SGEM#254: Probiotics for Pediatric Gastroenteritis – I Can’t Go For that…No Can Do

Date: April 16th, 2019 Reference: Schnadower et al. Lactobacillus rhamnosus GG versus placebo for acute gastroenteritis in children. NEJM 2018 Guest Skeptic: Dr. Anthony G. Crocco is a Pediatric Emergency Physician and is the Medical Director & Division Head of the Division of Pediatric Emergency at McMaster’s Children’s Hospital. He is an Associate Professor at McMaster University. Anthony is known for his online RANThonys and website SketchyEBM. Case: A two-year-old girl presents with two days of non-bloody watery stools and one episode of vomiting.  She is otherwise well appearing and has normal vitals and examines normally.  After you explain the diagnosis of gastroenteritis to the parents, and the importance of hand washing at home, they ask you whether they should give probiotics to help shorten the course of her illness. Background: We have covered many pediatric topics with you on the SGEM. One of them included a RANThony on getting x-rays for constipation. This time we are talking about stuff coming out too much rather than not enough.  Viral gastroenteritis is rivalled by bronchiolitis for one of the most common Pediatric presentations to the emergency department.  The discomfort this illness imbues, the time away from daycare required, and the time away from parental work necessitated can be quite disruptive.  Even small changes to the course of this illness, due to its prevalence, could have huge comfort and economic benefit. We looked at a trial by Freedman et al using half-strength apple juice or fluids of choice to treat mild gastroenteritis in children who were minimally dehydrated (SGEM#158). The bottom line from that episode was that this strategy was a better choice compared to electrolyte solutions. We have also reviewed a couple of papers that looked at using ondansetron in pediatric gastroenteritis (SGEM#12 and SGEM#122). There are some guidelines on managing gastroenteritis: TREKK- Gastroenteritis AAP- Managing Acute Gastroenteritis Among Children NICE- Diarrhoea and vomiting caused by gastroenteritis in under 5s: diagnosis and management AAFP– Gastroenteritis in Children Sick Kids– Acute Gastroenteritis In this episode we are going to be looking at using probiotics to treat pediatric gastroenteritis. The theory of using probiotics to replenish the normal gut flora to minimize disease is neither new nor unstudied.  Previous work in this area has been described as being “underpowered or had methodology problems related to the trial design and choice of appropriate end points.” Clinical Question: Does prescribing probiotics to children with gastroenteritis, specifically giving L. rhamnosus, improve the course of the illness? Reference: Schnadower et al.  Lactobacillus rhamnosus GG versus placebo for acute gastroenteritis in children. NEJM 2018 Population: Children three months to four years of age presenting to the emergency department with a diagnosis of acute gastroenteritis. This was defined as “three or more episodes of watery stools per day, with or without vomiting, for fewer than 7 days.” Exclusions: There were 18 exclusion criteria and these can be found at ClinicalTrials NCT 01773967. Intervention: L. rhamnosus GG twice a day for five days Comparison: Placebo twice a day for five days Outcome: Primary Outcome: Moderate-to-severe gastroenteritis. This was defined as an illness episode with a modified Vesikari scale greater than 8 during the 14-day follow-up period. The modified Vesikari Scale helps establish severity of gastro symptoms using a 7-item scale that ranges from 0-20 overall points.  Although I have never used this scale clinically, its utility is in being able to quantify symptom improvement in research. Secondary Outcomes: Frequency and duration of diarrhea and vomiting, the incidence of unscheduled health care visits for symptoms of gastroenteritis within two weeks after the index vi...