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Q&A: Should pediatricians suggest probiotics to reduce abdominal pain?
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Recurrent abdominal pain, or RAP, encompasses a group of functional gastrointestinal disorders commonly experienced by children. Currently, no consensus exists about what the gold standard treatment is for these conditions.
In a review published in JAMA Pediatrics, Tamsin Newlove-Delgado, PhD, an academic clinical lecturer in public health and honorary consultant in public health medicine at the University of Exeter Medical School, and colleagues reviewed currently available literature on the use of probiotics in children with RAP. She spoke with Infectious Diseases in Children about the findings of this review and what pediatricians need to know about recommending probiotics in children with abdominal pain. – by Katherine Bortz
What causes RAP, and is it common in the pediatric population?
Although the cause of RAP is unclear, it is thought that it is linked to an interaction of psychosocial factors and altered gut physiology. RAP is common and is thought to affect between 4% and 25% of children at some point.
These disorders are diagnosed according to criteria from the Rome Foundation, an organization founded to classify functional gastrointestinal disorders. In our original review, we used RAP as an umbrella term to refer to a group of childhood abdominal pain-related functional gastrointestinal disorders, including functional dyspepsia, irritable bowel syndrome, abdominal migraine, functional abdominal pain and functional abdominal pain syndrome.
The Rome criteria for RAP include one episode of abdominal pain per week for at least 2 months. Children may also experience other symptoms such as headaches and vomiting. RAP is important to identify because it can often cause anxiety for children and families and even unnecessary hospitalizations and surgical interventions.
How is RAP currently treated , and is treatment effective?
Clinicians use a variety of approaches, which can be broadly grouped into dietary (eg, probiotics or fiber supplements), pharmacological (eg, antispasmodics) and psychosocial (eg, cognitive-behavioral therapy [CBT]). The Cochrane Collaboration previously carried out systematic reviews into the three approaches in 2009, but they found no good-quality evidence to support any of them.
Our team, which included members from the University of Exeter, supported by the National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care South West Peninsula, carried out updates of these reviews for Cochrane to see whether there was any new evidence of effectiveness.
How are probiotics typically used in the pediatric population? Are they safe and effective for their intended purposes?
Probiotic use in children is becoming more common, and probiotic preparations are being used in various ways. For example, probiotics can be used in the treatment of acute infectious diarrhea. They can also be used in the prevention of antibiotic-associated diarrhea and diarrhea in hospitals and day care centers. There have been reviews suggesting that the quality of evidence for effectiveness of probiotics in three indications is generally low to moderate.
However, it is important to stress that the efficacy of probiotics varies by strain and dose, which makes it more complicated for pediatricians and researchers to assess the evidence.
In terms of safety, our review found no adverse events associated with using probiotics, but the general advice is that caution should be used in some patient groups, such as those with immunosuppression, and that it is not possible at the moment to make any definitive statements about safety.
Based on your review, what do pediatricians need to know about probiotic use for the treatment of RAP?
We found that overall there was some evidence to suggest that probiotics are effective in reducing pain in children with RAP in the short-term. This was a different conclusion from the previous review in 2009, which found no evidence of effectiveness.
More specifically, we found moderate-quality evidence that children who were treated with probiotics were more likely to experience reduction in pain at 0 to 3 months after intervention than those who were given placebo. There was also lower quality evidence that probiotics reduced the frequency and intensity of pain over the same time frame.
We could not find any evidence to assess how effective probiotics are in improving other outcomes that might be very important to children and families, such as school attendance and quality of life. We also included other dietary approaches including fiber supplements and low fermentable oligosaccharides, disaccharides, monosaccharides and polyols diets but found no convincing evidence that these were effective in improving pain in RAP.
It is important for clinicians to know that there were several limitations, including the fact that studies used different definitions and scales to assess pain and that very few studies assessed outcomes beyond approximately 3 months after intervention. This means that we could not determine how effective probiotics might be in the long term.
It is also important to highlight that the 15 probiotic trials we included all used different strains and doses of probiotic, although Lactobacillus rhamnosus GG was the most commonly used strain. Therefore, we need more research before being able to make any conclusions about the optimal strain and dose to use in clinical practice. Similarly, different subtypes of RAP (eg, irritable bowel syndrome) might respond differently to probiotic interventions. This is another topic requiring further research.
What advice do you have for pediatricians regarding the use of probiotics in patients with RAP?
Our advice for pediatricians would be that they may want to consider probiotic interventions as part of their management strategy for children with RAP and to discuss this with patients and their families. However, we are unable to recommend the optimum dose or strain to use.
When thinking about a holistic strategy, pediatricians may also be interested in our companion review, which found some evidence that CBT and hypnotherapy may be beneficial. I would also encourage clinicians to watch for future developments in this field. Evidence concerning probiotic use is always changing, and there may well be more definitive recommendations to be made in the future.
References:
Abott RA, et al. Cochrane Database Syst Rev. 2017;doi:10.1002/14651858.CD010971.pub2.
Goldenberg JZ, et al. Cochrane Database Syst Rev. 2015;doi:10.1002/14651858.CD004827.pub4.
Martin AE, et al. Cochrane Database Syst Rev. 2017;doi:10.1002/14651858.CD010973.pub2.
Newlove-Delgado T, et al. Cochrane Database Syst Rev. 2017;doi:10.1002/14651858.CD010972.pub2.
Newlove-Delgado T, et al. JAMA Pediatr. 2018;doi:10.1001/jamapediatrics.2018.4575.
Szajewska H. Arch Dis Child. 2016;doi:10.1136/archdischild-2015-308656.
Disclosure: Newlove-Delgado reports no relevant financial disclosures. The work of the evidence synthesis team is funded by the National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care South West Peninsula.