Early Human Development 135 (2019) 75–81

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Early Human Development

journal homepage: www.elsevier.com/locate/earlhumdev

The future of probiotics in the preterm infant☆ T

A R T I C LE I N FO A B S T R A C T

Keywords: Probiotic administration to preterm infants is not universal despite randomised trial data from > 10,000 infants,
Preterm infant significant observational data and multiple meta-analyses. Advocates point to reductions in necrotising en-
Probiotic terocolitis and sepsis, ‘sceptics’ hold concerns over data quality/interpretation or risks. Issues revolve around
Trials different products, primary outcomes, uncertain dosing strategies and individual large ‘negative’ trials alongside
Parents
probiotic associated sepsis and quality control concerns. We review concerns and how to move probiotic use
Mechanisms
forward. Surprisingly little is known about parental perspectives, vital to inform next steps. How to share in-
formation and decisions around probiotic use now, and how this impacts on future available strategies is dis-
Keywords:
Preterm infant cussed. We address placebo controlled trials and propose alternate designs, including head to head studies, using
Probiotic ‘routine’ data collection systems, opt out consents and ‘learning technologies’ embedded in health care systems.
Trials We also raise the importance of underpinning mechanistic work to inform future trials.
Parents
Mechanisms

1. Background
1.1. Decision making in medicine
Data on numbers of decisions made on neonatal intensive care units
(NICU's) is lacking: estimates on adult units exceed 250 every 24 h [1]
suggesting a preterm infant on a NICU will have ‘tens’ of decisions made
daily. Some are firmly evidence based, of which a proportion will be
formalised into recommendations from an expert body such as the
National Institute for Health and Care Excellence (NICE), a Royal Col-
lege or other expert group, whilst others are based on historical prac-
tices. Some are agreed across borders, allowing European or interna-
tional guidance to be developed and implemented wherever resource
allows (e.g surfactant at intubation of preterm infants [2]) although
some take many years before universal adoption occurs (as for an-
tenatal steroids [3]). Others are selectively implemented independent
of resource, with thresholds for practice change differing, and the idea
of ‘early’ and ‘late’ adopters of new treatments (as for less invasive
surfactant delivery [4]). Still more are implemented only by individual
consultants.
1.2. Necrotising enterocolitis (NEC), late onset sepsis (LOS) and probiotic
use
Probiotic use currently falls mostly within the ‘individual units or
consultants’ remit, although there are ‘universal adopters’ and countries
where access is difficult or precluded, but this prompts strong and op-
posing views: ‘time to end all controversies’ [5], ‘it is time to change
practice [6] ‘routine probiotics …: let's be careful [7] ‘further research
must be done … [8]’. Why is this so difficult, controversial, and emo-
tive? The data surpasses that underpinning many other neonatal
treatments, the diseases probiotics address remain important con-
tributors to death and morbidities: the UK SIFT [9] and ELFIN trials
[10] (> 4000 preterm infants < 32 weeks) had LOS in 31% and 30%
and NEC (stage II or above) of 5.3% and 5.5%. The financial and
emotional costs are huge: mortality up to 40% for NEC, impacts on
quality of life, $4 – 600 000 for NEC-related hospital care [11]. Despite
this, how cheap probiotics are (< $1 a day) and data from 20 years, the
neonatal community is divided. Routine use has not increased: UK 17%
[12] USA 14% [13]. Some call for ‘more data’ or ‘better trials' – without
certainty further trials will help. The million pound PiPS trial [14]
awaited as the ‘trial to end the probiotic debate’, n = 1305 with rig-
orous methodology, still has wide confidence intervals, high con-
tamination rates, and used a single strain ‘probiotic’. Probiotics offer
almost limitless future possibilities: the quest for a ‘better’ probiotic
dose, strain, combination or dosing strategy, in an increasingly specific
population (males born by caesarean weighing < 750 g colonised with
Klebsiella) is endless, so waiting for ‘more’ randomised controlled trial
(RCT) data could be an endless task [16].
We face complex challenges. We do not have one disease, one po-
pulation and one drug, the ideal therapeutic trial setting, but must
make wise decisions for babies currently in our care and invest our
time, energies and financial resources for the best benefit of future
babies.
Here we review specific issues relating to probiotic trial data in
relation to clinical decision making, ask whether there is a realistic
likelihood that this issue can be resolved with ‘more data’, discuss fu-
ture research options, and highlight the importance of openness and

☆
Neither author has any conflicts of interest to declare.

https://doi.org/10.1016/j.earlhumdev.2019.05.008

0378-3782/ © 2019 Published by Elsevier B.V.

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 Early Human Development 135 (2019) 75–81

Table 1
Summary of recent probiotic meta-analyses.
Study (ref) Population Trial n Patient n Outcome RR (95%CI) p

Thomas [15] RCTs < 1500 g 23 7325 NEC 0.57 (0.43–0.74) < 0.0001
22 6954 Mortality 0.72 (0.57–0.92) 0.009
RCTs < 1000 g 5 1596 NEC 0.86 (0.64–1.16) 0.32
Dermyshi [29] RCTs < 1500 g 29 8535 NEC 0.57 (0.47–0.7) < 0.00001
28 7987 LOS 0.88 (0.8–0.97) 0.01
27 8156 Mortality 0.77 (0.65–0.92) 0.003
14 13,779 0.51 (0.37–0.7) < 0.0001
8 8648 NEC 0.81 (0.69–0.96) 0.01
Observational 11 11,118 LOS 0.71 (0.62–0.81) < 0.00001
< 1500 g Mortality
Chang [20] RCTs < 1500 25 7345 NEC 0.6 (0.48–0.74) 0.01
or < 32 weeks 21 6291 Mortality 0.75 (0.6–0.92) 0.006
Sawh [21] RCTs < 37 or 35 10,520 NEC 0.53 (0.42–0.66) < 0.0001
< 2500 g 31 8707 LOS 0.88 (0.77–1.00) 0.05
29 9507 Mortality 0.79 (0.68–0.93) 0.003

