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Keywords enteral feeds, review, infants, neonates, nutrition, preterm, probiotic supplementation
INTRODUCTION
A recent updated Cochrane review (1) of randomized controlled trials (RCTs)4 (24 RCTs; 5529 neonates) confirmed
previous findings that probiotic supplementation significantly
reduces risk of stage II or greater necrotizing enterocolitis
(NEC) (RR: 0.43, 95% CI: 0.33,0.56) and all-cause mortality
(RR: 0.65; 95% CI: 0.52, 0.81) in preterm neonates. These results reemphasized previous recommendations that a change in
practice in favor of probiotic supplementation is needed (14).
However, the debate about risks compared with benefits of
probiotic supplementation in preterm neonates continues (57).
With consideration of the evidence from RCTs (1) and reports
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Am J Clin Nutr 2014;100:150819. Printed in USA. 2014 American Society for Nutrition
ABSTRACT
Introduction: The optimization of enteral nutrition is a priority in
preterm neonates worldwide. Probiotics are known to improve gut
maturity and function in preterm neonates. To our knowledge, previous systematic reviews have not adequately assessed the effects of
probiotic supplementation on enteral nutrition in preterm neonates.
Objective: We assessed the evidence on effects of probiotics on
enteral nutrition in preterm neonates.
Design: A systematic review of randomized controlled trials (RCTs) of
probiotic supplementation in preterm (gestation ,37 wk) or low-birthweight (birth weight ,2500 g) neonates was conducted. With the use of
the Cochrane Neonatal Review Group strategy, we searched the
Cochrane Central Register of Controlled Trials, PubMed, EMBASE, and
Cumulative Index of Nursing and Allied Health Literature databases and
proceedings of Pediatric Academic Society meetings in April 2014.
Results: A total of 25 RCTs (n = 5895) were included in the review.
A meta-analysis (random-effects model) of data from 19 of 25 trials
(n = 4527) estimated that the time to full enteral feeds was shorter in
the probiotic group (mean difference: 21.54 d; 95% CI: 22.75,
20.32 d; P , 0.00001, I2 = 93%). Other benefits included fewer
episodes of feed intolerance, better weight gain and growth velocity,
decreased transition time from orogastric to breast feeds, and increased postprandial mesenteric flow. There were no adverse effects
of probiotic supplementation.
Conclusions: Probiotics reduced the time to full enteral feeds in
preterm neonates. Additional research is necessary to assess the
optimal dose, duration, and probiotic strain or strains used specifically for facilitating enteral nutrition in this population.
Am J
Clin Nutr 2014;100:150819.
1509
Types of studies
Types of participants
Preterm neonates born at a gestational age ,37 wk or of low
birth weight (,2500 g) were included.
Intervention and comparison
Outcomes
Studies were included if they reported at least one of the
following outcomes:
1) TFEFs.
2) Other nutritional outcomes such as the time to regain birth
weight, anthropometric measure, extrauterine growth restriction, and feed intolerance (vomiting, abdominal distension, and gastric aspirates).
Review methods
Search strategy
The Cochrane Central Register of Controlled Trials (through
April 2014; www.thecochranelibrary.com), PubMed (19662014;
www.ncbi.nlm.nih.gov), EMBASE via Ovid (19802014; http://
ovidsp.tx.ovid.com), and Cumulative Index of Nursing and Allied
Health Literature (19802014; http://www.ebscohost.com/academic/
the-cinahl-database) databases and E-Abstracts from the Pediatric
Academic Society meetings (20002014; www.abstracts2view.com/
pasall) were searched in April 2014. Reference lists of identified
studies and key review articles were also searched. No language
restriction was applied.
PubMed was searched by using the strategy for our previous
systematic review (26) with the following Medical Subject
Headings terms: [Infant, Premature], OR [Infant, Very Low Birth
Weight] OR [Infant, Low Birth Weight] OR [Infant, Extremely
Low Birth Weight] OR Infant, Small for gestational age] AND
[Randomized Controlled Trials] OR [Controlled Clinical Trials]
OR [Clinical Trials] AND [Probiotic]. The term Probiotic was
replaced by Bifidobacterium OR Lactobacillus OR Saccharomyces for additional refined search.
Data extraction
All authors searched the literature independently and assessed
inclusion criteria. Authors GA-J and GD independently extracted
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ATHALYE-JAPE ET AL.
TABLE 1
Nutritional outcomes in clinical trials of probiotic supplementation in preterm neonates1
(No. of study) first author,
year of publication
(reference)
1) Kitajima, 1997 (37)
n = 91 (study: n = 45 compared with placebo: n = 46). Intervention: BBG compared with placebo (distilled water)
Type of milk: EBM/formula; type of delivery: data not available
Primary outcome: gut colonization with BBG
Nutritional outcomes: less air aspirated in first 4 wk of life and less vomiting and apneas in the BBG group (P . 0.05); colonized
infants established feeding earlier and had greater weight gain in the fourth and eighth weeks of life
n = 87 (study: n = 51 compared with placebo: n = 36). Intervention: Saccharomyces boulardii compared with maltodextrin
Type of milk: EBM. Type of delivery: CS, 49% (study group) compared with 38% (placebo group)
Primary outcome: tolerance to S. boulardiisupplemented formula, fecal flora analysis, intestinal D xylose absorption, and fecal
lipid excretion (80% power)
Secondary outcomes: incidence of NEC, 9.8% compared with 16% (P = 0.5); incidence of sepsis, 5.8% compared with 8.3%
(P = 0.7)
Nutritional outcome: median TFEF, 9.3 compared with 9.9 d (P . 0.1); median (IQR) weight gain (g/wk), 163.5 (17.7) compared
with 155.8 (16.5) (P . 0.05)
n = 145 (study: 72 n = compared with controls: n = 73). Intervention: (Bifidobacterium infantis + Streptococcus thermophilus +
Bifidobacterium bifidus) compared with no probiotic
Type of milk: EBM/formula. Type of delivery: 78% (LSCS in study group) compared with 78% (LSCS in controls)
Primary outcome: at least stage II NEC (80% power)
Nutritional outcomes: TFEF similar in both groups (P = 0.13). Mean (6SD) cumulative weight gain by 6 wk: 691 6 208 g in
probiotic group compared with 594 6 239 g in control group (P . 0.05)
n = 80 (study: 39 compared with controls: 40). Intervention: LGG compared with no probiotic
Type of milk: EBM/PDHM. Type of delivery: VD, 30% (study group) compared with 35% (controls)
Primary outcome: incidence of enteric fungal colonization (80% power)
Nutritional outcomes: mean (6SD) TFEF: 15 6 8 compared with 17 6 9 d (P = 0.15); duration of hospital stay: 30 6 28
compared with 35 6 30 d (P = 0.2)
n = 75 (study: 41 compared with controls: 34). Intervention: Bifidobacter lactissupplemented preterm formula compared with
preterm formula
Type of milk: preterm formula. Type of delivery: CS, 36.5% (study group) compared with 35% (controls)
Primary outcome: intestinal permeability
Nutritional outcomes [median (range)]: weight gain (g/d), 28.3 (1238) compared with 30 (1040) (P = 0.144); length gain (cm/wk).
