Probiotics for diarrhoea in children

A recent BMJ study was set up to compare the efficacy of five probiotic preparations recommended to parents in the treatment of acute diarrhoea in children.

This was a randomised controlled clinical trial in collaboration with family paediatricians over 12 months in primary care.

Children aged 3-36 months visiting a family paediatrician for acute diarrhoea were studied. Children's parents were randomly assigned to receive written instructions to purchase a specific probiotic product or oral rehydration solution in the control group; Lactobacillus rhamnosus strain GG; Saccharomyces boulardii; Bacillus clausii; mix of L delbrueckii var bulgaricus, Streptococcus thermophilus, L acidophilus, and Bifidobacterium bifidum; or Enterococcus faecium SF68.

The primary outcome measures were duration of diarrhoea and daily number and consistency of stools. Secondary outcomes were duration of vomiting and fever and rate of admission to hospital. Safety and tolerance were also recorded.

571 children were allocated to the intervention. Median duration of diarrhoea was significantly shorter (P<0.001) in children who received L rhamnosus strain GG (78.5 hours) and the mix of four bacterial strains (70.0 hours) than in children who received oral rehydration solution alone (115.0 hours). One day after the first probiotic administration, the daily number of stools was significantly lower (P<0.001) in children who received L rhamnosus strain GG and in those who received the probiotic mix than in the other groups. The remaining preparations did not affect primary outcomes. Secondary outcomes were similar in all groups.

The study concluded that not all commercially available probiotic preparations are effective in children with acute diarrhoea. Paediatricians should choose bacterial preparations based on effectiveness data.

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Managing dyspepsia in primary care

Delaney and colleagues have reported a randomised controlled trial of 699 people with uninvestigated dyspepsia, which compares the strategy of "test and treat" for Helicobacter pylori infection against empirical acid suppression using a proton pump inhibitor.

The test and treat group was tested for H pylori infection and positive patients were given eradication treatment, whereas negative patients were given proton pump inhibitors. Previous studies have looked at people who were H pylori positive or H pylori negative, but none has used test and treat as an overall strategy—instead, if patients were H pylori positive they were randomised to eradication treatment or placebo; if they were negative they were randomised to proton pump inhibitors, other drugs, or placebo.

Dyspepsia is a common symptom-complex of epigastric pain or discomfort—which includes symptoms of heartburn, acid regurgitation, excessive belching, increased abdominal bloating, nausea, feeling of abnormal or slow digestion, or early satiety—for which patients seek medical care. Upper gastrointestinal endoscopy should be performed in patients with alarm symptoms such as weight loss, vomiting, or overt bleeding.

In the UK, the National Institute for Health and Clinical Excellence (NICE) recommends that patients with epigastric pain and heartburn should be managed in the same way, rather than arbitrarily considering that epigastric pain represents dyspepsia and that heartburn diagnoses gastro-oesophageal reflux disease. It is not cost effective to perform endoscopy before treatment.

Delaney and colleagues followed the NICE guidelines and studied patients with dyspepsia who had epigastric pain, heartburn, or both. This was a pragmatic trial that allowed the practitioner to manage the patient according to their discretion during the next year. At 12 months, the patients in the two treatment groups did not differ significantly in terms of dyspeptic symptoms, quality adjusted life years, or costs.

The good news is, if the prevalence of H pylori is high enough, we cannot go wrong with either strategy. If H pylori test and treat is used, a reliable method such as urea breath test or stool antigen must be used because H pylori serology is unreliable. In uninvestigated patients without alarm symptoms, the initial choice of treatment still depends on individual considerations for each patient.

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NICE—Screen all pregnant women for gestational diabetes

Doctors and midwives are being asked to screen all pregnant women for risk factors for gestational diabetes at their first booking appointment and to offer them a test for the condition if their risk is raised.

The recommendation is included in the revised guidance from the National Institute for Health and Clinical Excellence on the routine care that should be offered to all pregnant women in England, which was first published in 2003.

Risk factors for gestational diabetes include a body mass index greater than 30; previous macrosomic baby above 4.5 kg; previous gestational diabetes; family history of diabetes; and family origin with high prevalence of diabetes, such as South Asian, black Caribbean, and Middle Eastern.

The guidance also says that the combined test to screen for Down’s syndrome (nuchal translucency, β human chorionic gonadotrophin, and pregnancy associated plasma protein A) should be offered earlier whenever possible—at between 11 weeks and 13 weeks and six days rather than 16 weeks.

In addition, screening for sickle cell disease and thalassaemia should be offered to all women by 10 weeks, says the guidance.

Midwives and doctors are also being asked to advise women who are pregnant or planning to become pregnant to avoid drinking alcohol in the first three months of pregnancy because of the increased risk of miscarriage. If they choose to drink alcohol after three months they should drink no more than one to two units once or twice a week.

The guidance says that new mothers should be seen by a woman from a similar background who has been trained to provide breastfeeding support within 48 hours of leaving hospital or a home birth.

The guidance includes 22 recommendations, two of which cover vitamin supplements. Midwives are being asked to explain the benefits of taking vitamin D supplements in pregnancy and breast feeding, and all health professionals are advised to tell women of childbearing age at appropriate opportunities about the importance of folic acid before pregnancy and up to 12 weeks.

Parents and carers are advised to eat home cooked meals with their children; to offer them a range of foods; and to keep offering them even if children refuse to eat them.

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