partnership with parents in making these decisions well.
2. Problems with existing data
2.1. Data interpretation/trial design issues
Utility of probiotic related data is frequently challenged by virtue of
differences in study design. Key differences are the probiotic strains
tested, gestational inclusion criteria (‘prematurity’ from < 32 weeks
to < 37), start and end points of supplementation, different primary
outcomes (affecting power for secondary outcomes that enter meta-
analyses (MA)), different outcome definitions, different geographical
settings and different background rates of LOS and NEC. At the time of
writing (Jan 2019) multiple MA exist, with the most recent summarised
(Table 1). Over 8500 < 1500 g infants contribute to RCTs and >
13,500 to observational studies of probiotics on NEC, slightly fewer
contributing mortality or LOS data. MA also report the impact of pro-
biotic use on outcomes including retinopathy of prematurity (none)
[17] BPD (none) [18] time to full feeds [19] and impact of product used
[20]. So we are not short of data per se. However the data we have is
both ‘broad and narrow’: the average effect may not be received by an
individual (too broad), the trial setting may not be representative of
real life (too narrow) [23] and suffers from other issues, below.
3. Product variation across studies
[28,29], and continues to be supported by emerging data, including
from large national databases [30] suggesting clinical benefit is not all
strain specific. Probiotics are not unique in this – we recognise class
effects of drugs (antibiotics, anti-hypertensives) and food classes (fibre).
3.1. Variation in primary outcomes
Probiotic studies report varying clinical end points: all-cause mor-
tality, BPD, ROP, time to full feeds, length of hospital stay, NEC (all
stages, just > II or only ‘surgical NEC’), and LOS. LOS is defined vari-
ably, including or excluding coagulase negative staphylococci (CONS)
or clinically suspected cases. These differing outcomes and definitions
impact on the power of trials including for secondary outcomes then
included in MA. Cause of death is often not well reported making
biological plausibility from probiotic effect difficult to judge. Some data
suggest that products may perform differentially in reducing NEC and
LOS [22,24] and trials ‘completely separate’ the two. Clinically there is
both genuine overlap of conditions (NEC with E coli sepsis) and sign/
symptom interpretation such that ‘culture negative sepsis’ in one unit
that would be classified as ‘NEC’ in another.
Neonatal medicine is complex, even cause of death is often multi-
factorial (is death from line-related sepsis after NEC due to sepsis or
NEC?) making data interpretation challenging. Long term develop-
mental outcomes remain challenging due to loss to follow up, cost and
resource implications, and no probiotic study to date has this as pri-
mary outcome.

Van den Akker [22] identified 25 separate single strain or combi-

nation products used in any RCT or head to head study reporting
mortality, NEC, LOS or time to full enteral feeds. Only five were studied
repeatedly (> two trials), three combination products reduced mor-
tality, seven (three single, four combination) reduced NEC and two
combination products reduced LOS. One combination (L acidophilus, B
longum, B bifidum, B infantis) used in two studies [24,25] showed effi-
cacy across all three in this network MA. Previous strain analyses have
compared single and multiple strain products, showing better results
with multiple strain products but noted larger number of infants ex-
posed to these than single strain products [21]. The different product
use allows the argument that no product has been sufficiently tested nor
shown effective across multiple studies, and MA is inappropriate.
However heterogeneity within MA and systematic reviews for probio-
tics are low and p values small suggesting biological effects independent
of strain [5]. The mechanisms by which probiotics act are unlikely to all
be strain specific with some expected common properties across strains
[26]. Mechanisms shared may be sub-species specific, species-specific
or genus specific: increasingly knowledge will allow predictions of
likely product efficacy ahead of trials [27]. In addition probiotic in-
tervention in observational studies with varying products shows benefit
3.2. Variations in population at risk
Should sub-populations of ‘preterm infants’ be treated differently?
Are there biologically plausible reasons why sex or gestation (treated
categorically) should affect probiotic efficacy? The infants at highest
risk of NEC and LOS are the lowest gestation, inevitably represented by
the smallest numbers within trial data, and the most immunologically
immature. Data is potentially conflicting: in Germany and Norway some
centres elect only to give probiotics to infants < 1000 g, and observa-
tional data from 5351 infants supports a reduction in NEC, mortality
and any abdominal surgery [31], other MA report ‘insufficient’ data
in < 28 or < 1000 g infants, or no significant effect [29]. Feed type
may be important, with efficacy appearing best in breast fed infants
[32] but small numbers were exclusively breast milk recipients.
4. Limited underpinning mechanistic work
Pathophysiological clarity of the processes that lead to NEC and LOS
is limited, but multiple pathways almost certainly lead to these final
‘diagnoses’. 14 sub-types of NEC are identified by Gordon [33] but only

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 Early Human Development 135 (2019) 75–81

Table 2
Mechanistic data on probiotic effect in the preterm probiotic exposed population.
Probiotic mechanism Measure Study Setting (GA (mean)) Probiotic (days exposed) Finding
[n]

Decreased inflammation Fecal cytokines Indrio [35] DBPCT Formula fed L Reuteri (0−30) Decreased inflammatory cytokines (IL6/8/
infants (30) [60] 17), increased anti-inflammatory (IL10)
Fecal Calpro- Indrio [35] *above *above Decreased
tectin Mohan [36] (31) [69] B Lactis Decreased
L Reuteri (4–21)
Enhanced immune function Stool IgA Indrio [35] *above *above Increased
Mohan [36] *above *above Increased
Production of beneficial SCFA Indrio [35] *above *above Increased
metabolites Mohan [36] *above *above Increased
Underwood [24] 3 arm RCT (29)[90] ProbioplusDDSb (0–28) No effect
or
Culturellec (0–28)
Competitive colonisation Relative Watkins [37] Open dose study with L acidophilus Increased lactobacillus
abundance control [38] B bifidum (0-34 weeks)
Millar [42] PiPs [14]infants [103] B Breve BBG-001 (0–36 weeks) No impact
Plummer [43] ProPrems infants [68] ABCDophilusa (first feed to Increased bifidobacteria
discharge or term)
Reduced ‘NEC associated taxa’ Relative Watkins [37] *above *above Reduced Streptococcacea and Enterococcacea
abundance Millar [42] *above *above No impact
Plummer [43] *above *above Reduced Enterococcus

a
Contains B Longum ssp infantis, Strep thermophilus, B animalis ssp lactis.
b
Contains L acidophilus, B longum, B bifidum, B infantis, inulin.
c
Contains L rhamnosus, inulin.

