Cochrane in context: probiotics for prevention of necrotizing enterocolitis in preterm infants

Background: Necrotizing enterocolitis (NEC) and nosocomial sepsis are associated with increased morbidity and mortality in preterm infants. Through prevention of bacterial migration across the mucosa, competitive exclusion of pathogenic bacteria and by enhancing the immune responses of the host, prophylactic enteral probiotics (live microbial supplements) may play a role in reducing NEC and the associated morbidity.

Objectives: To compare the efficacy and safety of prophylactic enteral probiotics administration versus placebo or no treatment in the prevention of severe NEC or sepsis, or both, in preterm infants.

Search methods: For this update, searches were made of MEDLINE (1966 to October 2013), EMBASE (1980 to October 2013), the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (2013, Issue 10), and abstracts of annual meetings of the Society for Pediatric Research (1995 to 2013).

Selection criteria: Only randomized or quasirandomized controlled trials that enrolled preterm infants <37 weeks gestational age or <2500 g birth weight, or both, were considered. Trials were included if they involved enteral administration of any live microbial supplement (probiotics) and measured at least one pre-specified clinical outcome.

Data collection and analysis: Standard methods of The Cochrane Collaboration and its Neonatal Group were used to assess the methodological quality of the trials and for data collection and analysis.

Main results: Twenty-four eligible trials were included. Included trials were highly variable with regard to enrolment criteria (i.e. birthweight and gestational age), baseline risk of NEC in the control groups, timing, dose, formulation of the probiotics and feeding regimens. In a meta-analysis of trial data, enteral probiotics supplementation significantly reduced the incidence of severe NEC (stage II or more) (typical relative risk 0.43, 95% confidence interval 0.33-0.56; 20 studies, 5529 infants) and mortality (typical relative risk 0.65, 95% confidence interval 0.52-0.81; 17 studies, 5112 infants). There was no evidence of significant reduction of nosocomial sepsis (typical relative risk 0.91, 95% confidence interval 0.80-1.03; 19 studies, 5338 infants). The included trials reported no systemic infection with the supplemental probiotics organism. Probiotics preparations containing either Lactobacillus alone or in combination with Bifidobacterium were found to be effective. AUTHORS’

Conclusions: Enteral supplementation of probiotics prevents severe NEC and all-cause mortality in preterm infants. Our updated review of available evidence strongly supports a change in practice. Head-to-head comparative studies are required to assess the most effective preparations, timing and length of therapy to be utilized.