1.4 (03) compared with 1.5 (03.5) (P = 0.271); head growth (cm/wk), 1.1 (0.451.9) compared with 0.9 (02) (P = 0.001); TFEFs
(d), 10 (052) compared with 10 (030) (P = 0.615); time to regain birth weight (d): 10 (420) compared with 13 (624)
(P = 0.072)
n = 434 (study: 217 compared with controls: 217). Intervention: (Lactobacillus acidophilus + Bifidobacterium bifidum) compared
with no probiotic
Type of milk: EBM/formula. Type of delivery: CS, 69.6% (study group) compared with 63.3% (controls)
Primary outcomes: death or NEC of at least stage II (P = 0.002) (power: 90%)
Nutritional outcomes (means 6 SDs): TFEFs, 29.8 6 19.7 compared with 27.0 6 18.7 d (P = 0.13); weight gain on day14 (53.4 6
53.1 compared with 52.7 6 59.8 g), day 28 (103.5 6 70 compared with 103.4 6 78.8 g), and day 42 (131.9 6 89.7 compared
with 139.7 6 85.6 g); hospital stay, 46.4 6 24.2 compared with 43.3 6 21.0 d (P = 0.16)
n = 186 (study: n = 91 compared with controls: n = 95). Intervention: probiotic mixture (B. infantis + B. bifidum + Bifidobacterium
longum + L. acidophilus) compared with no probiotic
Type of milk: EBM. Type of delivery: CS, 46.15% (study group) compared with 49.47% (controls)
Primary outcomes: feed tolerance (TFEFs), length of stay, comorbidities such as NEC, sepsis, and death due to NEC/sepsis
Nutritional outcomes: mean (6SD) TFEF lower in study group (13.76 6 2.28 d) than in controls (19.2 6 2.02 d) (P , 0.001),
mean (6SD) duration of hospital stay lower in study group (17.17 6 3.23 d) than controls (24.07 6 4 d) (P , 0.001), incidence
of NEC lower in study group (1.1%) than controls (15.8%) (P = 0.042) but no significant difference for NEC of at least stage II
(P = 0.62), lower culture-proven sepsis in study group (14.3%) than controls (29.5%) (P = 0.02), and lower death rate in study
group (4.4%) than controls (14.7%) (P = 0.032)
n = 94 (study: 45 compared with placebo: 49). Intervention: (B. longum + Lactobacillus rhamnosus GG) compared with placebo
(maltodextrin)
Type of milk: EBM/formula. Type of delivery: CS, 62.2% (study group) compared with 71.4% (placebo group)
Primary outcome: Percentage of age of infants receiving .50% of feeds via enteral route at day 14 of life (57.8% compared with
57.1%; P = 0.95) (80% power)
Nutritional outcomes: median TFEF, 16 compared with 26 d (P = 0.04)
n = 231 (study: n = 119 compared with controls: n = 112). Intervention: Yakult LB (Lactobacillus casei + Bifidobacterium breve)
compared with no probiotic
Type of milk: EBM/PDHM. Type of delivery, CS 53.8% (study group) compared with 49.1% (controls)
Primary outcome: confirmed NEC of at least stage II (80% power)
Nutritional outcomes: mean (6SD) TFEF, 15.2 6 5.2 compared with 17.4 6 5.7 d (P = 0.02); weight recovery in 14 d not much
different in study and control group (P = 0.82). Transition time from orogastric to breastfeeds: lesser in probiotic group
(P = 0.03)
(Continued)
Study characteristics
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TABLE 1 (Continued )
(No. of study) first author,
year of publication
(reference)
Study characteristics
(Continued)
n = 208 (study: n = 108 compared with controls: n = 100). Intervention: B. breve compared with no probiotic
Type of milk: EBM/formula. Type of delivery: data not available
Primary outcome: incidence rate of infection and sepsis
Nutritional outcomes (mean 6 SD): TFEF, 13.9 6 6.89 compared with 19.6 6 16.1 d (P , 0.01); weight on original EDD:
2412 6 441.5 (intervention) compared with 2113 6 58.9 g (controls) (P = 0.01); duration of hospital stay: 91.8 6 54.1
compared with 95.7 6 47.4 d (P = NS)
11) Mihatsch, 2010 (47) n = 183 (study: n = 93 compared with placebo: n = 90). Intervention: B. lactis compared with placebo
Type of milk: EBM/formula. Type of delivery: VD, 30% (study group) compared with 31% (placebo group)
Primary outcome: incidence density of nosocomial infections from days 742 of life after the initiation of enteral feeding (power:
80%); no significant effect on incidence of NEC of at least stage II (2% compared with 4%; P = NS)
Nutritional outcomes: no difference in mean (6SD) TFEFs (17.9 6 6.8 compared with 18.0 6 7.4 d; P = NS)
12) Al Hosni, 2011 (48) n = 101 (study: n = 50 compared with controls: n = 51). Intervention: (L. rhamnosus GG + B. infantis) compared with no
probiotics
Type of milk: EBM. Type of delivery: CS, 44% (study group) compared with 59% (controls)
Primary outcome: percentage of infants below 10th percentile at 34 wk PMA (power: 80%)