some relate mechanistically to how probiotics work. The complex host,
microbes and feed interactions, our small patient size and limited tissue
availability make understanding these mechanisms challenging, but
systems are developing [34] including biorepositories (Great North
Neonatal Biobank (www.neonatalreasearch.net and necsociety.org).
Available data exploring probiotic mechanisms in the preterm probiotic
exposed population is summarised in Table 2. Laboratory work ‘outside’
the preterm host, or with adult cells [38] will miss the preterm specific
and host elements of these complex interactions [39] but preterm
specific ‘enteroid’ models are now being successfully developed (CJ
Stewart personal communication). Biomarkers for gut health or disease
are not well explored within probiotic trials and generally perform
poorly in neonatal populations [40,41]. At present there is limited
microbiome data from large RCTs of probiotics [42,43]. Reductions in
‘NEC associated’ taxa may or may not translate to clinical benefit, and
are variable [44]. Association between intestinal permeability (IP) and
microbiota abundance of Clostridiales in infants < 33 weeks over the
first two weeks has been demonstrated [45] but not explored with
probiotic exposure. Less metabolomic data exist and performance as a
marker of functional effect of a probiotic is poorly explored: current
data is conflicting in terms of association with health and disease [46]
or not [47].
suggests that significant NEC reduction occurs with shorter courses
[51].
4.2. Learned society's perspectives
Many key groups have either not offered specific guidance or sug-
gested that more data is needed before use (American Academy of
Pediatrics (AAP) [52] and European Society of Paediatric Gastro-
enterology Hepatology and Nutrition [53]). An ESPGHAN working
group exists and new guidance is expected soon. In the US probiotic
research has been especially difficult due to regulatory challenges and
the International Scientific Association for probiotics and prebiotics
have produced a document addressing these and proposed strategies
[54]. The European Paediatric Association and Union of the National
European Paediatric Societies and Associations (EPA/UNEPSA), con-
vened an expert panel, published guidance for probiotic use in children,
but specifically avoided preterm NEC or LOS. They do however ‘cau-
tion’ use in preterm infants [55]. ESPGHAN have produced a paper
calling for better quality control (Qc) from commercial products [56] a
clear unmet need.
4.3. Risks of probiotic use

4.1. Dosing and duration
Most large trials use a dose of 1 × 108 or 1 × 109: stool colonisation
rates suggest this is not improved with higher doses (1 × 1010) [48].
However there may be better measures for optimising dosing/duration
of probiotics. In animals total bacterial load contributes to NEC pa-
thogenesis, but this was not seen in humans [49]. What could we
measure to ensure optimal dosing? Stool presence of probiotic organism
may indicate transit but not ecological establishment, and the re-
lationship to different dosing regimens explored in small numbers of
infants [37,50]. Two theoretical stances exist around starting: very
early treatment to prevent establishment of ‘pathogenic’ (unit) flora
versus establishment after breast milk priming. Which is best may de-
pend on what is used in the absence of early maternal milk, oral co-
lostrum practices, and unit flora, and is not currently known. When to
stop is easier, with agreement to stop ‘when the risk of NEC/LOS is low’,
generally interpreted as 34 weeks, or discharge, although cohort data
In comparison to risks with other interventions, and in light of po-
tential benefits, risks of probiotic use appear weighted highly by clin-
icians and important to non-adopters. The major risks are probiotic
sepsis [57] or sepsis from contamination [58]. The live nature of the
product appears associated with disproportionate fear in comparison to
other interventions that also contribute to LOS (antibiotic use en-
couraging resistant or dominant strains, anti-reflux treatments) and
other treatments that risk contamination such as parenteral nutrition
[59]. If probiotic strains translocate through leaky gut this is potentially
less harmful than a more pathogenic organism colonising the gut in the
absence of probiotics, yet we feel more responsible for the former.
Many pathogens causing LOS are ‘gut organisms’ [60]. Parents might
accept the idea of replacing ‘aggressive’ gut bacteria with those more
easily treated – if we asked. Concerns around long term effect of gut
microbiome manipulation from probiotics also exist with little ac-
knowledgement that many other clinical decisions have similar impact
(caesarean section, antibiotic exposure, formula feed). Data

