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Journal of the American College of Nutrition, Vol. 24, No. 5, 370-375 (2005)
Published by the American College of Nutrition

Evaluation of a Diet Containing Probiotics and Zinc for the Treatment of Mild Diarrheal Illness in Children Younger Than One Year of Age

Raanan Shamir, MD, Imad R. Makhoul, MD, DSc, Amos Etzioni, MD and Naim Shehadeh, MD

Division of Pediatric Gastroenterology and Nutrition (R.S.), Bruce Rappaport School of Medicine, Technion-Institute of Technology, Haifa, ISRAEL
Department of Neonatology (I.R.M.), Bruce Rappaport School of Medicine, Technion-Institute of Technology, Haifa, ISRAEL
Department of Pediatrics A (A.E., N.S.), Bruce Rappaport School of Medicine, Technion-Institute of Technology, Haifa, ISRAEL
Meyer Children’s Hospital of Haifa, Primary Pediatric Clinic, Tamra, Western Galilee (I.R.M., N.S.), Bruce Rappaport School of Medicine, Technion-Institute of Technology, Haifa, ISRAEL

Address reprint requests to: Raanan Shamir, MD, Division of Pediatric Gastroenterology and Nutrition, Meyer Children’s Hospital of Haifa, Rambam Medical Center, POB 9602, Haifa 31096, ISRAEL. E-mail: shamirr{at}netvision.net.il


   ABSTRACT
TOP
 FOOTNOTES
 ABSTRACT
INTRODUCTION
 PATIENTS AND METHODS
 RESULTS
 ACKNOWLEDGMENTS
 REFERENCES
 
Objectives: Supplementation of probiotics and supplementation of zinc during acute gastroenteritis in children have been shown to exert positive effects on diarrhea duration and severity. Our aim was to evaluate a new diet enriched with zinc and probiotic bacteria in the treatment of acute gastroenteritis in young children.

Methods: In a double blind prospective study, 65 children aged 6–12 months were randomized to receive 6 x 109 colony forming units of Streptococcus thermophilus, Bifidobacterium lactis, Lactobacillus acidophilus (2 x 109 of each strain), 10 mg of zinc/day, and 0.3 grams of fructo-oligosaccharides in the supplemented group (n = 33) or placebo (n = 32), given in a soy protein based rice cereal. For each child, age, sex, weight, degree of dehydration, the presence of fever or vomiting, stool frequency and consistency were recorded daily until diarrhea resolution.

Results: Diarrhea resolution occurred after 1.43 ± 0.71 days in the supplemented group vs. 1.96 ± 1.24 in the control group (p = 0.017). In the subset of children who presented with vomiting, time to vomiting resolution was 0.27 ± 0.59 vs. 0.81 ± 0.91 days in the supplemented and control groups, respectively (p = 0.06). On day 3, there was only 1 child with watery stools in the supplemented group versus 10 children in the control group (p = 0.02).

Conclusions: In our series, the feeding of a cereal containing Streptococcus thermophilus, Bifidobacterium lactis, Lactobacillus acidophilus and zinc, reduced the severity and duration of acute gastroenteritis in young children. However, whether this combination is better than either the addition of probiotics or zinc alone is yet to be determined.

Key words: Acute gastroenteritis, probiotics, Streptococcus thermophilus, Bifidobacterium lactis, Lactobacillus acidophilus, zinc


   INTRODUCTION
TOP
 FOOTNOTES
 ABSTRACT
 INTRODUCTION
PATIENTS AND METHODS
 RESULTS
 ACKNOWLEDGMENTS
 REFERENCES
 
Diarrheal diseases are a leading cause of mortality in infants and children world wide, and continue to be a significant cause for morbidity in industrialized countries [1]. In recent years, the major advance in the treatment of acute gastroenteritis in children was the introduction of oral rehydration solution (ORS) in the early stages of illness [2, 3]. In addition, rice water and rice based ORS are superior to ORS alone in reducing the frequency and stool volume in acute gastroenteritis [4, 5]. However, nutritional interventions during the diarrheal illness are usually not helpful in reducing the duration of diarrhea, and current recommendations call for the continuation of age-appropriate diets during mild diarrhea [1–3].