Nutritional outcome: better mean (6SD) growth velocity in study group (14.9 6 6.5 compared with 12.6 6 4.5 g/d in controls; P =
0.05). Similar daily weight gain in both groups (P = 0.06) and no significant difference in weights ,10th percentile at 34 wk
PMA (27% compared with 28%; P = 0.83)
13) Chrzanowskan = 47 (study: n = 21 compared with placebo: n = 26). Intervention: LGG compared with maltodextrin
Liszewska, 2011 (49) Type of milk: formula. Type of delivery: VD, 23% (study group) compared with 34% (controls)
Primary and nutritional outcome: presence of LGG colonization in stools, somatic growth, and length of hospital stay;
(80% power)
Nutritional outcome: weight gain at discharge (P = 0.567); mean duration of hospital stay, 49.9 compared with 46 d (P = 0.421)
14) Romeo, 2011 (50)
n = 249 (study: Lactobacillus reuteri 83 + L. rhamnosus, n = 83 compared with controls: n = 83). Intervention: (L. reuteri + L.
rhamnosus) compared with no probiotics
Type of milk: EBM/formula. Type of delivery: CS, 94% (L. reuteri group) compared with 86% (L. rhamnosus group) compared
with 93% (controls)
Primary outcomes: incidence of enteric colonization by Candida, LOS, neurological outcome at 12-mo corrected gestational age
(Hammersmith Infant Neurological Examination at corrected 12 mo of age)
Nutritional outcomes: lesser gastrointestinal symptoms (reflux, vomiting, abdominal distension) in L. reuteri group compared with
L. rhamnosus and controls (P , 0.05 for .1500 g and total population), lesser mean (6SD) hospital stay in L. reuteri group
compared with L. rhamnosus and controls (P , 0.05; 17.8 6 7.9 d for L. reuteri, 26.9 6 15.7 d for L. rhamnosus, and 31.3 6
16.3 d for controls)
15) Sari, 2011 (51)
n = 221 (study: n = 110 compared with controls: n = 111). Intervention: Lactobacillus sporogenes compared with no probiotic
Type of milk: EBM/formula. Type of delivery: CS, 67.3% (study group) compared with 75.7% (controls)
Primary outcome: death or NEC of at least stage II (P = 0.515) (power: 80%)
Secondary outcomes: culture-proven sepsis without NEC, grade 34 IVH (P = 0.983)
Nutritional outcomes: feed intolerance, 44.5% compared with 63.1% (P = 0.006); feeding amount at 14 d (P = 0.539), 28 d
(P = 0.099), and 42 d (P = 0.468); mean (6SD) TFEFs, 17.3 6 8.7 compared with 18.3 6 9.8 d (P = 0.438); mean (6SD)
weight gain at 14 d (3.7 6 7.1 compared with 3.7 6 6 g; P = 0.977), 28 d (10.0 6 5.1 compared with 10.5 6 5.2 g; P = 0.555),
and 42 d (12.6 6 4.3 compared with 12.3 6 5 g; P = 0.769); median duration of hospital stay, 34.5 compared with 30 d (P = 0.919)
16) Rojas, 2012 (52)
n = 750 (study: 372 compared with placebo: 378). Intervention: L. reuteri compared with placebo
Type of milk: EBM/formula. Type of delivery: noninstrumental VD, 16% (study) compared with 17% (placebo); instrumental VD,
0% (study) compared with 0.5% (placebo); elective CS, 18% (study) compared with 17% (placebo); nonselective CS,
65% (study) compared with 65% (placebo)
Primary outcome: death or nosocomial infections (power: 90%)
Nutritional outcomes: lesser episodes of feed intolerance: 7% compared with 10.6%; P = 0.08 with significant effects observed
in subjects #1500 g (17 episodes in study group compared with 31 episodes in control group; P = 0.04); similar durations
of hospitalization in both groups (20 d) (P = 0.53); for TFEFs, P = 0.134
17A)2 Demirel, 2013 (53) n = 179 (study: n = 81 compared with controls: n = 98). Intervention: S. boulardii compared with no probiotic
Type of milk: EBM/formula. Type of delivery: CS, 79.1% (study group) compared with 82.2% (controls)
Primary outcome (mean 6 SD): effect of probiotic on the course of indirect hyperbilirubinemia and duration of phototherapy (1.9
6 0.86 compared with 2.6 6 0.91 d; P , 0.05)
Nutritional outcome: lesser feeding intolerance in study group (20.9% compared with 47.9%; P = 0.00)
17B) Demirel, 2013 (54) n = 181 (probiotic: n = 91 compared with controls: n = 90). Intervention: S. boulardii compared with nystatin (control)
Type of milk: EBM/formula. Type of delivery: CS, 79.1% (study group) compared with 82.2% (controls)
Primary outcome: incidence of fungal colonization of skin and invasive fungal infection (power: 80%)
Secondary outcomes: incidence of sepsis, mortality, necrotizing enterocolitis, retinopathy of prematurity, severe IVH, and
bronchopulmonary dysplasia
Nutritional outcome: incidence of feeding intolerance in study group (at least one episode): 20.5% compared with 44.9% (P = 0.001)
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ATHALYE-JAPE ET AL.
