Probiotics in Pediatrics: Age-Specific Guidelines

Preterm Neonates

The American Academy of Pediatrics recommends using combination therapy with Lactobacillus rhamnosus ATCC 53103 plus Bifidobacterium longum subspecies infantis, or single-strain Bifidobacterium animalis subspecies lactis DSM 15954 to prevent necrotizing enterocolitis (NEC), sepsis, and all-cause mortality in preterm infants 3, 4.
B. animalis subsp. lactis reduces all-cause mortality (OR 0.56, 95% CI 0.39-0.80) and severe NEC (OR 0.31, 95% CI 0.13-0.74) with moderate-to-high quality evidence 6.
B. animalis subsp. lactis significantly reduces hospitalization days by 13 days (95% CI -22.71 to -3.29) with high certainty 6.
Combination products containing L. rhamnosus ATCC 53103 with Bifidobacterium species reduce severe NEC compared to placebo 5.
Alternative acceptable combinations include: L. acidophilus with B. bifidum, or L. acidophilus with B. longum subsp. infantis 3, 4.
Prioritize pharmaceutical-grade products over dietary supplements as manufacturing contaminants have caused fatal infections in preterm infants 5, 6.
Probiotics do not increase sepsis risk based on evidence from >10,000 preterm infants 6.
Exercise extreme caution or avoid use in immunocompromised infants, critically ill patients with indwelling central venous catheters, infants with cardiac valvular disease, and infants with short-gut syndrome 1, 2, 5, 6.

The American Academy of Pediatrics recommends using Lactobacillus reuteri DSM 17938 specifically for breastfed babies with infantile colic 1, 2.
This is the only probiotic strain with strong evidence for colic treatment 1, 2.
Evidence is less supportive for formula-fed infants 1.

The American Academy of Pediatrics recommends using Lactobacillus rhamnosus GG (LGG) at doses >10^9 CFU/day for prevention of nosocomial diarrhea 1, 2.
Use either Saccharomyces boulardii CNCM I-745 or LGG for prevention of antibiotic-associated diarrhea 1, 2.
Meta-analysis shows probiotics at 5-40 × 10^9 CFUs daily (L. GG, L. sporogens, or S. boulardii) reduce antibiotic-associated diarrhea (RR 0.36, 95% CI 0.25-0.53) 1, 2.
Consider Saccharomyces boulardii CNCM I-745, LGG, or L. reuteri DSM 17938 for adjunct treatment of acute gastroenteritis (outside North America) 1, 2.

Exercise extreme caution or avoid probiotics in premature neonates, immunocompromised patients, critically ill patients with central venous catheters, patients with cardiac valvular disease, and patients with short-gut syndrome 1, 2, 9.
Always verify the precise bacterial identity at the strain level when selecting a probiotic 9.
Consider products deposited at biodepositories such as the American Type Culture Collection (ATCC) for quality assurance 9.
The amount of dead bacteria in a preparation is inversely proportional to product quality 9.
Avoid products with extremely high concentrations (450-900 billion bacteria per dose) as safety becomes more sensitive 9.