Two meta-analyses have demonstrated a therapeutic effect of probiotics, mainly Lactobacillus GG, on acute diarrhea caused by rota virus [6, 7]. This treatment usually reduces the duration of diarrhea by a few hours [6, 7]. Possible explanations for the observed effects include inhibition of adhesion of pathogens, enhanced mucosal integrity, beneficial effects on the dysregulated immune response, production of antimicrobial substances, and intestinal receptor modification [6–10].

In addition to probiotics, intervention trials have demonstrated that the addition of oral zinc can also reduce the duration and severity of acute diarrhea in children [7, 11, 12]. The rationale for the beneficial effect of zinc supplementation is based on the depletion of zinc due to diarrhea [11, 13] and the deleterious effects of zinc deficiency on the immune system, leading to more severe enteric infections [14]. In support of zinc supplementation is that there is no evidence that zinc cause harm when given to non-septic immunocompetent children [15].

On the other hand, results of zinc supplementation studies were not consistent, with a very modest effect observed when zinc was added to an ORS solution [16].

Since zinc and probiotics work via different mechanisms it is possible that adding both would have a synergistic effect. One study, in rhesus monkeys, showed a prophylactic effect of the combination of probiotics and zinc [17]. However, the combination of probiotics and zinc in the treatment of acute diarrheal illness in children has not been tested.

Our study aim was to evaluate the effectiveness of a new diet enriched with zinc and probiotic bacteria in the treatment of acute diarrhea in young children.


   PATIENTS AND METHODS
TOP
 FOOTNOTES
 ABSTRACT
 INTRODUCTION
 PATIENTS AND METHODS
RESULTS
 ACKNOWLEDGMENTS
 REFERENCES
 
Patients
Sixty five consecutive children attending the Primary Pediatric Clinic, Tamra, Western Galilee, Israel, were prospectively enrolled to this double blind placebo controlled randomized study between April 2002 and April 2003. At enrollment children were randomized using sealed envelopes containing a note assigning the patient to one of the 2 study arms. There were 33 children (19 males) in the study group (supplemented), and 32 (14 males) in the control group. One child in the supplemented group (9 month old female) and 2 children in the control group (an 11 month old male and a 12 month old female) did not drink the formula in the amount specified by the protocol, but their data were collected when available (see footnotes for Table 2), and the analysis was based on intention to treat.


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  		Table 2. Characteristics of Participants at Study Entry

 
Inclusion criteria for the children were age between 6–12 months, the presence of acute diarrheal illness, and the presence of mild to moderate dehydration. Acute diarrheal illness was defined as passage of four or more watery stools in 24 hours for more than one day and less than 7 days [11]. The presence of mild to moderate dehydration was established as previously defined [18]. Exclusion criteria included severe dehydration, exclusively breast-feeding, clinical dysentery, toxic clinical appearance, and immuno-suppressed children.

For each child age, sex, weight, degree of dehydration, the presence of fever or vomiting, number of bowel movements and stool consistency (watery, loose or solid) were recorded. Children were seen every day, and weight, degree of dehydration, presence of fever or vomiting, number of bowel movements and stool consistency were recorded. Diarrhea resolution was established when stool consistency ceased to be watery, or when the number of bowel movements was lower than 3 in 24 hours. Due to the ambulatory setting of the study, after diarrhea resolution, parents were instructed to return to the clinic if diarrhea resumed, and daily telephone calls were made to ensure that there are no relapses.

The Institutional Ethics Committee approved the study. All parents gave informed consent for their child’s participation in the study.

Methods
Children diagnosed with acute gastroenteritis were instructed to drink an ORS solution according to previously established guidelines [3, 18]. In short, oral rehydration with ORS was calculated to replace the estimated fluid deficit, and given over 4 hours. After that, parents were instructed to continue ORS supplementation with 10 ml/kg of fluids for each watery stool or vomitus. In addition, rapid introduction of feedings were practiced (three hours after the beginning of ORS). After randomization (see patients section) patients were assigned to group 1 or 2 in a double blind manner (cereals were sealed as cereal 1 and 2 by the manufacturer). Both groups were instructed to consume 600 ml of cereals (Baby-Biocal, Remedia, Israel) with or without added probiotics and zinc, in a lactose free, soy protein-based formula (Remedia Tsimchit, Remedia, Israel). The instructions were to provide the rest of the infant’s feeding regimen with the regular diet used before the episode of diarrhea. The composition of the soy based formula is shown in Table 1, as well as the nutrient composition of the study and control formula and the probiotic content of the study formula. The viability of the probiotic strains was examined after six months of storage and determined to be 7 x 109 colony forming units/100 g cereal. All cereals used in this study were consumed within 6 months of addition of the probiotics.