TABLE 1 (Continued )
(No. of study) first author,
year of publication
(reference)
17C) Demirel, 2013 (55)
18) Fernandez-Carrocera,
2013 (56)
n = 271 (study: n = 135 compared with controls: n = 136). Intervention: S. boulardii compared with no probiotic
Type of milk: EBM/formula. Type of delivery: CS, 79.1% (study group) compared with 82.2% (controls)
Primary outcome: NEC of at least stage II (4.4% compared with 5.1%; P = 1.000), death (3.7% compared with 3.6%; P = 1.000)
(power: 80%)
Nutritional outcomes: feeding intolerance (at least one episode), 222.9% compared with 48.1% (P , 0.001). TFEF:
11.7 d (10.9812.58 d) compared with 13.2 d (11.1415.4 d) (95% CI: 23.86, 20.87 d); weight gain (g): at 14 d, 1202
(1154.51249.5) compared with 1186 (1137.11234.9) (95% CI: 254.72, 287.09); at 28 d, 1369 (1314.61423.7) compared
with 1378 (1323.51433.9) (95% CI: 299.09, 280.10); and at 42 d, 1571 (1503.41639.8) compared with 1555 (14931617.6)
(95% CI: 2109.19, 2141.72)
n = 150 (study: n = 75 compared with placebo: n = 75). Intervention: (L.acidophilus + L. rhamnosus + L. casei + Lactobacillus
plantarum + B. infantis + S. thermophiles) compared with no probiotics
Type of milk: EBM/formula. Type of delivery: data not available
Primary outcome: development of NEC (stages IIAIIIB), mortality, and combined NEC and death (power: 80%)
Nutritional outcomes [median (range)]: TFEF, 18 d (056 d) compared with 15 d (039 d) (P = 0.092). Total hospital stay: 45
d (13134 d) compared with 40 d (8120 d) (P = 0.343)
n = 31 (study: n = 15 compared with controls: n = 16). Intervention: L. rhamnosus GG compared with no probiotics
Type of milk: EBM. Type of delivery: CS, 47% (study group) compared with 63% (controls)
Primary outcome: effect of enteral probiotics on intestinal blood flow (superior mesenteric artery); P = 0.035 (power 92.3%)
Nutritional outcomes: mean (6SD) TFEF: 23.9 6 8.3 compared with 22.1 6 8.5 d P = 0.55
n = 1099 (probiotic: n = 548 compared with placebo: n = 551). Intervention: (B. infantis + S. thermophilus + B. lactis) compared
with maltodextrin
Type of milk: EBM/formula. Type of delivery: CS, 65.5% (study group) compared with 68.4% (controls)
Primary outcome: LOS (power 80%)
Secondary outcomes: incidence of definite or clinical sepsis, composite outcome of definite or clinical sepsis, number of courses
and duration of antibiotic treatment, incidence of definite sepsis, mortality, incidence of NEC, and at least stage NEC, PDA,
IVH grade 3 or 4, cystic PVL, ROP of at least stage 3, oxygen requirement at 36 wk PMA, or at 28 d of age
Nutritional outcomes: study compared with controls for all outcomes; median (IQR) duration of hospitalization, 71 d (5492 d)
compared with 74 d (5893 d) (P = 0.09); TFEF, 12 d (916 d) compared with 12 d (1017 d) (P = 0.31); mean (6SD) time to
regain birth weight, 11.1 6 4.5 compared with 11.7 6 4.8 d (P = 0.06); weight at 28 d of age, 1495.0 6 401.2 compared with
1446.0 6 379.2 g (P = 0.04); and weight at discharge: 2870.5 6 748.8 compared with 2864 6 738.9 g (P = 0.89)
n = 208 (probiotic: n = 104 compared with placebo: n = 104). Intervention: S. boulardii compared with distilled water
Type of milk: EBM/formula. Type of delivery: CS, 80.8% (study group) compared with 88.5% (controls)
Primary outcome: at least stage II NEC (6.7% compared with 6.7%; P = 1.0), at least stage II NEC or late-onset culture-proven sepsis
(28.8% compared with 23%, P = 0.34), and at least stage II NEC or death (9.6% compared with 7.7%; P = 0.62) (power: 80%)
Nutritional outcomes: mean (6SD) TFEF, 11 6 7 compared with 12 6 7 d (P = 0.37); weight gain (g/wk), 113 6 61 compared
with 129 6 65 (P = 0.31); and median (IQR) duration of hospital stay: 39 d (2860 d) compared with 43 d (2960 d) (P = 0.62)
Other secondary outcomes: oxygen dependency at 36 wk (P = 0.82) and mortality until hospital discharge (P = 0.74)
n = 400 (probiotic: n = 200 compared with placebo: n = 200). Intervention: L. reuteri (DSM 17938) compared with oil-based placebo
Type of milk: EBM/formula. Type of delivery: CS, 75% (study group) compared with 76% (placebo group)
Primary outcome: frequency of NEC and or death after 7 d of life (power 80%), frequency of proven sepsis, rates of feed
intolerance, and duration of hospital stay (power: 80%)
Nutritional outcomes: study compared with placebo for all outcomes; feed intolerance, 28% compared with 39.5% (P = 0.015);
median (range) duration of hospital stay, 38 d (10131 d) compared with 46 d (10180 d) (P = 0.022); and mean (6SD) TFEF,
9.1 6 3.2 compared with 10.1 6 4.3 d (P = 0.006)
n = 159 (study: n = 79 compared with placebo: n = 80). Intervention: B. breve M16 V compared with dextrin
Type of milk: EBM. Type of delivery: CS, 75% (study group) compared with 65% (placebo group)
Primary outcome: B. breve fecal counts (power: 90%)
Nutritional outcome: TFEF [median (IQR)]: 12 d (921, 571 d) for study group compared with 12 d (816, 381 d) for placebo
group; P = 0.306
Secondary outcomes: proven EOS, 5% compared with 3% (probiotics compared with placebo) (P = 0.681); proven LOS,
78% compared with 84% (probiotics compared with placebo) (P = 0.465)
n = 112 (study: n = 56 compared with placebo: n = 56). Intervention: (B. longum + L. acidophilus + B. lactis +
B. bifidum) compared with sterile water
