The certainty of evidence is downgraded due to serious inconsistency (the magnitude of statistical heterogeneity was high, with I^2: high 55%).
Adjunctive probiotics are recommended rather than no probiotics in children under 2 years receiving antibiotics.
Rationale: We issue a strong recommendation for probiotics in children less than 2 years because we believe that the desirable consequences clearly outweigh the undesirable consequences when compared to no probiotics. Although we are only moderately certain in the effect on AAD, the effect was large and there is little evidence of harm. Probiotics are generally inexpensive and widely available. Values and preferences: Patients and their caregivers are likely to place a relatively higher value on preventing AAD, particularly severe AAD than on the relatively minimal costs and burden of probiotics. Resources: Probiotics are generally inexpensive and accessible throughout the world. Many caregivers with lower disposable income, particularly those without socialized pharmacare or private insurance, may not have the means to afford probiotics.
A Cochrane review [Abstract] 1 included 23 studies with 3938 patients aged 0 to 18 years receiving antibiotics. Most participants were under 6 years of age. The studies compared probiotics to placebo, active alternative prophylaxis, or no treatment and measured the incidence of diarrhea secondary to antibiotic use. Trials included treatment with either Bacillus spp., Bifidobacterium spp., Clostridium butyricum, Lactobacilli spp., Lactococcus spp., Leuconostoc cremoris, Saccharomyces spp., or Streptococcus spp., alone or in combination. Eleven studies used a single strain probiotic, four combined two strains, and eight studies combined three or more strains. The probiotic species with most data were Lactobacillus rhamnosus or Saccharomyces boulardii, at a dose of 5 to 40 billion colony forming units/day.
The incidence of AAD in the probiotic group was 8% (163/1992) compared to 19% (364/1906) in the control group (RR 0.46, 95% CI 0.35 to 0.61; I2 = 55%, 3898 participants), NNT 10 (95% CI 8 to 12). Single-strain probiotics appeared as effective as multiple-strain preparations.
None of the 16 trials (n = 2455) that reported on adverse events documented any serious adverse events attributable to probiotics. There is insufficient evidence on the safety of probiotics in immunocompromized children.
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