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reassuringly show potential reduction in the ‘resistome’ in infants <
1000 g exposed to probiotics and antibiotics compared to less antibiotic
exposed more mature infants [61]. MA of long term developmental
outcomes for probiotic exposed infants are also reassuring though
limited in number [62].
5. How could we progress?
5.1. Parental perspectives
Parental perspectives are poorly reflected in the literature. Parents
of surviving infants given probiotics (and a leaflet) were mostly positive
about probiotic use, but may not be representative [63]. Similarly a
survey of parents of infants with NEC identified dissatisfaction with
information provided, but may not represent NICU parents whose in-
fants never get NEC [64]. In a general survey most mothers (55%) felt
probiotics were ‘safe’ or ‘very safe’, ranking safety ahead of antibiotics
and vitamins, and 73% thought them ‘beneficial’. 61% said they would
give probiotics ‘if research showed they reduced the chance of their
baby getting a disease’ but only 1.8% would if research ‘showed that
their microbiota were permanently changed’ [65]. How to handle
competing beliefs (beneficial but not safe) and outcomes (disease vs
microbiota) is challenging. There are issues that would benefit clin-
icians, parents and babies if shared openly, honestly and realistically
with parents seeking representative views in an unbiased way. These
include: factual information about NEC and LOS, local rates compared
to national/trial data (and potential explanations), that ‘zero’ NEC and
LOS rates are impossible, even when ‘everything’ known is done, how
risk changes with probiotics, the realistic limits of Qc of products and
the frequency of probiotic sepsis or contamination. We need to explain
continuous new data, mechanistic work, and other practice changes
that impact on outcomes or probiotic ‘effectiveness’ but are only known
with time. The complexities of host, microbiome, nutrient and probiotic
interactions will not stop because they raise complex and difficult is-
sues. Agreed written guidance informed by parents, supported by pro-
fessionals, developed in partnership with parents of infants with and
without NEC would help. Shared decision making in this area is pos-
sible if we develop clear tools, present information appropriately [66]
and learn to listen. These parental perspectives would allow clinicians
to progress with parents as active partners.
6. Probiotic use now
6.1. Status quo
The status quo could simply continue: individual trials could be
performed as currently, with appropriate parental representation and
ethics, more data could accumulate, and individuals continue to eval-
uate and respond to this as they see fit. This would feel much more
comfortable if it incorporated better informed parents and standardised
sharing of information by both adopters and non-adopters, with a
strong argument that identical information be given by both. Where
clinicians still hold equipoise, trial participation is possible, and parents
should be informed that in itself this improves outcomes [67], and in
general new treatments out-perform old treatments [68]. This may
enable parent/clinician collaboration in further studies (below).
6.2. Universal adoption
Units would offer the current ‘best available’ probiotic to infants
below an agreed gestational threshold, without further attempts to
clarify potentially better strains, doses etc. Choice could be determined
by individual units based on availability. Advantages are that all below
target gestation would be exposed to a strain with known safety profile,
with demonstrated benefit improving equity of access, although reg-
ulatory issues may make this difficult. This approach is also ‘easy’ to
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Early Human Development 135 (2019) 75–81
share with parents – ‘we are acting on what we know at the moment’.
Disadvantages are that the chosen product may not work for all, and
this approach removes a more individualised one. It also does not offer
a co-ordinated attempt to resolve outstanding issues.
6.3. Targeted adoption
Units could more selectively offer probiotics based on a combination
of factors including gestation, gestation-specific local NEC/LOS rates,
milk exposures, etc. moving towards an individualised approach or
‘designer’ probiotics. This requires thorough understanding of local
burden of disease, careful consistent disease classification and review.
As we understand better microbiome/host interactions and bedside
microbiomic or metabolomics become more available, we may be
better able to identify which infants may benefit most from which
probiotics [69]. Targeted adoption could also be combined with routine
data collection for research purposes (below) such that alternate
thresholds for offering probiotics could be compared.
6.4. Future research
Neonatal care faces many unanswered questions, and phase 1, 2 and
3 trials and large RCTs are the cornerstone of answering many [70] but
time, cost and other practical issues mean that we simply cannot (and
should not) address everything this way. Probiotic research could use
different trial designs dependent on current equipoise, parental per-
ceptions, some technologies, clinician willingness and progress in me-
chanistic understanding.
6.5. Placebo controlled trials
Controversy exists as to whether placebo controlled trials (PCT) are
still justifiable given the current data [71]. It is clear from adoption
rates that many clinicians maintain equipoise making further placebo
controlled trial(s) ethical [72]. To make significant progress future
trials need a high Qc product with underpinning mechanistic data
ideally with supportive pilot data in preterm humans, (gut microbial
taxa changes, establishment of the administered strain), using an es-
tablished dosing regime, powered to address all of NEC, LOS and
mortality, be delivered in a rapid time frame (to prevent other practices
changing) and including sufficient lowest gestation infants. Use of tools
such as PRECIS -2 can help ensure trials generate results that meet the
needs of the population they were intended to help [73]. Perceived
barriers relate to the ability of the neonatal community to find funding
for a further blinded PCT of probiotics soon after PiPS, the potential
lack of clinician equipoise when actually faced with a placebo arm,
parental willingness to participate given existing data (unknown), the
several thousand infants required, and the complexities of standardising
the diagnoses of NEC and LOS. However a well-designed large study
with a probiotic with demonstrable mechanistic action, might be suf-
ficient to allow the ‘data sceptics’ to be assured about data quality,
whatever the findings of that study might be.
6.6. Adoption with embedded ongoing research
Units adopting probiotic use as standard practice could embed
studies of comparative effectiveness of strains or combination products,
such that all infants would receive probiotics, but missing gaps in
knowledge are filled and products and strategies optimised over time.
There are currently limited head to head studies [24] (two prebiotic/
probiotic combinations) and none of dual strain versus single strain
products. Randomisation by baby or unit, or opt out randomisation may
be acceptable to parents. Group randomised trials need larger ‘n’ but
designs exist to minimise this [74]. Overall ongoing programmes of
treatment strategies are likely to improve outcomes over time (with
a > 50% probability) [68] and allow retention of processes and staff to