Type of milk: EBM. Type of delivery: CS, 83.9% (study group) compared with 76.8% (controls)
Primary outcome: enteric fungal colonization (overall P = 0.03; for ,1000 g, P = 0.02) (power: 80%)
Secondary outcomes: incidence of LOS (gram positive: 16.1% compared with 32.1%, P = 0.055; gram negative: 21.4% compared
with 26.8%; P = 0.053), NEC (3.6% compared with 3.6%; P = 1.0), and mortality (15.2% compared with 17.21%; P = 0.5)
Nutritional outcomes (means 6 SDs): duration of hospitalization [25.77 6 9.16 compared with 31.21 6 12.67 d (P = 0.002 especially
for ,1000 g); 28.78 6 9.16 compared with 34.21 6 11.68 d; P = 0.004], TFEF [overall, 11.22 6 5.04 d in study group compared with
15.41 6 8.07 d in placebo group (P = 0.016); and in ,1000 g, TFEF of 13.22 6 5.04 compared with 17.41 6 8.07 d (P = 0.014)]
(Continued)
Study characteristics
1513
TABLE 1 (Continued )
(No. of study) first author,
year of publication
(reference)
25) Totsu, 2014 (63)
Study characteristics
n = 283 (probiotic: n = 153 compared with placebo: n = 130). Intervention: B. bifidum compared with dextrin
Type of milk: EBM/formula. Type of delivery: CS, 50.5% (study group) compared with 79.2% (placebo group)
Primary outcome (mean 6 SD): postnatal day when enteral feed exceeding 100 mL $ kg21 $ d21 (11 6 3.6 d in probiotic group
compared with 12.1 6 3.8 d in controls; P , 0.05) (power: 80%)
Secondary outcomes: morbidities, probiotics compared with controls (LOS: 3.9% compared with 10%; P , 0.05); mean (6SD)
length of hospital stay, 92.3 6 44.5 compared with 92.9 6 40.2 d (P = NS); weight gain in hospital stay (g/d), 20.1 6 3.7
compared with 20.8 6 4 (P = NS); and somatic growth before discharge (head circumference at discharge; P = NS)
For all outcome comparisons, results in the study group are presented first. BBG, Bifidobacterium breve YIT4010; CS, cesarean delivery; EBM,
expressed breast milk; EDD, expected date of delivery; EOS, early-onset sepsis; IVH, intraventricular hemorrhage; LGG, Lactobacillus rhamnosus GG
(ATCC 53103) Gorbach and Goldin; LOS, late-onset sepsis; LS, lower segment; LSCS, lower-segment cesarean section; NEC, necrotizing enterocolitis; PDA,
patent ductus arteriosus; PDHM, pasteurized donor human milk; PMA, postmenstrual age; PVL, periventricular leukomalacia; ROP, retinopathy of prematurity; TFEF, time to full enteral feed; VD, vaginal delivery.
2
Study numbers 17A, 17B, and 17C are 3 publications from the same study population.
the neonatal period (35). Therefore, we aimed to conduct the following 3 subgroup analyses: Bifidobacterium or non-Bifidobacterium
strains, single- or multiple-strain usage, and early (#72 h) or late
(.72 h) initiation of probiotic supplementation. Previous systematic reviews have not addressed these important issues.
Heterogeneity and assessment of publication bias
Clinical heterogeneity was assessed and reported by summarizing characteristics such as the study population, type, dose and
duration of probiotic supplementation, and other characteristics.
Statistical heterogeneity was estimated by using the I2 statistic.
Publication bias was assessed by using the funnel plot (36).
RESULTS
Of 466 citations that met criteria after the initial broad database
search, 25 studies (27 publications) were included in the review
(Figure 1; 3763). There were 3 publications from the same
study population by Demirel et al. (5355) that evaluated the
effect of probiotic supplementation on different outcomes;
hence, we have considered these 3 publications as a single study.
The total sample size in the review was 5895 subjects with
a median of 183 subjects (range: 311099 subjects). A total of
14 trials used a placebo (n = 3812). Fifteen trials used singlestrain probiotic supplementation. Only 2 trials [Samanta et al.
(43) and Totsu et al. (63)] reported the TFEF as the primary
outcome. Only one trial [Al Hosni et al. (48)] reported extrauterine growth restriction as the primary outcome. Other
trials assessed NEC, sepsis, mortality, gut colonization, gut
permeability, and other outcomes as major outcomes. Details
of study participants, sample sizes, interventions, and outcomes of included RCTs are given in Table 1.
Primary outcome
Prespecified subgroups
Bifidobacterium are the dominant beneficial gut flora in healthy
breast-milkfed infants (32). Evidence has indicated that supplementation with multiple strains may be more effective than with a
single strain (33, 34). Investigators have also reported better colonization of the gut if supplementation is commenced very early in
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ATHALYE-JAPE ET AL.
whether single or multiple strains were used (Figure 3). Beneficial effects were also shown in both early and late commencements of probiotics (Figure 4).
Secondary outcomes
Secondary nutritional outcomes reported in trials are reported
in Table 1. Probiotic supplementation was shown to reduce the
duration of hospitalization (43, 50, 60, 62), incidence of feed
intolerance (37, 46, 50, 55, 60), and duration of indirect
hyperbilirubinemia (53). The supplementation improved weight
gain in the hospital (37, 46) and growth velocity (48). None of the
trials showed any adverse effects of probiotics on these or other
defined outcomes.
