Probiotics: Use in Preterm Neonates: Nestle

Speaker: Dr Pankaj Garg, Consultant Neonatologist, Department of Neonatology, Institute of Child Health, Sir Ganga Ram Hospital, New Delhi Presented at: 1st annual conference of Probiotic Association of India in association with Nestlé Nutrition Institute, New Delhi

Summary

This presentation talks about morbidity and mortality of preterm neonates. Primary preterm issue is survival scare followed by late onset of sepsis and GI morbidities. Late onset sepsis, issues such as pneumatises intestinalis and multi-drug resistant organisms are main cause for high mortality rates in India. Dr.Garg shares that probiotics are living organisms which may have useful or even harmful effects on preterm babies. He touches upon normal bacterial colonisation of GUT, the mode of action, effects of probiotics on NEC, all-cause mortality and prevention of necrotising enterocolitis. The presentation also enlists probiotic associated infections and challenges in adopting them.

In India there is a 76.2% survival rate of babies born after 27 weeks though western figures show survivals at 22 weeks also. The survival rate is 63.2% of preterm babies who have a weight above 800gms. The mortality has also shown a downward trend with the lowest ebb in 2010.

Probiotic are live microorganism which when administered in adequate amounts confers a health benefit to the host. The mode of action to create a bacterial colonization of gut is by promoting helpful bacteria in gut, inhibiting pathogenic bacteria, modulate immune function, and stimulate maturity and function of gut mucosal barrier.

Cochrane conclusions suggest that, in VLBW neonates starting probiotics (irrespective of type) started on D1-D7 of life and continued till 30 days of life results in prevention of severe NEC, reduction in all-cause mortality and current evidence also supports change in practice. They also suggest that in ELBW neonates more research needed to assess, efficacy, assess the most effective formulation and the dosage.

There are infections associated with probiotics. A PREMPARO study in which 26-31 weeks (700-1600gms) babies received placebo vs. probiotics till 4-6 weeks and digestive tolerance and aerobic, anaerobic cultures were analyzed, no significant differences were found in sepsis and no culture grew bifidobacteria. Pharmacological details deal with the following. Optimal mass or dose is essential while standard dose or strain of probiotic has not yet been established and based on the median dose used in the RCTs in preterm neonates it has been suggested that a required daily dose may be appropriate for neonates of less than 32 weeks gestation. It should be started as early as possible and could be continued till corrected gestational age of 36 to 37 weeks, when the risk of NEC is minimal.

Challenges in adopting probiotics are availability in Indian market, right probiotic and right dosage at reasonable cost. Key Messages are that there are preterm issues like mortality, NEC and late onset sepsis and time to full feeds. Probiotics have been shown to benefit all-cause mortality, NEC related mortality, severe NEC in VLBW neonates without increasing the risk of probiotics associated infections They also mandates a change in practice, while more work is needed in ELBW neonates, issues are more related to logistics than medical in not adopting this strategy.