diarrhea in children with respiratory infections: a randomized study. Pediatrics. 1999;104(5):e64. (PubMed)
4. Vanderhoof JA, et al. Lactobacillus GG in the prevention of antibiotic-associated diarrhea in children. The Journal of Pediatrics. 1999;135(5):564-8. (PubMed)
5. Hojsak I, et al. Lactobacillus GG in the prevention of nosocomial gastrointestinal and respiratory tract infections. Pediatrics. 2010;125(5):e1171-7. (PubMed)
6. Thiagarajah JR, et al. Secretory diarrhoea: mechanisms and emerging therapies. Nat Rev Gastroenterol Hepatol. 2015;12(8):446-57. (PubMed)
7. Hodges K, Gill R. Infectious diarrhea: Cellular and molecular mechanisms. Gut Microbes. 2010;1(1):4-21. (PubMed)
8. Walker CLF, et al. Global burden of childhood pneumonia and diarrhoea. Lancet. 2013;381(9875):1405-16. (PubMed)
9. Lemberg DA, et al. Probiotics in paediatric gastrointestinal diseases. J Paediatr Child Health. 2007;43(5):331-6. (PubMed)
10. Yan F, et al. Soluble proteins produced by probiotic bacteria regulate intestinal epithelial cell survival and growth. Gastroenterology. 2007;132(2):562-75. (PubMed)
11. Seth A, et al. Probiotics ameliorate the hydrogen peroxide-induced epithelial barrier disruption by a PKC- and MAP kinase-dependent mechanism. Am J Physiol Gastrointest Liver Physiol. 2008;294(4):G1060-9. (PubMed)
12. Chen L, et al. Lactobacillus rhamnosus GG treatment improves intestinal permeability and modulates microbiota dysbiosis in an experimental model of sepsis. Int J Mol Med. 2019;43(3):1139-48. (PubMed)
13. Claes IJ, et al. Lipoteichoic acid is an important microbe-associated molecular pattern of Lactobacillus rhamnosus GG. Microb Cell Fact. 2012;11:161. (PubMed)
14. Lebeer S, et al. Functional analysis of Lactobacillus rhamnosus GG pili in relation to adhesion and immunomodulatory interactions with intestinal epithelial cells. Appl Environ Microbiol. 2012;78(1):185-93. (PubMed)
15. Lu R, et al. Isolation, identification, and characterization of small bioactive peptides from Lactobacillus GG conditional media that exert both anti-Gram-negative and Gram-positive bactericidal activity. J Pediatr Gastroenterol Nutr. 2009;49(1):23-30. (PubMed)
16. Marianelli C, et al. Evaluation of antimicrobial activity of probiotic bacteria against Salmonella enterica subsp. enterica serovar typhimurium 1344 in a common medium under different environmental conditions. Res Microbiol. 2010;161(8):673-80. (PubMed)
17. Lo Vecchio A, et al. Rotavirus immunization: Global coverage and local barriers for implementation. Vaccine. 2017;35(12):1637-44. (PubMed)
18. World Health Organisation. Diarrhoea: Why children are still dying and what can be done. 2009.
19. Szajewska H, 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. (PubMed)
20. Barbut F, Meynard JL. Managing antibiotic associated diarrhoea. BMJ. 2002;324(7350):1345-6. (PubMed)
21. McFarland LV. Epidemiology, risk factors and treatments for antibiotic-associated diarrhea. Dig Dis. 1998;16(5):292-307. (PubMed)
22. McFarland LV, et al. Risk factors for Clostridium difficile carriage and C. difficile-associated diarrhea in a cohort of hospitalized patients. J Infect Dis. 1990;162(3):678-84. (PubMed).
23. McFarland LV. Meta-analysis of probiotics for the prevention of antibiotic associated diarrhea and the treatment of Clostridium difficile disease. Am J Gastroenterol. 2006;101(4):812-22. (PubMed).
24. Hasan N, Yang H. Factors affecting the composition of the gut microbiota, and its modulation. PeerJ. 2019;7:e7502-e. (PubMed).
25. World Gastroenterology Organisation. World Gastroenterology Organisation Global Guidelines - Probiotics and prebiotics. 2011..
26. World Health Organization. Prevention of Hospital-acquired Infections. Geneva, Switzerland; 2002.
27. World Health Organisation. Report on the Burden of Endemic Health Care-associated Infection Worldwide. Geneva, Switzerland; 2011. 
28. Muhlemann K, et al. Prevalence of nosocomial infections in Swiss children's hospitals. Infect Control Hosp Epidemiol. 2004;25(9):765-71. (PubMed)
29. Rutledge-Taylor K, et al. A point prevalence survey of health care-associated infections in Canadian pediatric inpatients. Am J Infect Control. 2012;40(6):491-6. (PubMed)
30. Kinnula S, et al. Hospital-associated infections in children: a prospective post-discharge follow-up survey in three different paediatric hospitals. J Hosp Infect. 2012;80(1):17-24. (PubMed)
31. Hojsak I, et al. Probiotics for the Prevention of Nosocomial Diarrhea in Children. J Pediatr Gastroenterol Nutr. 2018;66(1):3-9.  (PubMed)

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