Check out the PedsDocTalk YouTube Video: Probiotics in Infants for more information and guidance including how method of delivery and antibiotics can impact the infant microbiome, common kinds of infant probiotics and what to consider when purchasing, dose and duration of treatment, and complications or side effects of probiotics.
Chances are you’ve heard of probiotics or wondered if you should give your infant probiotics. They’re often the promised remedy for so many things in infants, including colic, constipation, gassiness, and diarrhea – but is there evidence to show probiotics are helpful?
What are probiotics?
Probiotics are “good” bacteria or microorganisms that live in your gut. We often associate bacteria with harm and sickness, but your body has bacteria that work to help your body. Probiotics keep your gut, or intestines, healthy and create a balance preventing too much harmful bacteria from taking over.
Probiotics are in certain foods, like yogurt, kefir, sourdough bread, some soft cheeses, and pickles. They are also available as dietary supplements or are sometimes added to certain formulas or other foods.
the method of delivery and the infant microbiome
Each method of delivery, whether by vaginal delivery or by cesarean section, produces a different level of exposure to “good” bacteria and therefore a different colonization pattern. For babies born via vaginal delivery, they ingest maternal microbiota, or good bacteria, as they pass through the birth canal. This exposure helps develop the infant’s microbiome, which produces intestinal protection from infection and inflammation. Infants born via c-section typically have less diverse bacteria and fewer health-promoting bacteria than those babies born via vaginal delivery because they are born in a more sterile environment (surgical space) and don’t come through the vaginal canal.
A Denmark study showed that babies born via c-section were at increased risk for allergies and juvenile arthritis over the first 5 years of life compared to infants born via vaginal delivery. However, it’s difficult to determine if this is directly because of the method of delivery or other factors – for example, antibiotics are commonly administered during c-section deliveries to prevent infection.
Antibiotics are known to disrupt the microbiome and kill good bacteria, so it’s difficult to know if this disruption is from antibiotic administration, the decreased exposure to bacteria during a c-section, or a mix of both.
Regardless, studies show that supplementing a breastfed infant born via c-section with multispecies probiotics does produce a similar level of beneficial bacteria as infants born via vaginal delivery.
Beyond these studies, the research is lacking to support probiotic supplementation in babies born via C-section. Therefore, no official organization like the AAP has a recommendation on probiotics for those born via C-section. So, deciding to start one for your infant should be a discussion between you and your child’s clinician.
From the studies we do have, there is a potential benefit of the use of probiotic supplementation in breastfed infants born via c-section or infants born via c-section who are at higher risk of developing allergies or eczema, but the quality of evidence is low, and more studies are needed.
Colic and probiotics
You’ve probably seen probiotics marketed for colic. The data supporting the use of probiotics in colic is conflicted. A systematic review in 2017 showed that infants receiving a probiotic containing L. reuteri had a 2.3-fold greater chance of having at least a 50% decrease in crying/fussiness compared to the control group. The problem with the study was it didn’t control for other factors, like if babies were consuming a formula that had probiotics added to it or if the mothers of breastfeeding babies had cut out things like dairy from their diet. Both of these factors make the study harder to interpret. Still, with this potential for symptom improvement, many parents feel it’s at least worth trying to see if it helps ease their baby’s symptoms.
Preterm Infants and probiotics
What about probiotic use in preterm babies or babies born at less than 37 weeks gestation? There is actually high-quality evidence that supplementing preterm, low-birth-weight infants with specific probiotics can reduce the risk of necrotizing enterocolitis and decrease the duration of hospitalization for infants in the NICU. There is strong evidence that probiotic supplementation, specifically with L. rhamnosus, B. Bifidus, and B. Infantis, decreases the risk of NEC, but it should be noted that these studies looked at multi-strain probiotics, making it hard to determine which particular probiotic is most useful. We do not, however, currently have studies showing safety and efficacy in preterm infants outside of the hospital who have not experienced NEC.
When it comes to preterm babies, it’s important to take a risk vs. benefit approach in discussing OTC probiotic supplementation – this involves a conversation with your baby’s clinician.
Constipation and probiotics
Constipation is another reason many parents will start a probiotic. First – it’s important to confirm that constipation is the true medical concern.
A study completed in 2010 showed that infants with constipation supplemented with L. reuteri had more frequent bowel movements compared to infants given a placebo, but there was no significant difference in stool consistency, like hardness, or in inconsolable crying episodes. Therefore, a probiotic is not typically recommended as first-line therapy to treat constipation. Some pediatricians will recommend a change in diet, switching formulas, offering small sips of water in infants over 6 months of age, or they may recommend certain medications. Talk with your clinician about the best treatment for your child.
Formula and probiotics
So you may be wondering – if your infant is formula fed, how important is it to give them a formula that has a probiotic? Probiotics being added to formulas is a relatively new phenomenon, first coming to market in the United States in 2007. It’s important to note that all formulas on the US market must meet strict federal nutrition requirements. There is no strong evidence that a formula with a probiotic added to it is superior to other formulas overall. Probiotics are typically just a marketing tool to try to set a formula apart from competitors. HOWEVER, the one instance where it may be worth talking with your child’s clinician about switching formulas is in the case of colic or excessive gas. As mentioned, some studies have shown L. Reuteri helps in colicky infants compared to placebo or gas drops, and certain formulas have L. Reuteri added. However, not all babies will see an improvement in symptoms with switching and it’s important to consider the cost of these formulas. It’s helpful to discuss this option with your child’s clinician to decide if it’s worth trying for your child.
Of note, OTC probiotics are not regulated in the U.S. for safety and efficacy as they are considered a supplement; however, when probiotics are in a formula in the US, they are regulated for safety and efficacy.
What about the side effects of probiotics?
More research is also needed to determine the optimal types, doses, and duration of probiotic supplementation. So far, it appears that effects from probiotics are only noted when they are actively being taken, and once use is discontinued the gut bacteria goes back to its original species breakdown.
It’s also important to weigh possible benefits and risks. Probiotics are generally considered safe for healthy infants, but there have been rare cases where probiotics have been contaminated and resulted in harm, particularly in very low-birth infants or immunocompromised infants.
The U.S. Food and Drug Administration doesn’t regulate probiotics. They can rarely be contaminated and sometimes don’t contain the exact probiotic amounts as advertised. Therefore, parents and clinicians should weigh the individual risks and benefits for each infant. As long as the dose is taken appropriately, side effects are rare but possible side effects may include gassiness, bloating, abdominal discomfort, vomiting or diarrhea. If side effects are noted the supplement should be discontinued.