Q: I have found that my child always gets diarrhea when he is treated with an antibiotic. We are planning to take a winter vacation to a warm spot during Christmas, so I am also concerned about traveler's diarrhea. What can I do to prevent these problems?
A: Children who are prone to ear infections are particularly exposed to a wide number of antibiotics. At this time of year, these children are more likely to begin journey after journey to their physician's office or the emergency room for an antibiotic to "solve" their recurrent ear infections.
One of the most common side effects of antibiotic use in children is diarrhea. Antibiotic Associated Diarrhea (AAD) occurs in 5% to 30 % of patients sometime between the initial use of the antibiotic and up to two months after the end of treatment.
The bacterial agent most commonly associated with AAD is Clostridium difficile. However, there may also be an overgrowth of many other harmful bacteria due to a strong antibiotic "wiping out" of the good bacteria, which normally colonize our bowels.
There is a fine balance in our bodies between good bacteria, which serve a role to protect us, and bad bacteria, which can cause us harm. Proponents of probiotics, derived from a Greek term meaning "for life", claim that a lack of good bacteria can be countered by the regular use of various kinds of probiotics products.
The first reference to the potential health benefits of probiotics dates back to the early 1900s. The Russian physician and Nobel prizewinner Ellie Methnikoff hypothesized that Bulgarian peasants lived longer, healthier lives because they consumed fermented milk products, which contain probiotics such as lactobacilli.
Lactobacilli and bifidobacteria are two well-known probiotics that provide a wide spectrum of potential benefits. Most probiotics are very safe and patients experience few side effects. However, patients who have an immune-deficiency should probably avoid using them.
A recent publication showed that AAD in children can be prevented. In a random, double-blind, placebo-controlled trial, a dose of 250 mg twice daily of the probiotic Saccharomyces boulardi (Florastor) effectively reduced the risk of AAD in children between the ages of 6 months and 14 years old. It is important to note that S. boulardi provides little support in the treatment of AAD; it mostly helps in the prevention.
The mechanism by which beneficial yeast such as S. boulardi works in preventing AAD is unclear. However, similar research in animals showed that it might work by producing a substance, which rallies against the toxins produced by dangerous bacteria. Alternatively, it may raise the levels of local immunoglobulins (a type of antibody) in the bowel, such as Immunoglobulin A, which covers and protects the surface of the bowel similar to varnish on a deck or paint on the body of a car.
Other probiotics have shown promising results in reducing the duration of diarrhea in some children who were sick enough to be hospitalized. Probiotic strains, such as Lactobacillus reuteri and L. rhamnosus, provided a significant reduction in the duration of diarrhea and in the duration of the child’s hospital stay. Recent data on the role of yeasts such as S. boulardi have shown similar benefits to Lactobacilli (specifically, reduced duration of diarrhea), but S. boulardi had no effect on the frequency of vomiting and the duration of fever associated with diarrhea illnesses.
Not all physicians are enthusiastic about the use of probiotics. A survey published by the Canadian Medical Association Journal asked whether physicians recommend probiotics to their patients to prevent AAD. Only 32 % of physicians reported recommending a probiotic product to their patients when prescribing antibiotics (CMAJ 2001; 164 (11): 1577)
Dr. Brenda A. Huff published a paper in the Canadian Family Physician Journal (2004; 50:583-587) entitled "Caveat Emptor" (Latin for “let the buyer beware”), in which she claimed probiotics are not what they seem. Probiotic products were randomly purchased and subsequently carefully tested in a hospital-based laboratory in British Columbia. Dr. Huff concluded that most products did not adequately match their labeled microbiological specifications. She also lamented the fact that no current government regulations apply to over-the-counter probiotic products.
For those who only rely on government-approved products, a recent FDA-approved product Rifaximin, a nonabsorbed antibiotic, is available to treat travelers' diarrhea. Rifaximin is only effective in cases of E. coli, but not in any other bacteria induced diarrhea such as salmonella, shigella or campylobacter. When traveling, remember that no treatment is 100% effective. The best advise still, according to some public health experts, is to "boil it, peel it, cook it or forget it"
For more general information on probiotics, see the seminar on www.healthykids.ca (Use "office" as the coupon code to access the PowerPoint seminar).
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