Probiotics in pediatric gut health is an expanding field, and research is ongoing about the role of the microbes in our digestive system. Maintaining a healthy gut flora is linked to better cardiovascular functioning, immunity, mental health, digestion, and overall well-being. Probiotics are supplements that introduce beneficial bacteria into the digestive system to improve the overall microbial balance. High-quality probiotics in the care of pediatric patients can be used to help improve their systemic health and prevent disease. Introducing certain beneficial microbes can also be useful in treating acute gastrointestinal diseases, such as gastritis and diarrhea. A healthy microbial colony can prevent the overgrowth of pathogens, such as C. difficile.

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Understanding Gut Health in Children 

The gut microbiome in children is important for their health in childhood and appears to influence their systemic health as an adult. The primary microbes in the infant microbiome are Lactobacillus, Bacteroides, and Bifidobacterium. Several factors influence the makeup of the initial gastrointestinal flora, including delivery method, timing of birth, and breastfeeding status. There appears to be a difference between infants born via vaginal birth versus cesarean section, as passage through the vaginal canal can influence bacteria type in the gastrointestinal tract. Breastmilk can introduce certain bacteria called Proteobacteria, which influences the difference in bacterial makeup between babies fed with formula versus breastmilk. The pediatric microbiome changes considerably with the introduction of solid foods around six months to one year of age. The role of these microbes is still being studied, but recent findings have uncovered the extensive impact these beneficial bacteria have on health. 

A balanced and diverse microbiome can help digestion and improve gastrointestinal conditions. Bacterial populations may affect allergies and autoimmune diseases. Children with allergies have different microbial populations than non-allergic children. The balance of the gut microbiome can influence the immune system and the levels of inflammation in the body. The gut microbiome seems to play a role in conditions common in children, such as colic, diarrhea, constipation, and allergies. 

What Are Probiotics? 

What are probiotics? A probiotic is a live, beneficial microbe that can be introduced to the body to promote a certain function. Probiotics can be in pill, liquid, or powder form and have different bacteria combinations. There are also differences in the number of colony-forming units (CFU) in probiotic products; some require refrigeration to maintain efficacy. Some beneficial bacteria may die while the product is on the shelf, so observing the number of CFU at the end of a probiotic's shelf life is important. The most common bacteria in probiotic products are Lactobacillus, Escherichia, Enterococcus, Bifidobacterium, and Saccharomyces. Probiotics are also present in food, especially fermented products like yogurt and kimchi. 

Prebiotics are fiber in food that we do not digest but are used by bacteria in the gut to make energy and perform essential functions. Prebiotics are also available in supplement form. When probiotics are being administered to a patient, it is important that they maintain a healthy diet with soluble and insoluble fiber. This allows the bacteria in the probiotic to get the nutrients they need to perform their intended function. Probiotics can be used when the microbial flora is out of balance or lacking specific bacteria. This can happen after antibiotic use, illness, environmental factors, and dietary patterns. Introducing helpful bacteria can address certain acute and chronic diseases or enhance the immune response in a pediatric patient.    

Benefits of Probiotics in Pediatric Care 

Clinical evidence for probiotics in pediatrics supports the use of beneficial bacteria to support certain acute and chronic conditions. Using probiotics is a low-risk intervention that also supports the overall health of the child. Eczema (atopic dermatitis) is a common condition in pediatrics that can cause significant distress to the patient. Eczema causes itching and dry skin (xerosis) and can be a cosmetic concern for the child. Using probiotics in the mother may reduce the incidence of atopic dermatitis. Supplementation during pregnancy with Propionibacterium, Lactobacillus, and Bifidobacterium reduced the incidence of eczema in a cohort study. Probiotics can also be given to children with eczema to reduce the clinical manifestations of the disease. The World Allergy Association (WAO) suggests the supplementation of probiotic products to pediatric patients to reduce the risk of atopic dermatitis. 

Diarrhea in childhood is a common condition and can be associated with increased mortality, especially in developing nations. The use of probiotics to treat diarrhea is one of the most promising applications of this intervention. 

Evidence supports using Lactobacillus rhamnosus GG (LGG) and Saccharomyces boulardii  as a complementary treatment for acute diarrhea. These interventions should be used with other treatments, such as oral or intravenous rehydration therapy. The use of these probiotics shortened the duration of the acute diarrhea episode by about one day. Acute diarrhea may happen as a result of antibiotic use, and probiotics may be a beneficial treatment for this condition. Introducing beneficial bacteria back into the gastrointestinal (GI) tract can rebalance the microbial colony affected by antibiotics. 

Constipation in pediatric patients can cause discomfort and more severe sequelae over time. A randomized controlled trial was performed where some infants with constipation were given oligosaccharides (a probiotic) and others were given a placebo. The infants given the prebiotic had softened stools and constipation relief compared to placebo. These oligosaccharides improved the composition of the gut microbiome in these infants by promoting beneficial bacteria. There is currently no particular probiotic supplement routinely used to treat constipation, but the efficacy of prebiotics is a promising result.