ROB
Results of the ROB assessment are reported in Table 2. All but
one trial used some form of a random sequence generation
method. Allocation concealment was achieved in 17 of 25 trials
but was unclear in the remaining trials. The funnel plot for the
assessment of publication bias showed a symmetrical distribution of most studies (Figure 5).
DISCUSSION
FIGURE 2 Probiotics compared with controls: subgroup analysis by presence or absence of Bifidobacteria. Fern. -Carro., Fernandez-Carrocera; IV,
inverse variance.
1515
FIGURE 3 Probiotics compared with controls: subgroup analysis by number of strains (single or multiple). Fern. -Carro., Fernandez-Carrocera; IV,
inverse variance.
1516
ATHALYE-JAPE ET AL.
Different probiotic strains may have effects on different aspects of gut maturity and function and to different extents. Hence,
large definitive trials are needed to assess specific strains for the
optimization specific enteral nutrition-related primary outcomes
in preterm neonates. However, because it has been proven beyond
doubt that probiotic supplementation reduces risk of death and
NEC, placebo controlled trials to evaluate nutritional outcomes in
which the control arm receives no probiotics are unethical (26).
Strains with a documented ability to stimulate gut motility and
gastric emptying and reduce the incidence and severity of NEC
such as L. reuteri DSM 17938 may be suitable for such trials
(11, 8084). For example, future RCTs could compare probiotics
with L. reuteri DSM 17938 with probiotics without L. reuteri
DSM 17938.
For primary outcomes such as postnatal growth restriction, it is
important to use standardized parenteral and enteral nutrition
protocols in the trial protocol. With consideration of direct and
indirect clinical and economic benefits of a reduced duration of
hospital stay and parenteral nutrition, an assessment of economic
benefits and long-term neurodevelopment is important.
Strengths of our study were the large sample size (n = 5895)
and the fact that significant benefits were observed irrespective
of the variations in patient characteristics and the probiotic
strain, dose, time of commencement, and duration of supplementation. Unlike a randomized trial, which usually involves the
comparison of 2 specific treatment strategies inn a defined
population, the meta-analysis enabled the combination of trials
with similar conceptual intents but quite different treatments
FIGURE 4 Probiotics compared with controls: subgroup analysis by time of commencement (early or late). Fern. -Carro., Fernandez-Carrocera; IV,
inverse variance.
1517
Allocation
concealment
Blinding of
participants
and personnel
Blinding
of outcome
assessment
Incomplete
outcome data
Selective
reporting
Free of
other bias
Unclear
Unclear
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Unclear
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Unclear
Yes
Yes
Yes
Yes
Unclear
Unclear
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Unclear
Yes
Unclear
Yes
Yes
Yes
Unclear
Yes
Unclear
Yes
Unclear
Unclear
Yes
Yes
Unclear
Yes
Yes
Yes
Unclear
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Unclear
Yes
Unclear
Yes
Yes
Yes
Yes
Yes
Unclear
Yes
Unclear
Unclear
Yes
Yes
Yes
Yes
Unclear
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Unclear
No
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Unclear
Yes
Yes
Unclear
Unclear
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
No
Yes
Yes
No
Yes
No
Unclear
Unclear
No
No
No
No
Unclear
Unclear
No
Yes
No
No
No
No
No
No
No
No
Unclear
Unclear
No
No
No
Unclear
Yes
Unclear
Yes
Unclear
Yes
Yes
Yes
Yes
Yes
Yes
Unclear
Yes
Unclear
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Unclear
Yes
Unclear
Yes
Yes
New Zealand in Perth, Western Australia, and the Pediatric Academic Society
of the United States in Vancouver, Canada.
The authors responsibilities were as followsGA-J: independent literature search and writing of the first and final drafts of the manuscript; SR and
SP: supervision of GA-J; GD: independent literature search, rechecking and
interpretation of data, and writing of the first and final draft of the manuscript; SR: rechecking literature search results and data, handling the metaanalysis software, and supervising the first and final draft of the manuscript;
SP: concept and design, rechecking and interpreting data, and supervising of
the first and final drafts of the manuscript; and all authors: saw and approved
the final version of the manuscript that was submitted. None of the authors
declared a conflict of interest.
REFERENCES
1. Alfaleh K, Anabrees J. Probiotics for prevention of necrotizing enterocolitis in preterm infants. The Cochrane Database Syst Rev 2014;
10;4:CD005496.
2. Tarnow-Mordi W, Soll RF. Probiotic supplementation in preterm infants: it is time to change practice. J Pediatr 2014;164:95960.
3. Barrington KJ. Review: probiotics prevented necrotising enterocolitis
and reduced mortality in preterm neonates. Arch Dis Child Educ Pract
Ed 2011;96:199.
4. Downard CD, Renaud E, St Peter SD, Abdullah F, Islam S, Saito JM,
Blakely ML, Huang EY, Arca MJ, Cassidy L, et al. Treatment of
necrotizing enterocolitis: an American Pediatric Surgical Association
Outcomes and Clinical Trials Committee systematic review. J Pediatr
Surg 2012;47:211122.
5. Modi N. Probiotics and necrotising enterocolitis: the devil (as always)
is in the detail. Commentary on N. Ofek Shlomai et al.: probiotics for
preterm neonates: what will it take to change clinical practice? Neonatology 2014;105:713.
6. Mihatsch WA, Braegger CP, Decsi T, Kolacek S, Lanzinger H, Mayer
B, Moreno LA, Pohlandt F, Puntis J, Shamir R, et al. Critical systematic review of the level of evidence for routine use of probiotics for
reduction of mortality and prevention of necrotizing enterocolitis and
sepsis in preterm infants. Clin Nutr 2012;31:615.