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  		Table 1. Composition of Study and Control Formulas

 
Statistical Analysis
Differences between groups were evaluated using two-tailed Student t-test. For single parameters, the Fisher Exact test was used. P values less or equal to 0.05 were considered statistically significant.


   RESULTS
TOP
 FOOTNOTES
 ABSTRACT
 INTRODUCTION
 PATIENTS AND METHODS
 RESULTS
ACKNOWLEDGMENTS
 REFERENCES
 
The characteristics of the study groups are presented in Table 2. There were 32 children with mild dehydration in the supplemented group (plus one with moderate dehydration), and 32 children with mild dehydration in the control group.

Season of gastroenteritis occurrence was similar in both groups. Most of the cases occurred between May and July (12 in the supplemented group and 12 in controls) and between November and February (14 in the supplemented group and 12 in controls).

Clinical characteristics of the study groups are shown in Table 3. The mean duration of diarrhea was 0.62 days (14 hours and 53 minutes) shorter in the supplemented group compared to the control group (p = 0.017). On daily follow up for 7 days after diarrhea resolution, none of the children in both study arms had a repeated diarrheal episode.


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  		Table 3. Clinical Characteristics of Study Groups

 
There were no differences in weight change from base line (weight on study entry) between the supplemented group and the control group (Fig. 1). Although these numbers are too small for statistical comparison, after 3 days, the supplemented group as regained their mean base line weight while the mean weight of the control group remained below their base line weight.



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  		Fig. 1. Changes in % body weight in study groups. Changes in % body weight (base line referred to as zero for both groups) are presented for both groups as mean ± standard deviation. Children who recovered ceased to attend the Pediatric Clinic; therefore, of the supplemented group, there were 33 children on day 1, 27 on day 2, and 12 on day 3, and of the control group, there were 32 children on day 1, 30 on day 2, and 17 on day 3.

 
There were no differences between the groups in the number of bowel movements per day (Fig. 2). Regarding stool consistency, there was no difference between the groups on day 1 and day 2. However, on day 3, there was only 1 child with watery stools in the supplemented group compared with 10 children in the control group (p = 0.02).



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  		Fig. 2. Number of stools per day in study groups. At base line, the number of stools per day was higher in the supplemented group (5.7 ± 2.6) than in the control group (5.0 ± 2.1, p = 0.14), and was similar on day 3 (2.6 ± 1.2 in the supplemented group, 2.9 ± 1.6 in the control group). Since children who recovered ceased to attend the Pediatric Clinic, in the supplemented group, there were 33 children on day 1, 27 on day 2, and 12 on day 3. In the control group there were 32 children on day 1, 30 on day 2, and 17 on day 3. Data are presented for both groups as Mean ± Standard Deviation.

 

   DISCUSSION
 
Supplementation of Lactobacillus during acute gastroenteritis in children has been consistently demonstrated to have a beneficial effect on both diarrhea duration and severity [6, 7]. Since the effect of Lactobacillus is not limited to rota virus infection, this treatment may be useful not only in the hospital setting but also in the ambulatory setting, where a variety of pathogens are most likely to be at play [6]. In the present study of children in the community, we were able to demonstrate similar beneficial effects of a combination of probiotic bacteria.

Administration of several probiotics species, namely VSL#3, that contains three species of Bifidobacteriae, four strains of lactic acid bacteria and one strain of Streptococcus, has been demonstrated to be useful in the treatment of adults with various gastrointestinal disorders including prevention of acute pouchitis [19], prevention of flare-ups in chronic pouchitis [20], irritable bowel syndrome [21], and radiotherapy induced diarrhea [22]. Although the concept of using a mixture of probiotic bacteria was successful in gastrointestinal inflammation, this combination has not been studied in acute gastroenteritis, and it is unknown whether specific bacteria contained in the VSL#3 combination are responsible for the observed effect. Since we did not compare the effect of adding one probiotic bacteria to that of a combination of probiotic species, the rationale for a combination of species for the treatment of acute gastroenteritis is yet to be evaluated.