continue to refine ‘best’ product and strategy including in sub-popula-
tions. Group randomisation by unit would avoid cross-contamination
issues, but leaves other confounders. Designs that prevent randomisa-
tion of individual infants may be differently viewed by parents as in-
dividual infants are potentially ‘denied’ access to the best product.
6.7. Use of routinely collected data
As electronic patient data increases and collaborations reach inter-
nationally (e.g ALPHA collaboration – advancing large publicly
prioritised perinatal trials for health outcomes assessment worldwide)
the capacity for ‘every’ baby to contribute data becomes a reality. With
good data quality assurance the natural experiments that are occurring
currently, or would occur with universal or targeted adoption, can
contribute large amounts of data, refining risk ratios and addressing
currently underpowered sub-groups. Rigorous coding of disease and
exposures with rigorous definitions of outcomes is required. National
datasets already exist and observational studies are emerging using this
approach [75] and with embedded interventions (wheat trial www.
npeu.ox.ac/wheat). Such systems could help cheap delivery of trials in
low/middle income settings where performance is likely to differ from
high income countries [76]. Observational data will remain just that
and is unable to discern causal inference – probiotic adopters might also
employ other successful strategies for NEC/LOS/mortality reduction
making probiotic use a marker not the cause of differences. However,
embedding randomised trials within electronic health records ‘fixes’
several problems with RCTs, including cost, produces both broad and
narrow answers, reduced discomfort with randomisation and improved
speed of knowledge translation [77]. Learning health care systems are
developing [78] and hold future potential: big datasets can learn from
accumulating data. An RCT embedded within electronic health records
can learn that one outcome appears better for one phenotype, and use
patient characteristics to determine ‘best’ treatment option and weight
randomisation accordingly. These designs are described as randomised
multifactorial adaptive platform (REMAP) studies and allow adaptive
trial designs over time. For long term success health care systems rather
than individual clinicians need to answer research questions: opt out
consent and cluster methodologies lend themselves to these ap-
proaches. Parents perspectives are needed on this, but ethics commit-
tees in the UK are in general agreement [79]. Probiotic research is
currently stuck in the RCT or observational era – platform trials are
disease focussed not therapy focussed and allow testing of differing and
multiple exposures dependent on phenotype [80]. They are underway
in similarly challenging diseases with differing aetiology such as adult
community acquired pneumonia.
6.8. Mechanistic work
Table 2 identified mechanistic measures of gut health and disease
that can be measured in relation to probiotic exposure. This offers the
potential to generate pilot data pre implementation of a new probiotic
to ensure that probiotic effects are seen in the host ahead of a large trial,
or embedded within it. This was recently successfully undertaken in the
MAGPIE trial a mechanistic exploration embedded in the ELFIN trial of
stool microbiome, metabolome, host metabolomics and biomarkers
such as calprotectin [81]. These steps would allow refinement of pro-
biotic mixtures for maximum mechanistic effect that would be expected
to translate to clinical benefit. Biobanks of stool and breast milk offer
rapid sample availability to test theories and hypotheses. As under-
standing of the host/microbiome interface increases [82], maternal
milk oligosaccharide profile (HMO) relationship to preterm health [83]
and probiotic utilisation of HMOs [84] future options may include
matching choice of probiotic to maternal HMO profile, and/or ‘perso-
nalised’ analysis of microbiota to determine appropriate probiotic.
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Early Human Development 135 (2019) 75–81
6.9. Other innovative ‘probiotic’ strategies
Although the current definition of probiotics includes that they are
live when administered to the host, it is known that non-viable or-
ganisms elicit immune responses, making it possible to gain benefit
without risking host dissemination of the live organism, with the terms
‘paraprobiotic’ or ghost probiotic used for intact but non-viable cells or
cell extracts [85]. B breve M-16 V currently available and used by some
units has demonstrated suppression of pro-inflammatory responses
from a heat-killed form in a mouse model [86]. A systematic review in
2017 identified 19 paediatric trials of ‘modified’ probiotics, none tar-
geted at NEC or LOS, only one in neonates (targeting atopic dermatitis),
but overall no improvement in safety profile compared to live probio-
tics [87]. Further exploration may be beneficial however [88] given the
anxiety that live bacteria administration causes.
Key guidelines:
• Meta-analyses exist from > 10,000 preterm infants in probiotic
trials
• Many clinicians still hold equipoise making further placebo con-
trolled trials ethical
• Units can make sensible ‘best product’ decisions using available data
• Mechanistic measures of effect can inform probiotic choice before
undertaking large trials
Research directions:
• Parental views require further exploration and standardised in-
formation generating for parents
• Trial designs other than RCT have important advantages
• Head to head trials are lacking and beneficial where equipoise no
longer exists
• Mechanistic learning to help individualise probiotic use are on the
horizon
References
[1] H. Lundgrén-Laine, E. Kontio, J. Perttilä, H. Korvenranta, J. Forsström, S. Salanterä,
Managing daily intensive care activities: an observational study concerning ad hoc
decision making of charge nurses and intensivists, Crit. Care 15 (4) (2011) R188.
[2] O.D. Saugstad, D.G. Sweet, C.P. Speer, et al., European consensus guidelines on the
management of respiratory distress syndrome - 2016 update, Neonatology 111
(2017) 107–125.
[3] C. Bonanno, R.J. Wapner, Antenatal corticosteroids in the management of preterm
birth: are we back where we started? Obstet. Gynecol. Clin. N. Am. 39 (2012)
47–63.
[4] C. Lau, R. Chamberlain, S. Sun, Less invasive surfactant administration reduces the
need for mechanical ventilation in preterm infants, Glob Pediatr Heal 4 (2017) 1–9.
[5] G. Athalye-Jape, S. Patole, Probiotics for preterm infants – time to end all con-
troversies, Microb. Biotechnol. (2019), https://doi.org/10.1111/1751-7915.13357.
[6] W. Tarnow-Mordi, R.F. Soll, Probiotic supplementation in preterm infants: it is time
to change practice, J Peds 12 (2014) 959–960.
[7] J. Neu, Routine probiotics for premature infants: Let's be careful!, J Peds 158 (2011)
672–674.
[8] S. Kona, D. Matlock, Probiotics, prebiotics, and synbiotics for preterm neonates,
Neoreviews 19 (11) (2018) e654–e663.
[9] J. Abbott, J. Berrington, U. Bowler, et al., The speed of increasing milk feeds: a
randomised controlled trial, BMC Pediatr. 17 (1) (2017) 39.
[10] The ELFIN investigator group, Enteral lactoferrin supplementation for very preterm
infants: a randomised controlled trial, Lancet 393 (2019) 423–433.
[11] A. Stey, E. Barnert, C.-H. Tseng, et al., Outcomes and costs of surgical treatments of
necrotizing enterocolitis, Pediatrics 135 (5) (2015) e1190–e1197.
[12] S.D. Duffield, P. Clarke, Current use of probiotics to prevent necrotising en-
terocolitis, Arch Dis Child - Fetal Neonatal Ed. 104 (2) (2018).
[13] S. Viswanathan, C. Lau, H. Akbari, C. Hoyen, M.C. Walsh, Survey and evidence
based review of probiotics used in very low birth weight preterm infants within the
United States, J. Perinatol. 36 (12) (2016) 1106–1111.
[14] K. Costeloe, P. Hardy, E. Juszczak, M. Wilks, M.R. Millar, Bifi dobacterium breve
BBG-001 in very preterm infants: a randomised controlled phase 3 trial, Lancet 387
(2016) 649–660.
[15] J.P. Thomas, T. Raine, S. Reddy, Belteki. Probiotics for the prevention of necrotising
enterocolitis in very low birth weight infants: a meta-analysis and systematic re-
view, Acta Paediatr. 106 (2017) 1729–1741.
[16] D. Zeilstra, J.A. Younes, R.J. Brummer, M. Kleerebezem, Perspective: fundamental

