 |
|
Brief Reports Indian Pediatrics 2001; 38: 905-910 |
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
Lactobacillus Cassei in the Control of Acute Diarrhea - A Pilot Study |
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
In recent years, Lactobacillus strains have been found to promote recovery from acute diarrhea in children, mainly non bloody and non mucoid. The effect was specifically observed for reducing duration of acute diarrhea, control of relapsing Clostridium difficile colitis, antibiotic induced gastro-enteritis and even in diarrhea due to Vibrio cholerae and enterotoxigenic Escherichia coli(1-5). Lactobacillus strains have also been found effective in improving immunogenecity of Rota virus vaccine(6). and shedding of Rota virus in diarrhea(7). A specific strain L.cassei DN-114001 was able to protect mice against infection by Rotavirus(8). The present study was conducted to find out the effect of a milk fermented by Lactic cultures (including L. casei DN-114001) on the control of diarrhea in children. Subjects and Methods The present study was a community cum hospital based clinical study. The study was carried out in the Departments of Pediatrics and Community Medicine, University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi. Seventy five children (6 months to 5 years) with diarrhea were admitted for the study in the hospital. Simultaenously, the study was also carried out on 75 children having diarrhea in a slum area named Nand Nagri in one of its dispensary run by State Government of Delhi. Children with acute diarrheal diseases (3 loose stools per day without blood/mucus) were selected in both the studies. Majority of the parents of these children had education less than fifth class. All the study children families were in low socioeconomic category. For the community study, treatment was given from the OPD of the dispensary and the intervention product was provided by the field workers twice a day at their homes in refrigerated conditions. Both breast-fed and bottle-fed children with or without dehydration were included for the study prupose. Following children were excluded from the present study after taking a detailed history: (a) drug-induced diarrhea, (b) malabsorption syndrome, (c) persistent diarrhea, (d) diarrhea associated with other systemic diseases like pneumonia, (e) those who had taken antibiotics, (f) those having allergy to dairy products. The study was approved by the Hospital Ethical Committee. Written consent was obtained from one of the parents. A detailed history regarding number, consistency of stools and presence of mucus and blood was obtained. The information was recorded on a pre-structured schedule. All the children were treated as per the recommended WHO diarrhea treatment plan(9). The diarrhea was considered controlled when the consistency of stools turned semi-solid or solid. The study period was April 1 to June 30, 1999. One group of children was provided a fermented milk containing 108 L. casei DN-114001 per g (Actimel by Danone, France). Second group was provided with Dahi, a type of commonly used yoghurt in India and the third group was provided ultra heated yoghurt. Each group in both the hospital and community comprised of 25 subjects, i.e., 75 subjects in both hospital and in the community. Fermented Milk with L.casei, and Indian Dahi and Ultra Heated Yoghurt (UHY) were aprovided by M/s. Britannia India Limited, Delhi. All the three preparations were supplied to us every week under refrigerated conditions. One consumption regimen of all the three preparations was one serving (100 ml) given 3 times a day. These preparations were given double blind along with the rehydration therapy. The three preparations used were similar in all aspects like packaging, taste, colour, quantity etc. and were stored at 10°C to 4°C. The composition of the three preparations had similar protein content of 2.8% in the preparation. UHY sugar was marginally higher but the fat content was double as compared to the other two preparations. This was also reflected in the higher solid content in UHY preparation. Preparation of UHY did not have any bacteria; Indian Dahi contained 108 Lactococcus lactis, Lactococcus lactis cremoris and Leuconostac mesenteroids cremoris per g, while Actimel contained 108 of each Lactobacillus casei DN-114001, Lactobacillus bulgaricus and Streptococcus thermophilus per g (Table I). Cultures were neumerated on specific medium 8 days after production. Patients to each of these three groups were allotted based on the random table provided by the Biostatistical Unit. Each group was assigned a particular code. The code was revealed to the authors at the end of the study. Simultaneously the stool samples of these children were collected and using a transport medium the samples were sent to the Department of Microbiology. Stool samples available by 11 am could only be examined for microbiology. The following Microbiological tests were conducted: (i) Direct microscopy for possible ova and cysts; (ii) profile of anerobic bacterial flora; (iii) isolation and identification of the following pathogens, V. cholerae 01 (Ogawa), Salmonella serovars, Shigella species, E.coli–EPEC, ETEC and EHEC, and Rota virus. The patients having Shigella, Salmonella, V. cholerae were excluded from the study. Identification of Lactobacillus casei in feces was done by using acid MRS agar plates (Lab M, Amersham, Aylerbury, England). Plates were incubated anerobically for 72 h at 37°C and checked for isolates. Catalase negative, gram positive bacteria were labelled as Lactobacilli. Lactobacillus isolates were further characterized and identified by criteria outlined in the anerobe laboratory manuals(10,11). Hemoglobin and Serum Na+ and K+ were also estimated. The data collected were entered in the computer using SPSS program. To find out the statistically significant difference in the duration of control of diarrhea amongst three groups, ANOVA test was applied. Table I__Comparison of The Three Preparations Used
