There is such a thing as “choice overload” – when you can’t make a choice (“choice paralysis”) because there are too many options. I imagine that this is what neonatologists feel when they think about all of the -biotics (pro-, pre-, and syn-) that have been studied in premature infants, with the goal of favorably altering the gut microbiome and decreasing the risk of necrotizing enterocolitis (NEC) and sepsis.
This week, Pediatrics is releasing a meta-analysis by Chi et al that looks at all of these pro-, pre-, and syn-biotic choices (10.1542/peds.2020-0706). The meta-analysis includes 45 trials of probiotic supplementation with 12,320 participants.
The meta-analyses showed that:
- Compared to placebo, Bifidobacterium + Lactobacillus was associated with the lowest odds of overall mortality (44% decreased odds).
- Compared to placebo, Lactobacillus + Prebiotic was associated with the lowest odds of NEC morbidity (94% decreased odds), but Bifidobacterium + Prebiotic (68% decreased odds), Bifidobacterium + Streptococcus(57% decreased odds), and Bifidobacterium + Lactobacillus (53% decreased odds) also significantly lowered risk of NEC morbidity.
- Compared to placebo, Lactobacillus + Prebiotic was associated with the lowest odds of sepsis morbidity (82% decreased odds).
So, does this help with choice overload?
It seems clear that Bifidobacterium and Lactobacillus are associated with the most positive outcomes.
Additionally, it appears that there is potential synergy among the different strains, and so perhaps you should use a combination of Bifidobacterium + Lactobacillus or one of these in combination with a prebiotic. The authors note that the studies included in this meta-analysis did not find any problem with safety or side effects when probiotic/prebiotic combinations were used.
The Chi et al. article has many additional analyses that will be of interest to pediatricians who care for these infants.
In an accompanying commentary, Patel and Pammi note that there are other considerations in selecting a probiotic – such as quality and cost (10.1542/peds.2020-039735). Since most probiotics are marketed as dietary supplements, they are not regulated, nor do they require FDA approval. The quality and effectiveness of probiotics may not be consistent. These considerations all need to be taken into account by the team caring for these at-risk infants.