limitations of the randomized controlled trial method in nutritional research: the
example of probiotics, Adv. Nutr. 9 (2018) 561–571.
[17] G. Cavallaro, E. Villamor-Martínez, L. Filippi, F. Mosca, E. Villamor, Probiotic
supplementation in preterm infants does not affect the risk of retinopathy of pre-
maturity: a meta-analysis of randomized controlled trials, Sci. Rep. 7 (1) (2017),
https://doi.org/10.1038/s41598-017-13465-2.
[18] E. Villamor-Martínez, M. Pierro, G. Cavallaro, F. Mosca, B. Kramer, E. Villamor,
Probiotic supplementation in preterm infants does not affect the risk of broncho-
pulmonary dysplasia: a meta-analysis of randomized controlled trials, Nutrients. 9
(11) (2017) 1197, https://doi.org/10.3390/nu9111197.
[19] D. Gori, F. Meneghin, L. Morelli, et al., Probiotics and time to achieve full enteral
feeding in human milk-fed and formula-fed preterm infants: systematic review and
meta-analysis, Nutrients. 8 (2016) 471, https://doi.org/10.3390/nu8080471.
[20] H.Y. Chang, J.H. Chen, J.H. Chang, H.C. Lin, C.Y. Lin, C.C. Peng, Multiple strains
probiotics appear to be the most effective probiotics in the prevention of necrotizing
enterocolitis and mortality: an updated meta-analysis, PLoS One 12 (2) (2017)
e0171579.doi.10.1371/journalpone.0171579.
[21] S.C. Sawh, S. Deshpande, S. Jansen, C.J. Reynaert, P.M. Jones, Prevention of ne-
crotizing enterocolitis with probiotics: a systematic review and meta-analysis, PeerJ
4 (2016) e2429, https://doi.org/10.7717/peerj.2429.
[22] C. Van den Akker, J. Van Goudever, H. Szajewska, et al., Probiotics for preterm
infants: a strain specific systematic review and network meta-analysis, JPGN 67
(2018) 103–122.
[23] P.M. Rothwell, Treating individuals 1 – External validity of randomised controlled
trials: ‘To whom do the results of this trial apply?’, Lancet 365 (2005) 82–93.
[24] M.A. Underwood, N.H. Salzman, S.H. Bennett, M. Barman, D.A. Mills, A. Marcobal,
et al., A randomized placebo-controlled comparison of 2 prebiotic/probiotic com-
binations in preterm infants: impact on weight gain, intestinal microbiota, and fecal
short-chain fatty acids, JPGN. 48 (2) (2009) 216–225.
[25] M. Samanta, M. Sarkar, P. Ghosh, J.K. Ghosh, M.K. Sinha, S. Chatterjee,
Prophylactic probiotics for prevention of necrotizing enterocolitis in very low birth
weight newborns, J. Trop. Pediatr. 55 (2) (2009) 128–131.
[26] C. Hill, F. Guarner, G. Reid, et al., Expert consensus document: the international
scientific association for probiotics and prebiotics consensus statement on the scope
and appropriate use of the term probiotic, Nat Rev Gastroenterol Hepatol. 11
(2014) 506–514.
[27] M.E. Sanders, A. Benson, S. Lebeer, D.J. Merenstein, Klaenhammer, Shared me-
chanisms among probiotic taxa: implications for general probiotic claims. Curr OP,
Biotech 49 (2018) 207–216.
[28] R. Olsen, M. Schrøder, Prophylactic probiotics for preterm infants: a systematic
review and meta-analysis of observational studies, Neonatology 109 (2016)
105–112.
[29] E. Dermyshi, Y. Wang, C. Yan, et al., The “golden age” of probiotics: a systematic
review and meta-analysis of randomized and observational studies in preterm in-
fants, Neonatology. 112 (2017) 9–23.
[30] Singh B, Shah PS, Afifi J et al. Probiotics for preterm infants: A National
Retrospective Cohort Study. J Perinatol. 2019; 0.1038/s41372-019-0315-z.
[31] C. Härtel, J. Pagel, J. Rupp, et al., Prophylactic use of lactobacillus acidophilus/
bifidobacterium infantis probiotics and outcome in very low birth weight infants, J.
Pediatr. 165 (2014) 285–289.
[32] N. Samuels, Van den Graaf, J. Been, et al., Necrotising enterocolitis and mortality in
preterm infants after introduction of probiotics: a quasi-experimental study, Sci.
Rep. 6 (2016) 31643.
[33] P.V. Gordon, J.R. Swanson, B.C. MacQueen, R.D. Christensen, A critical question for
NEC researchers: can we create a consensus definition of NEC that facilitates re-
search progress? Sem Peri 41 (2017) 7–14.
[34] N.D. Embleton, E. Turnbull, S. Turner, J.E. Berrington, Successful blood salvaging
from preterm infants: maximizing opportunities, minimizing interventions, Acta
Paediatr. 102 (11) (2013), https://doi.org/10.1111/apa.12373.
[35] F. Indrio, G. Riezzo, S. Tafuri, et al., Probiotic supplementation in preterm:feeding
intolerance and hospital cost, Nutrients 9 (2017) 965, https://doi.org/10.3390/
nu9090965.
[36] R. Mohan, C. Koebnick, J. Schildt, M. Mueller, M. Radke, M. Blaut, Effects of
Bifidobacterium lactis Bb12 supplementation on body weight, fecal pH, lactate,
calprotectin and IgA in preterm infants, Ped Res 64 (2008) 418–422.
[37] C. Watkins, B.P. Murphy, C.A. Ryan, et al., Dose-interval study of a dual probiotic in
preterm infants, Arch Dis Child - Fetal Neonatal Ed. 104 (2019) F159–F164.
[38] T. Fofanova, C.J. Stewart, Auchtung, et al., A novel human enteroid-anaerobe co-
culture system to study microbial-host interaction under physiological hypoxia,
bioRxiv (2019), https://doi.org/10.1101/555755.
[39] M. Ventura, S. Duranti, J.M. Rodriguez, et al., The first microbial colonizers of the
human gut: composition, activities, and health implications of the infant gut mi-
crobiota, Microbiol. Mol. Biol. Rev. 81 (4) (2017) (e0036-17).
[40] P.C. Ng, Biomarkers of necrotising enterocolitis, Sem Fet and Neo Med. 19 (2014)
33–38.
[41] P.C. Ng, T.P.Y. Ma, H.S. Lam, The use of laboratory biomarkers for surveillance,
diagnosis and prediction of clinical outcomes in neonatal sepsis and necrotising
enterocolitis, Arch. Dis. Child. Fetal Neonatal Ed. 100 (2015) F448–F452.
[42] M. Millar, J. Seale, M. Greenland, et al., The microbiome of infants recruited to a
randomised placebo-controlled probiotic trial (PiPS trial), EBioMedicine 20 (2017)
255–262.
[43] E.L. Plummer, D.M. Bulach, G.L. Murray, S.E. Jacobs, S.N. Tabrizi, S.M. Garland,
Gut microbiota of preterm infants supplemented with probiotics: sub-study of the
ProPrems trial, BMC Microbiol. 18 (2018) 184.
[44] M. Pammi, J. Cope, P.I. Tarr, et al., Intestinal dysbiosis in preterm infants preceding
necrotizing enterocolitis: a systematic review and meta-analysis, Microbiome. 5
80
Descargado para Anonymous User (n/a) en Free University de ClinicalKey.es por Elsevier en enero 23, 2020.
Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2020. Elsevier Inc. Todos los derechos reservados.
Early Human Development 135 (2019) 75–81
(2017) 31.
[45] B. Ma, E. Mccomb, P. Gajer, et al., Microbial biomarkers of intestinal barrier ma-
turation in preterm infants, Front. Microbiol. 9 (2018) 2755, , https://doi.org/10.
3389/fmicb.2018.02755.
[46] C.J. Stewart, N.D. Embleton, E.C.L. Marrs, et al., Temporal bacterial and metabolic
development of the preterm gut reveals specific signatures in health and disease,
Microbiome 4 (2016) 67, https://doi.org/10.1186/s40168-016-0216-8.
[47] Wandro S, Osborne S, Enriquez C et al. The Microbiome and Metabolome of
Preterm Infant Stool Are Personalized and Not Driven by Health Outcomes,
Including Necrotizing Enterocolitis and Late-Onset Sepsis mSphere 3;e00104–18.
[48] S. Dutta, P. Ray, A. Narang, Comparison of stool colonization in premature infants
by three dose regimes of a probiotic combination: a randomized controlled trial,
Am. J. Perinatol. 8 (2015) 733–740.
[49] B. Abdulkadir, A. Nelson, T. Skeath, et al., Stool bacterial load in preterm infants
with necrotising enterocolitis, Early Hum. Dev. 95 (2016) 1–2.
[50] M.A. Underwood, K.M. Kalanetra, N.A. Bokulich, et al., A comparison of two pro-
biotic strains of bifidobacteria in premature infants, J. Pediatr. 163 (2013)
1585–1591.
[51] F. Guthmann, R.P. Arlettaz Mieth, H.U. Bucher, C. Bührer, Short courses of dual-
strain probiotics appear to be effective in reducing necrotising enterocolitis, Acta
Paediatr. 105 (2016) 255–259.
[52] D. Thomas, F. Greer, Clinical report - probiotics and proebiotics in pediatrics,
Pediatrics 126 (2010) 1217–1231.
[53] C. Braegger, A. Chmielewska, T. Decsi, et al., Supplementation of infant formula
with probiotics and/or prebiotics: a systematic review and comment by the
ESPGHAN committee on nutrition, JPGN 52 (2011) 238–250.
[54] M.E. Sanders, A.L. Shane, D.J. Merenstein, Advancing probiotic research in humans
in the United States: challenges and strategies, Gut Microbes 7 (2) (2016) 97–100.
[55] M. Pettoello-Mantovani, I. Hojsak, V. Fabiano, et al., European guidance on pae-
diatric use of probiotics states that benefits are limited to several conditions and
urges caution with specific vulnerable groups, Acta Paediatr. 107 (2018) 927–937.
[56] S. Kolaček, I. Hojsak, R. Berni Canani, et al., Commercial probiotic products: a call
for improved quality control. A position paper by the ESPGHAN working group for
probiotics and prebiotics, JPGN 65 (1) (2017) 117–124.
[57] A. Sullivan, C.E. Nord, Probiotic lactobacilli and bacteraemia in Stockholm, Scan J
Infect Dis (5) (2006) 327–331.
[58] S. Vallabheni, T.A. Walker, S.R. Lockhart, et al., Fatal gastrointestinal mucormy-
cosis in a premature infant associated with a contaminated dietary supplement,
MMWR 64 (6) (2015) 155–156.
[59] W. Zingg, M. Tomaske, M. Martin, Risk of parenteral nutrition in neonates—an
overview, Nutrients 4 (2012) (1490-03).
[60] S. Vergnano, E. Menson, N. Kennea, et al., Neonatal infections in England: the
neonIN surveillance network, Arch. Dis. Child. Fetal Neonatal Ed. 96 (1) (2011).
[61] T. Pedersen, C. Klingenberg, E. Hjerde, et al., Effects of probiotic supplementation
on the gut microbiota and antibiotic resistome development in preterm infants,
Front. Pediatr. 6 (2018) 347, , https://doi.org/10.3389/fped.2018.00347.
[62] R.P. Upadhyay, S. Taneja, R. Chowdhury, T.A. Strand, N. Bhandari, Effect of pre-
biotic and probiotic supplementation on neurodevelopment in preterm very low
birth weight infants: findings from a meta-analysis, Pedaitr Res. (2018), https://doi.
org/10.1038/s41390-018-0211-9.
[63] Sesham R and Clarke P. What do parents think about probiotic use in preterm in-
fants. Arch. Dis. Child. 99(S2):A448.
[64] S. Gadapalli, J. Canvasser, Y. Eskenazi, M. Quinn, J. Kim, S. Gephart, Roles and
experiences of parents in necrotizing enterocolitis: an international survey of par-
ental perspectives of communication in the NICU, Adv Neo Care. 17 (2017)
489–498.
[65] S.L. Bridgman, M.B. Azad, C.J. Field, et al., Maternal perspectives on the use of
probiotics in infants: a cross-sectional survey, BMC Complement. Altern. Med. 14
(2014) 366.
[66] E. Umberger, J. Canvasser, S.L. Hall, Enhancing NICU parent engagement and
empowerment, Semin. Pediatr. Surg. 27 (2018) 19–24.
[67] M. Clarke, K. Loudon, Effects on patients of their healthcare practitioner's or in-
stitution's participation in clinical trials: a systematic review, Trials 12 (2011) 16.
[68] B. Djulbegovic, A. Kumar, P. Glasziou, B.C.I. Miladinovic, Trial unpredictability
yields predictable therapeutic gains, Nature 500 (2013) 395–396.
[69] N. Zmora, G. Zilberman-Schapira, J. Suez, et al., Personalized gut mucosal coloni-
zation resistance to empiric probiotics is associated with unique host and micro-
biome features, Cell. 174 (2018) 1388–1405.
[70] W. Tarnow-Mordi, M. Cruz, J. Morris, B.W. Mol, RCT evidence should drive clinical
practice: a day without randomisation is a day without progress, BJOG. (2017) 613.
[71] J. Neu, J. Shuster, Nonadministration of routine probiotics unethical—really?
Pediatrics 126 (2010) e740.
[72] R. Mhaskar, B.B. Bercu, B. Djulbegovic, At what level of collective equipoise does a
randomized clinical trial become ethical for the members of institutional review
board/ethical committees? Acta Inform Med. 21 (2013) 156–159.
[73] K. Loudon, S. Treweek, F. Sullivan, P. Donnan, K.E. Thorpe, M. Zwarenstein, The
PRECIS-2 tool: designing trials that are fit for purpose, BMJ. 350 (2015) h2147.
[74] E.L. Turner, M. Prague, J.A. Gallis, F. Li, D.M. Murray, Review of recent metho-
dological developments in group-randomized trials: part 2—analysis, AJPH. 107
(2017) 1078–1086.
[75] C. Battersby, N. Longford, S. Mandalia, K. Costeloe, N. Modi, Incidence and enteral
feed antecedents of severe neonatal necrotising enterocolitis across neonatal net-
works in England, 2012–13: a whole-population surveillance study, Lancet
Gastroenterol Hepatol. 2 (2017) 43–51.
[76] G. Deshpande, G. Jape, S. Rao, S. Patole, Benefits of probiotics in preterm neonates
in low-income and medium- income countries: a systematic review of randomised