Results One hundred and ten children could be followed. Stool examination revealed that of the 89 stool samples sent for culture, V. cholera 01 (Ogawa) was seen in 15, Salmonella in 2 and E. coli in 1. These children were excluded from the study. Twenty two dropped out or were lost to follow up. The stool sample in 5 patients showed rotavirus . No ova/cyst was seen. All products were well accepted by the children. Of these, fifty two children were studied in the hospital and fifty eight in the community. Fifty eight children were male and fifty two were female. The proportion of patients with 1,2,3,4 and 5 days of duration of diarrhea was 43%, 12%, 29%, 11% and 1.1% respectively. Mild dehydration was present in 40% of the cases and moderate dehydration in 38%. Remaining had no dehydration. No serum Na+ or K+ level alteration was observed. The age and sex of the children, literacy of the parents and duration of diarrhea in both the community and hospital study were matched. The hemoglobin level of the children varied between 84 to 113 g/L (mean 101 g/L). Ninety per cent of the study children were undernourished as compared to 50th centile weight for age(12). Serum albumin level varied from 46 to 63 g/L. The main outcome measure evaluated was days taken for control of diarrhea. It was seen that for both the hospital and the community study, diarrhea was controlled much earlier in the group that received preparation containing Lactobacillus casei but the results were statistically significant only in the hospital study (p = 0.0004; Table II). The time taken to control diarrhea also decreased in the group which received Indian Dahi though, it was not as effective as with the group receiving L. casei preparation. In this short duration of treatment, the change in weight (loss) was around 2% in all the groups which may be due to dehydration. Lacto-bacillus casei were seen in all the stool samples in children given L.casei preparation. Discussion The results of the present study documents that the L. casei DN-114001 preparation was significantly superior to Indian Dahi in reducing the duration of diarrheal episodes. In the western studies, administration of yoghurt as well as L.casei DN-114001 fermented milk reduced severity of diarrhea in normal children over a period of 6 months(13). In infants fed these preparations for one month it was observed that the number of enterococci increased in faecal matter and proteolytic fermentation decreased in those receiving yoghurt. Those on L. casei DN-114001 pre-paration showed increase in Lactobacilli per g feces and activity of b-glucuronidase b-glucoside (harmful enzymes) decreased(14). In mice both the preparations increased lactase activity in small intestine(15). These possible gut alterations may be helping in control of diarrhea. It may be mentioned here that Indian Dahi has no lactase activity. The first study using L. rhamnosus GG in the treatment of acute diarrhea in 71 Finnish children between the ages of 4 and 45 months showed that the children who received L. rhamnosus GG had a significantly shorter duration of diarrhea (mean duration 1.4 days) than those who received a pasteurized yoghurt placebo (mean duration 2.4 days) with the effect becoming apparent on the second day of treatment. Kaila et al.(16) in another finnish study showed similar results (mean duration 1.1 day vs 2.5 days, respectively). These results are quite similar to those of the present study. Raza et al.(2) in a prospective triple blind clinical trial carried out in Pakistan amongst 31 hospitalized children between the ages of 1 and 24 months with acute diarrhea reported that the response in the group using Lactobacillus GG was evident on day 2 when the frequency of both vomiting and diarrhea was less than the placebo group. We docu-mented similar results. In fact the antibacterial activity of Lactobacillus is well established against a wide range of both aerobic and anerobic bacteria(17). Studies(18) using Dahi have already shown both reduction in the number of episodes as well as duration of diarrhea. Dahi is the most representative yoghurt type product and is the starting point for a variety of other products. It is made throughout India and adjoining countries like Bangladesh, Bhutan, Nepal and Pakistan with cows, buffaloes or yak’s milk which is cultured for 8-12 hours with a starter taken from the previous days batch of Dahi. Western style yoghurt using pure strains of L. bulgari-cus, Streptococcus lactis and Streptococcus thermophillus are not in use in our country. The results of the present study with L.casei DN-114001 in a commercial prepara-tion show that it could be a tool in control of diarrhea in developing countries or use of L. cassei DN-114001 as a starter for Dahi may achieve the same effect. To assess the same, a portion of Lactobacillus preparation was used as a starter at the community level, the families recorded lower episodes of diarrhea. However long term studies are needed covering different seasons with gut bacterial flora studies in chronic diarrhea. Table II__Days For Control of Diarrhea With Different Preparations (n=110)
p = 0.004; p = 0.406 Acknowledgement We are grateful to Dr. J. Antoine, M.D. Danone, CIRDC, France and Dr. K.L. Gaba for valuable criticisms. Contributors: KNA and SKB planned and monitored the study. MMAF and SG performed the clinical hospital study. MM performed the microbiological tests. All authors were involved in drafting of the manuscript. KNA will act as guarantor for the manuscript. Funding: Brittania India provided the preparations used in the study. Competing interests: None stated.
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
