Safety aspects of probiotics in infants

Several articles are known in which the safety of probiotics (in general) has been described. Probiotics are regarded as safe, also for children, but a few specific strains should not be used in probiotic products for infants. Several studies have been conducted in the past, with a diversity of probiotic products, for the prevention of atopic eczema and asthma, but also for the prevention of diarrhoea (infants diarrhoea). It should be known that clinical studies always have to be approved by the medical ethical committee. In case such a committee does not believe in its safety, it will not be approved and such a study can not be performed. Some examples of (approved) clinical studies with probiotics in infants: o o o o Influence of probiotic supplemented infant formula on composition of plasma lipids in atopic infants, by Pasi E. Kankaanp (2003). Probiotics in the management of atopic eczema, by E. Isolauri (2000). Enteral feeding of premature infants with Saccharomyces boulardii, by C.Costalos (2003) Probiotics in the Treatment and Prevention of Acute Infectious Diarrhea in Infants and Children: A Systematic Review of Published Randomized, Double-Blind, Placebo-Controlled Trials, by Szajewska (2001)

The last article gives an overview of the studies that have been conducted with young children (starting from 1 month old) and it states which probiotics have been used. The third article describes a study in which even preterm born babies receive probiotics (S.boulardii). In de first two studies, probiotics have been given to children <1 year of age. The literature is about the use of probiotics in infants and not exclusively about safety; much of the literature is actually about the beneficial effects of probiotics in infants and neonates. Two examples are: o o Clinical applications of probiotic agents, by J.Saavedra (2001). Intestinal microflora of human infants and current trends for its nutritional modulation, by KC.Mountzouris (2002).

PANDA Study

At the moment, a trial with probiotics is running in the Wilhelmina Childrens Hospital (WKZ) in Utrecht, the Netherlands, in which the prevention of allergy and asthma is studied in children at high risk (due to allergic parents). In this study, pregnant women start to take probiotics 6 weeks before the expected delivery date. After birth, the babies will start taking the same probiotics on a daily base (starting at day 1) during the first year of their lives. A part of the (by the medical ethical committee) approved protocol will be described below. Probiotic preparation Probiotics are food supplements with live micro-organisms (mainly lactic acid bacteria) with a beneficial effect for the host. It is known from probiotics that they can inhibit (over-)growth of pathogens and increase the intestinal barrier function. It is also known that certain probiotics can affect our immune system in a positive manner. Development In this study, a probiotic preparation has been developed in collaboration with Winclove Bio Industries BV, Amsterdam, the Netherlands. The preparation exists of 3 well-known probiotic strains that are commonly used in dairy products, which are selected from a databank that includes over 75 probiotic strains. Individual properties like stability in the end-product, survival of the gastrointestinal tract, and antibiotic resistance are known from all these strains. This information has been used to select 14 strains to be

Document of Winclove Bio Industries BV, June 2005

characterised in a more extensive way. A multispecies preparation has been chosen above a monospecies preparation, because multispecies preparations may have the advantage of synergy or symbiosis between the different strains, which may increase the overall effect of the preparation. Selection criteria 3 strains have been selected for the multispecies preparation to be used in this study by in vitro research. In summary, the strains have been selected by means of the above mentioned individual properties, as well as their in vitro capacity to induce antiinflammatory cytokines (IL-10) and suppress the production of cytokines related to allergy (IL-4, IL-5 and IL-13), their capacity to attach to dendritic cells and because of safety reasons and their common use in dairy products. Administration The probiotic product will be administered once a day with a dose of 3 x 109 Colony Forming Units (CFU). For a preparation existing of 3 strains, this means a concentration of 1 x 109 CFU per strain. The babies will be breast- or bottle-fed depending on the choice of the parents. The probiotic preparation will be administered in 10ml bottles containing food chosen by the parents. This will be administered before feeding the baby. Safety The preparation exclusively contains probiotic strains that have been used for a long period of time in the food industry for the production of food supplements and dairy products like cheese and yoghurt. Most probiotic strains are commensal micro-organisms without pathogenic activity. Recent articles describe the safety of Lactobacilli and Bifidobacteria. These articles give a review of the available literature en show that these bacteria might cause infections in very rare cases in healthy or immunocompromised patients. An extended literature study after infectious complications caused by specific probiotic strains resulted in publications about 2 probiotic strains, Lactobacillus rhamnosus and Enterococcus faecium. Although it is unclear if these infections have been caused by probiotic strains or commensal strains of the same species, these strains will not be used in this preparation. Because of experiences of probiotic use in infants, e.g. studies about probiotics in infectious diarrhoea, unwanted side effects or serious adverse events are not expected. Strains As mentioned in the text above, there are 2 species that could have caused an infection, although it is not even clear if the infections were really caused by these bacteria; Lactobacillus rhamnosus and Enterococcus faecium. To be sure, it will be recommended not to use these strains in probiotics for certain risk groups like immunocompromised individuals. For safety considerations we recommend not to use these strains in products for infants and/or clinical settings either. D-lactate Most probiotic bacteria are lactic acid bacteria. Lactic acid bacteria produce lactate; Llactate and sometimes also D-lactate. L-lactate is absolutely safe. However, it is known that very young children do not tolerate D-lactate, as they lack the enzyme needed to degrade D-lactate. This enzyme will be available when children are 3-4 months old. Bacteria that produce a lot of D-lactate should therefore not be used in probiotics for babies, because D-lactate can cause acidosis (over-acidification). Winclove knows from most of its strains if they produce L- and/or D-lactate. Bifidobacteria are known to be homofermentative, they exclusively produce L-lactate.

Document of Winclove Bio Industries BV, June 2005

Lactose and (cows) milk protein Probiotics are hardly ever lactose free and neither free of cows milk protein. This is because the bacteria are cultured in media containing milk components. Residues of these media might still be found in the product in very low concentrations. Nowadays, it is possible to culture certain probiotic strains in media without milk components. These strains are recommended for usage in products for infants and products for allergy, atopy, etc. Conclusion Probiotics products are safe; In the Netherlands they are considered to be food or food supplements and therefore they are produced under HACCP regulations, which is the Dutch regulation system for safety and hygiene in food and food supplements. For the efficacy (and safety) of a product, it is important to realise that not every strain can or should be used for every purpose. In the Wilhelmina Childrens Hospital, 3 strains have been selected for application in infants with a high risk of allergies. Certain strains are dissuaded to be used in very young children. There are simply no negative effects; several studies have already shown the positive effects of different probiotics, e.g. the prevention of diarrhoea.

Document of Winclove Bio Industries BV, June 2005