Probiotics Reduce All-Cause Mortality and Necrotizing Enterocolitis: It Is Time to Change Practice

Delay in adopting effective treatment has serious consequences.1 Hundreds of thousands more infants could have lived had antenatal corticosteroids been introduced sooner after evidence to support their use was published in 1972.2,3 A systematic review, published in this issue of Pediatrics , by Deshpande et al4 of 11 randomized, controlled trials (RCTs) in 2176 infants of <34 weeks' gestation revealed that oral probiotics reduced all-cause mortality and necrotizing enterocolitis (NEC) by more than half ( P < .00001). These results suggest that current probiotics could prevent tens of thousands of deaths annually. The unusually large effect implies that most deaths or cases of NEC in eligible infants who are not given probiotics may, on balance of probability, be ascribed to that omission. Few infants receive probiotics outside RCTs. Should this practice change? After birth at term, the gut is colonized with probiotic organisms such as lactobacilli and bifidobacteria. Probiotics upregulate local and systemic immunity, increase anti-inflammatory cytokines and gut impermeability to bacteria and toxins, and suppress pathogens associated with NEC.5 Probiotics are susceptible to antibiotics, which could explain why prolonged antibiotic use is associated with NEC6,7 and death.7 The authors of a Cochrane review article recommended probiotics for infants of >1000 g birth weight but also recommended more research in smaller infants.8 However, in a subsequent … Address correspondence to William Odita Tarnow-Mordi, BA(Cantab), MBChB, MRCP(UK), DCH, FRCPCH, Westmead Hospital WINNER Centre and Centre for Newborn Care, University of Sydney, Hawkesbury Road, Wentworthville, Sydney, New South Wales 2122, Australia. E-mail: williamtm{at}med.usyd.edu.au