by Anne Eglash MD, IBCLC, FABM
Does the probiotic Lactobacillus reuteri (L. reuteri) have the same beneficial effect for colic in breastfed vs formula fed infants? In CQW #85 we highlighted a December 2015 systematic review on interventions that are likely to be helpful for colic. L. reuteri DSM 17938 had the strongest evidence for reducing crying time. Many other interventions such as simethicone (gas drops) and changes in the maternal diet were not shown to be effective.
What’s colic again? Colic is typically defined by the Wessel rule of ‘3’s, occurring in infants who are growing well, healthy, but have episodes of irritability and who cry inconsolably for at least 3 hours a day, at least 3 days a week, for a period of 3 weeks or longer. Evidence has shown that colic starts before or at 3 weeks of age, peaks at 6-8 weeks of age, and diminishes by 3-4 months of age. The underlying cause of colic is not well understood but several studies have shown a different in gut microbiota between infants with and without colic.
I am raising this topic again because of a recent meta-analysis on the effectiveness of L. reuteri, and whether the effectiveness depends on feeding type, e.g. breastfeeding vs formula feeding. Also, the response to L. reuteri is variable, and there are questions whether other interventions for colic, such as medications for infant GE reflux alter the response to L. reuteri as a treatment.
The meta-analysis included 4 double-blind randomized controlled trials involving a total of 345 infants, with 174 receiving the Biogaia brand infant probiotic and 171 placebo. The studies all measured duration of crying time.
According to the authors of this meta-analysis, which statements do you think are accurate? (choose 1 or more):
- Infants treated with L. reuteri had twice the reduction in crying time as compared to the infants who received a placebo.
- Breastfed infants treated with L. reuteri had a significantly greater reduction in crying time as compared to formula-fed infants treated with L. reuteri.
- The formula fed infants treated with L. reuteri had a significant reduction in crying compared to formula fed infants given a placebo.
- Infants in the study who were taking acid-reducing medication and antibiotics were less likely to gain benefit from L. reuteri.
See the Answer
Answers - A and B (not C or D)
Pediatrics. 2018 Jan;141(1). pii: e20171811. doi: 10.1542/peds.2017-1811.
Lactobacillus reuteri to Treat Infant Colic: A Meta-analysis.
Sung V, D'Amico F, Cabana MD, Chau K, Koren G, Savino F, Szajewska H, Deshpande G, Dupont C, Indrio F, Mentula S, Partty A, Tancredi D.
Lactobacillus reuteri DSM17938 has shown promise in managing colic, but conflicting study results have prevented a consensus on whether it is truly effective.
Through an individual participant data meta-analysis, we sought to definitively determine if L reuteri DSM17938 effectively reduces crying and/or fussing time in infants with colic and whether effects vary by feeding type.
We searched online databases (PubMed, Medline, Embase, the Cumulative Index to Nursing and Allied Health Literature, the Database of Abstracts of Reviews of Effects, and Cochrane), e-abstracts, and clinical trial registries.
These were double-blind randomized controlled trials (published by June 2017) of L reuteri DSM17398 versus a placebo, delivered orally to infants with colic, with outcomes of infant crying and/or fussing duration and treatment success at 21 days.
We collected individual participant raw data from included studies modeled simultaneously in multilevel generalized linear mixed-effects regression models.
Four double-blind trials involving 345 infants with colic (174 probiotic and 171 placebo) were included. The probiotic group averaged less crying and/or fussing time than the placebo group at all time points (day 21 adjusted mean difference in change from baseline [minutes] -25.4 [95% confidence interval (CI): -47.3 to -3.5]). The probiotic group was almost twice as likely as the placebo group to experience treatment success at all time points (day 21 adjusted incidence ratio 1.7 [95% CI: 1.4 to 2.2]). Intervention effects were dramatic in breastfed infants (number needed to treat for day 21 success 2.6 [95% CI: 2.0 to 3.6]) but were insignificant in formula-fed infants.
There were insufficient data to make conclusions for formula-fed infants with colic.
L reuteri DSM17938 is effective and can be recommended for breastfed infants with colic. Its role in formula-fed infants with colic needs further research
Milk Mob Comment by Anne Eglash MD, IBCLC, FABM
This meta-analysis is convincing that breastfed infants with colic gain a significant benefit from L. reuteri, as measured by a reduction in crying time. In fact, the formula fed infants had less response to L. reuteri than to placebo. Based on this data, I do not plan to continue recommending a trial of L. reuteri treatment to my families who have a formula-feeding infant with colic. The authors indicate that the effectiveness of this probiotic seems to be related to breastfeeding, possibly because the gut microbiota is different between breastfed and formula fed infants. The authors could not measure whether acid-reducing medication or antibiotics, both of which alter the gut microbiota, alter the effect of L. reuteri on colic. My impression is that we will see more research on this in the future!