controlled trials, BMJ Open 7 (2017) 1–15, https://doi.org/10.1136/bmjopen-
2017-0176382017 e017638.
[77] D.C. Angus, Fusing randomized trials with big data: the key to self-learning health
care systems? JAMA 314 (2015) 767–768.
[78] K. Grumbach, C.R. Lucey, S.C. Johnston, Transforming from centers of learning to
learning health systems: the challenge for academic health centers, JAMA 311
(2014) 1109–1110.
[79] C. Gale, M.J. Hyde, N. Modi, Research ethics committee decision-making in relation
to an efficient neonatal trial, Arch. Dis. Child. Fetal Neonatal Ed. 102 (2017)
F291–F298.
[80] S.M. Berry, J.T. Connor, R.J. Lewis, The platform trial: an efficient strategy for
evaluating multiple treatments, JAMA 313 (2015) 1619–1620.
[81] N.D. Embleton, J. Berrington JE Dorling, et al., Mechanisms affecting the gut of
Preterm infants in enteral Feeding trials, Front. Nutr. 4 (2017) 14, , https://doi.org/
10.3389/fnut.2017.00014.
[82] K. Ganguli, D. Meng, S. Rautava, L. Lu, W. Walker, N. Nanthakumar, Probiotics
prevent necrotizing enterocolitis by modulating enterocyte genes that regulate in-
nate immune-mediated inflammation, Am. J. Physiol. Gastrointest. Liver Physiol.
304 (2013) G132–G141.
[83] C.A. Autran, B.P. Kellman, J.H. Kim, et al., Human milk oligosaccharide composi-
tion predicts risk of necrotising enterocolitis in preterm infants, Gut 67 (2017) 6.
[84] K.M. Meyer, M. Mohammad, C. Autran, L. Bode, M. Haymond, K. Aagaard, Maternal
secretor status and the milk microbiota composition, Am. J. Obstet. Gynecol. S180
⁎
Corresponding author.
81
Descargado para Anonymous User (n/a) en Free University de ClinicalKey.es por Elsevier en enero 23, 2020.
Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2020. Elsevier Inc. Todos los derechos reservados.
Early Human Development 135 (2019) 75–81
(2018) 283.
[85] V. Taverniti, S. Guglielmetti, The immunomodulatory properties of probiotic mi-
croorganisms beyond their viability (ghost probiotics: proposal of paraprobiotic
concept), Genes Nutr. 6 (2011) 261–274.
[86] H. Sugahara, R. Yao, T. Odamaki, J.Z. Xiao, Differences between live and heat-
killed bifidobacteria in the regulation of immune function and the intestinal en-
vironment, Benef Microbes. 8 (2017) 463–472.
[87] L. Zorzela, S.K. Ardestani, L.V. McFarland, S. Vohra, Is there a role for modified
probiotics as beneficial microbes: a systematic review of the literature, Benef
Microbes 8 (2017) 739–754.
[88] G. Deshpande, G. Athalye-Jape, S. Patole, Para-probiotics for preterm neona-
tes—the next frontier, Nutrients 10 (2018) 871–880.
⁎
Janet Elizabeth Berringtona,b, , Stefan Zalewskia,
a
Newcastle upon Tyne Hospitals NHS Foundation Trust, Richardson Road,
Newcastle NE1 4LP, United Kingdom of Great Britain and Northern Ireland
b
Newcastle University, United Kingdom of Great Britain and Northern
Ireland
E-mail addresses: j.e.berrington@ncl.ac.uk (J.E. Berrington),
s.zalewski2@newcastle.ac.uk (S. Zalewski).