“Low quality of evidence; strong recommendation” for Probiotics in Gastroenteritis

Recently a position paper on “Use of probiotics for management of acute gastroenteritis: a position paper by the ESPGHAN working group for probiotics and prebiotics” was published (JPGN 2014; 58: 531-39).

Two specific probiotics were recommended “strongly” but the working group describes the evidence for both as “low quality.”  This strikes me as odd.  The authors extensively reviewed previous studies and used the “GRADE” system to classify the quality of evidence and the category of recommendation.  There were 4 categories of quality of evidence: high, moderate, low and very low.  There were 2 possible recommendation categories: strong or weak.

The summary recommendations included the following:

  • Rehydration is the key treatment for AGE
  • Probiotics, overall, reduce diarrhea by approximately 1 day
  • However, probiotic effects are strain specific; findings from one probiotic cannot be extrapolated to another
  • The group recommends choosing probiotics with efficacy confirmed in well-conducted RCTs from a reputable manufacturer
  • Two specific recommended probiotics: Lactobacillus GG and Saccromyces boulardii

Take-home message: This article summarizes the available evidence for the use of probiotics in acute gastroenteritis.  Despite their classification as  “low quality of evidence,” the authors provide a strong recommendation for two probiotics (Lactobacillus GG and Saccromyces boulardii) as adjunctive therapy.

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Probiotics, Atopy, and Asthma

Moving from theory to practice with probiotics has been problematic in many areas.  That is, theoretically probiotics by altering the microbiome should have numerous beneficial effects; however, demonstrating these positive effects in practice has been difficult for many conditions.  A recent study (thanks to Mike Hart for this reference) highlights this issue with regard to asthma:  Pediatrics 2013; 132: e666-76. Full article:


Background: Due to the immune modulating effects of probiotics and mindful of the hygiene hypothesis regarding the rise of atopic diseases, some have proposed the use of probiotics to reduce the risk of atopy and asthma in children.

Methods: In this study, the authors performed a meta-analysis of numerous randomized studies.  Out of a total of 1081 articles, 25 studies met predefined criteria, with a total of 4031 participants (see Table 1 in publication).  Numerous probiotics were administered.  The most common probiotic in these trials, Lactobacillus GG,  was used in 8 of the studies.


  • For serum immunoglobulin E (IgE) levels, 9 of the trials (n=1103) provided data.  Probiotics were associated with a -7.59 U/mL reduction in total IgE (P= .044).  The effect of probiotics was more pronounced with longer, follow-up periods.
  • Probiotics, in comparison to placebo, were associated with a reduced risk of atopic sensitization based on positive skin prick and/or elevated specific IgE to common allergens.  This was true whether the probiotic was administered prenatally (relative risk 0.88, P=.035) or postnatally (relative risk 0.86, P=.027)
  • Probiotics did not reduce the risk of asthma/wheeze (relative risk 0.96 [95% CI 0.85-1.07]

Study limitations: heterogeneity of clinical trials in meta-analysis, various probiotic strains, variable duration and timing of probiotic use.

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