Choosing the Right Probiotics for Children 

Probiotic supplements for children come in multiple forms, and the appropriate probiotics for different age groups depend on the ability of the child to tolerate pills and the type of probiotic needed. The primary forms are capsules, liquids, and powders. The number of CFUs is very important when selecting a probiotic because quality can vary. When purchasing a supplement, the number of CFU at the end of the product’s shelf life should be noted, rather than the CFU at the time of formulation. The specific CFU dosage for a particular condition depends on the bacteria and formulation. Specific tables are available to guide dosing based on clinical studies. It is important for consumers to store the product properly; some probiotic supplements require refrigeration. 

Probiotics in Special Pediatric Conditions

 Probiotics in managing pediatric inflammatory bowel disease (IBD) and irritable bowel syndrome (IBS) show promise in clinical trials. Inflammatory bowel disease consists of Crohn’s disease and ulcerative colitis, two conditions that can cause a significant decrease in a patient’s quality of life and cause an increased risk for colon cancer. Some studies have shown improved ulcerative colitis symptoms when probiotics are used. Bacteria such as Saccharomyces boulardii and Lactobacillus plantarum were introduced to patients with IBD. Clinical manifestations of ulcerative colitis were reduced with the use of these products when combined with conventional therapies. Data on probiotic use and disease improvement in Crohn’s disease is limited, so more studies are necessary before recommendations can be made. 

Irritable bowel syndrome (IBS) causes constipation, diarrhea, or a combination of both. This condition can cause significant life disruption among those who suffer from it. Microbial flora of the GI tract appears to play in a role in IBS. Patients with the condition often have larger populations of bacteria that promote inflammation, such as Enterobacteriaceae. 

Additionally, patients with IBS have lower amounts of beneficial gut bacteria, such as Lactobacillus and Bifidobacterium. Randomized controlled trials show the benefit of probiotic supplementation in patients with IBS. Patients given supplements containing Bifidobacterium breve and Lactobacillus acidophilus had improvements in abdominal pain and flatulence. Quality of life scores also improved in the study groups that received probiotic supplements, a very important consideration in this population. 

Not all probiotic products and bacteria strains are created equal. Different conditions require specific formulations in order to improve the delicate balance of the GI tract flora.  

Integrating Probiotics with Other Therapeutic Interventions 

Combining probiotics with other treatments is an important part of a holistic approach to pediatric gut health. Like many health interventions, probiotics should be used as a part of a treatment plan that treats the child as a whole, not just providing temporary solutions to systemic issues. Dietary changes can be used with probiotics to support the child’s well-being and the microbes introduced in the supplement. A diet rich in plant fiber should be introduced to complement probiotics. Like any lifestyle intervention for a child, dietary changes should be introduced to the whole family. The child should not feel singled out or like they are being “placed on a diet”. Gradual, realistic lifestyle interventions should be implemented for the family. Introducing movement into the family’s routine can also help the pediatric patient. Appropriate exercise supports overall health and is an adjunct treatment to probiotic supplementation. When probiotics are used for a specific disease, they should integrated into the treatment plan with any necessary medications and other therapeutic interventions. 

Potential Challenges and Considerations 

Safely using probiotics in children is an important consideration for the healthcare provider. In general, mainstream probiotic strains are safe and unlikely to cause side effects. If they do occur, they are generally mild (e.g., flatulence) and resolve quickly. Probiotics may not be safe for certain populations, such as preterm infants, those with chronic illnesses, and patients with compromised immune systems. Individuals taking immunosuppressants may not be good candidates for treatment with probiotics; the risks versus benefits should be weighed. There is limited data on probiotic interaction with medications, but a thorough medication review should be performed before integrating these products into treatment. 

The provider should also address patient and caregiver adherence to probiotic treatment. It can be difficult for children to take any supplement or medication, especially if the form is difficult to ingest. Choosing the right supplement form is an important part of adherence. One example is switching the child to a flavored liquid probiotic supplement rather than a large pill. Emphasizing the role of the supplement and the intended outcome can improve adherence for the parents and patient. 

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Probiotics in Pediatric Care: Key Takeaways

The importance of probiotics in pediatric health is an emerging field showing promising for treating disease and supporting overall health. Healthy microbial populations can promote good digestion and support mental health in children and adults. Healthcare providers should consider probiotic use in treating pediatric conditions such as diarrhea, eczema, inflammatory bowel disease, and irritable bowel syndrome. These products can also repopulate the microbiome after antibiotic use and illness. 

Like all healthcare interventions, probiotics should be customized depending on the condition, patient needs, and child age. A healthcare provider should be consulted before probiotics are used to ensure safety and efficacy.