7. Ofek Shlomai N, Deshpande G, Rao S, Patole S. Probiotics for preterm
neonates: what will it take to change clinical practice? Neonatology
2014;105:6470.
8. Janvier A, Malo J, Barrington KJ. Cohort study of probiotics in a North
American neonatal intensive care unit. J Pediatr 2014;164:9805.
9. Luoto R, Ruuskanen O, Waris M, Kalliomaki M, Salminen S, Isolauri
E. Prebiotic and probiotic supplementation prevents rhinovirus infections in preterm infants: a randomized, placebo-controlled trial.
J Allergy Clin Immunol 2014;133:40513.
10. Manzoni P, Rizzollo S, Vain N, Mostert M, Stronati M, Tarnow-Mordi
W, Farina D. Probiotics use in preterm neonates: what further evidence
is needed? Early Hum Dev 2011;87(Suppl 1):S34.
Randomsequence
generation
1518
ATHALYE-JAPE ET AL.
34. Ishizeki S, Sugita M, Takata M, Yaeshima T. Effect of administration
of Bifidobacteria on intestinal microbiota in low-birth-weight infants
and transition of administered Bifidobacteria: a comparison between
one-species and three-species administration. Anaerobe 2013;23:3844.
35. Yamasaki C, Totsu S, Uchiyama A, Nakanishi H, Masumoto K, Washio
Y, Shuri K, Ishida S, Imai K, Kusuda S. Effect of Bifidobacterium administration on very-low-birthweight infants. Pediatr Int 2012;54:6516.
36. Sterne JA, Sutton AJ, Ioannidis JP, Terrin N, Jones DR, Lau J. Recommendations for examining and interpreting funnel plot asymmetry in
meta-analyses of randomised controlled trials. BMJ 2011;343:d4002.
37. Kitajima H, Sumida Y, Tanaka R, Yuki N, Takayama H, Fujimura M.
Early administration of Bifidobacterium breve to preterm infants:
randomised controlled trial. Arch Dis Child Fetal Neonatal Ed 1997;
76:F1017.
38. Costalos C, Skouteri V, Gounaris A, Sevastiadou S, Triandafilidou A,
Ekonomidou C. Enteral feeding of premature infants with Saccharomyces boulardii. Early Hum Dev 2003;74:8996.
39. Bin-Nun A, Bromiker R, Wilschanski M, Kaplan M, Rudensky B,
Caplan M. Oral probiotics prevent necrotizing enterocolitis in very low
birth weight neonates. J Pediatr 2005;147:1926.
40. Manzoni P, Mostert M, Leonessa ML, Priolo C, Farina D, Monetti C,
Latino MA, Gomirato G. Oral supplementation with Lactobacillus
casei subspecies rhamnosus prevents enteric colonization by Candida
species in preterm neonates: a randomized study. Clin Infect Dis 2006;
42:173542.
41. Stratiki Z, Costalos C, Sevastiadou S, Kastanidou O, Skouroliakou M,
Giakoumatou A. The effect of a Bifidobacter supplemented bovine
milk on intestinal permeability of preterm infants. Early Hum Dev
2007;83:5759.
42. Lin HC, Hsu CH, Chen HL, Chung MY, Hsu JF, Lien RI. Oral probiotics prevent necrotizing enterocolitis in very low birth weight preterm infants: a multicenter, randomized, controlled trial. Pediatrics
2008;122:693700.
43. Samanta M, Sarkar M, Ghosh P, Ghosh JK, Sinha MK, Chatterjee S.
Prophylactic probiotics for prevention of necrotizing enterocolitis in
very low birth weight newborns. J Trop Pediatr 2009;55:12831.
44. Rouge C, Piloquet H, Butel MJ, Berger B, Rochat F, Ferraris L. Oral
supplementation with probiotics in very-low-birth-weight preterm infants: a randomized, double-blind, placebo-controlled trial. Am J Clin
Nutr 2009;89:182835.
45. Braga TD, Da Silva GAP, De Lira PIC, De Carvalho Lima M. Efficacy
of Bifidobacterium breve and Lactobacillus casei oral supplementation
on necrotizing enterocolitis in very-low-birth-weight preterm infants: A
double-blind, randomized, controlled trial. Am J Clin Nutr 2011;93:816.
46. Hikaru U, Koichi S, Yayoi S, Hiromichi S, Hiroaki S, Yoshikazu O,
Seigo A, Satoru N, Toshiaki S, Yuichiro Y. Bifidobacteria prevents
preterm infants from developing infection and sepsis. Int J Probiotics
Prebiotics 2010;5:336.
47. Mihatsch WA, Vossbeck S, Eikmanns B, Hoegel J, Pohlandt F. Effect
of Bifidobacterium lactis on the incidence of nosocomial infections in
very-low-birth-weight infants: a randomized controlled trial. Neonatology 2010;98:15663.
48. Al-Hosni M, Duenas M, Hawk M, Stewart LA, Borghese RA, Cahoon
M. Probiotics-supplemented feeding in extremely low-birth-weight
infants. J Perinatol 2012;32:2539.
49. Chrzanowska-Liszewska D, Seliga-Siwecka J, Kornacka MK. The effect of Lactobacillus rhamnosus GG supplemented enteral feeding on
the microbiotic flora of preterm infants-double blinded randomized
control trial. Early Hum Dev 2012;88:5760.
50. Romeo MG, Romeo DM, Trovato L, Oliveri S, Palermo F, Cota F. Role
of probiotics in the prevention of the enteric colonization by Candida in
preterm newborns: incidence of late-onset sepsis and neurological
outcome. J Perinatol 2011;31:639.
51. Sari FN, Dizdar EA, Oguz S, Erdeve O, Uras N, Dilmen U. Oral
probiotics: Lactobacillus sporogenes for prevention of necrotizing
enterocolitis in very low-birth weight infants: a randomized, controlled
trial. Eur J Clin Nutr 2011;65:4349.