In hospitalized children, the combination of Bifidobacterium lactis and Streptococcus thermophilus was proved useful in the prevention of acute gastroenteritis [23]. In another study in hospitalized children with a wide age range (6 to 60 months), supplementation of the formula with Bifidobacterium infantis and Lactobacillus acidophilus reduced the duration of diarrhea by 0.5 days [24].

In the present study we were able to demonstrate, in a primary care setting, that the addition of 6 x 109 colony forming units of Streptococcus thermophilus, Bifidobacterium lactis, Lactobacillus acidophilus (2 x 109 of each strain) and 10 mg/day of zinc significantly reduced the duration of acute gastroenteritis in children aged 6–12 months (by close to 15 hours) and induced quicker resumption of normal stool consistency. At this stage, it is impossible to ascertain whether the observed effects were induced by the combination of probiotics or by any one of the strains in the mixture that was added to the formula. Furthermore, the presence of minimal amounts of oligosaccharides in the study formula may have contributed to the beneficial effects, since the addition of oligosaccharides to infant formula has a dose-dependent stimulating effect on Bifidobacteria and Lactobacilli [25].

Oligosaccharides have been shown to increase stool frequency and decrease stool consistency [26], but such effect was not demonstrated at a dosage as employed in our study [25]. Furthermore, since stools became harder in the supplemented group without a significant effect on the number of stools, it is unlikely that the observed effects on stool frequency and consistency were related to the oligosaccharides. One explanation for harder stools without a change in the number of stools could be that the treatment influenced electrolytes and fluids absorption and excretion rather than intestinal motility or immune responses.

In acute gastroenteritis, zinc supplementation reduces the duration and severity of the disease [11, 12]. Furthermore, zinc supplementation for 4 months reduces the incidence of severe and prolonged diarrhea in children [27]. On the other hand, the addition of probiotics to infant formula in rhesus monkeys decreased the severity of experimentally induced diarrhea, but no additional benefit was obtained adding zinc to the probiotics [17]. Moreover, a study in young children in Peru reported that morbidity was greater following supplementation with zinc plus multivitamins and minerals than with supplementation with zinc alone [28]. Since a cereal containing only zinc was not included in our study, the potential specific (beneficial or detrimental) contribution of zinc to our results remains uncertain.

There are several limitations to our study. The sample size was small, due to the primary care setting, there was no isolation of pathogens, and all participants consumed a soy protein based formula and rice. Although stools were not examined for pathogens, the study and the control groups were recruited from the same villages with presented at the same season, suggesting a similar distribution of causative agents. Thus, our results demonstrate the efficiency of the investigated preparation in an ambulatory setting, but the efficiency related to specific pathogens can not be established. Soy protein and rice had probably no effect on the outcome since they were equally consumed by both groups. Despite the small sample size, we were able to demonstrate a significant effect of feeding a formula supplemented with a mixture of probiotics and zinc, although our study design precludes the possibility to determine whether one ingredient or a combination of ingredients was responsible for earlier resolution of diarrhea and improvement in stool consistency.

In summary, the supplementation of a Streptococcus thermophilus, Bifidobacterium lactis, Lactobacillus acidophilus and zinc combination to a soy-protein based rice cereal, can shorten the severity and duration of mild acute gastroenteritis in children six to twelve months of age. However, whether this combination is better than adding only probiotics or only zinc is yet to be determined.


   ACKNOWLEDGMENTS
TOP
 FOOTNOTES
 ABSTRACT
 INTRODUCTION
 PATIENTS AND METHODS
 RESULTS
 ACKNOWLEDGMENTS
REFERENCES
 
This work was supported in part by Remedia, Israel.


   FOOTNOTES
TOP
 FOOTNOTES
ABSTRACT
 INTRODUCTION
 PATIENTS AND METHODS
 RESULTS
 ACKNOWLEDGMENTS
 REFERENCES
 
Financial interest: Dr. Shehadeh and Dr. Shamir served as consultants to Remedia, Israel, in the design of this product. Remedia, Israel, supplied the study cereals free of charge.

Received March 24, 2004. Accepted March 20, 2005.


   REFERENCES
TOP
 FOOTNOTES
 ABSTRACT
 INTRODUCTION
 PATIENTS AND METHODS
 RESULTS
 ACKNOWLEDGMENTS
 REFERENCES
 

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