52. Rojas MA, Lozano JM, Rojas MX, Rodriguez VA, Rondon MA,
Bastidas JA. Prophylactic probiotics to prevent death and nosocomial
infection in preterm infants. Pediatrics 2012;130:e111320.
53. Demirel G, Celik IH, Erdeve O, Dilmen U. Impact of probiotics on the
course of indirect hyperbilirubinemia and phototherapy duration in
very low birth weight infants. J Matern Fetal Neonatal Med 2013;26:
2158.
11. Hunter C, Dimaguila MA, Gal P, Wimmer JE Jr, Ransom JL, Carlos
RQ. Effect of routine probiotic, Lactobacillus reuteri DSM 17938, use
on rates of necrotizing enterocolitis in neonates with birthweight , 1000
grams: a sequential analysis. BMC Pediatr 2012;12:142.
12. Singhal A, Farooqi IS, ORahilly S, Cole TJ, Fewtrell M, Lucas A.
Early nutrition and leptin concentrations in later life. Am J Clin Nutr
2002;75:9939.
13. Singhal A, Cole TJ, Lucas A. Early nutrition in preterm infants and later
blood pressure: two cohorts after randomised trials. Lancet 2001;357:4139.
14. Fewtrell MS, Cole TJ, Bishop NJ, Lucas A. Neonatal factors predicting
childhood height in preterm infants: evidence for a persisting effect of
early metabolic bone disease? J Pediatr 2000;137:66873.
15. Ehrenkranz RA, Dusick AM, Vohr BR, Wright LL, Wrage LA, Poole
WK. Growth in the neonatal intensive care unit influences neurodevelopmental and growth outcomes of extremely low birth weight
infants. Pediatrics 2006;117:125361.
16. Franz AR, Pohlandt F, Bode H, Mihatsch WA, Sander S, Kron M.
Intrauterine, early neonatal, and postdischarge growth and neurodevelopmental outcome at 5.4 years in extremely preterm infants after
intensive neonatal nutritional support. Pediatrics 2009;123:e1019.
17. Stephens BE, Walden RV, Gargus RA, Tucker R, McKinley L, Mance
M. First-week protein and energy intakes are associated with 18-month
developmental outcomes in extremely low birth weight infants. Pediatrics 2009;123:133743.
18. Odberg MD, Sommerfelt K, Markestad T, Elgen IB. Growth and somatic health until adulthood of low birthweight children. Arch Dis
Child Fetal Neonatal Ed 2010;95:F2015.
19. Singhal A, Fewtrell M, Cole TJ, Lucas A. Low nutrient intake and
early growth for later insulin resistance in adolescents born preterm.
Lancet 2003;361:108997.
20. Vohr BR, Allan W, Katz KH, Schneider KC, Ment LR. Early predictors
of hypertension in prematurely born adolescents. Acta Paediatr 2010;
99:18128.
21. Clark RH, Wagner CL, Merritt RJ, Bloom BT, Neu J, Young TE.
Nutrition in the neonatal intensive care unit: how do we reduce the incidence of extrauterine growth restriction? J Perinatol 2003;23:33744.
22. Sweet MP, Hodgman JE, Pena I, Barton L, Pavlova Z, Ramanathan R.
Two-year outcome of infants weighing 600 grams or less at birth and
born 1994 through 1998. Obstet Gynecol 2003;101:1823.
23. Embleton NE, Pang N, Cooke RJ. Postnatal malnutrition and growth
retardation: an inevitable consequence of current recommendations in
preterm infants? Pediatrics 2001;107:2703.
24. Di Mauro A, Neu J, Riezzo G, Raimondi F, Martinelli D, Francavilla R.
Gastrointestinal function development and microbiota. Ital J Pediatr
2013;39:15.
25. Rao RK, Samak G. Protection and restitution of gut barrier by probiotics: nutritional and clinical implications. Curr Nutr Food Sci 2013;
9:99107.
26. Deshpande G, Rao S, Patole S, Bulsara M. Updated meta-analysis of
probiotics for preventing necrotizing enterocolitis in preterm neonates.
Pediatrics 2010;125:92130.
27. Wang Q, Dong J, Zhu Y. Probiotic supplement reduces risk of necrotizing enterocolitis and mortality in preterm very low-birth-weight
infants: an updated meta-analysis of 20 randomized, controlled trials.
J Pediatr Surg 2012;47:2418.
28. Bernardo WM, Aires FT, Carneiro RM, Sa FP, Rullo VE, Burns DA.
Effectiveness of probiotics in the prophylaxis of necrotizing enterocolitis in preterm neonates: a systematic review and meta-analysis.
J Pediatr (Rio J) 2013;89:1824.
29. Centre for Reviews and Dissemination. CRDs guidance for undertaking
reviews in health care [Internet] [cited 2014 Mar 14]. Available from:
www.york.ac.uk/inst/crd/systematic_reviews_book.htm.
30. Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items
for systematic reviews and meta-analyses: the PRISMA statement.
BMJ 2009;339:b2535.
31. Higgins JPT, Green S, editors. Cochrane Handbook for Systematic
Reviews of Interventions, Version 5.1.0 [Internet]. The Cochrane Collaboration; 2011 [updated March 2011]. Available from: http://www.
cochrane-handbook.org.
32. Fanaro S, Chierici R, Guerrini P, Vigi V. Intestinal microflora in early
infancy: composition and development. Acta Paediatr Suppl 2003;91:
4855.
33. Chapman CM, Gibson GR, Rowland I. Health benefits of probiotics:
are mixtures more effective than single strains? Eur J Nutr 2011;50:117.
71.
72.
73.
74.
75.
76.
77.
78.
79.
80.
81.
82.
83.
84.
85.
86.
87.
1519