Probiotic, Prevention and Management Allergy and Asthma In Children

The increase in allergic diseases is attributed to a relative lack of microbial stimulation of the infantile gut immune system. Probiotics, live health-promoting microbes, might offer such stimulation. Over the last decade, there has been a growing interest in the use of probiotics for allergic diseases. In the last years, some studies showed a significant improvement for atopic eczema by the administration of probiotics during pregnancy and postnatally. About food allergy, probiotics administration seems to be effective in the management of food allergy symptoms but has no effect on the prevention of sensitization.

The intestinal microbiota plays an important role in immune development and may play a role in the development of allergic disorders. Manipulation of the intestinal microbiota may therefore offer an approach to the prevention or treatment of allergic diseases. Probiotics and prebiotics, used alone or together (synbiotics), can influence the intestinal microbiota and modulate immune responses in vitro and in vivo. Clinical studies suggest a potential role for selected probiotics (alone or in combination with prebiotics) in the prevention of atopic eczema. A prenatal component of treatment appears important for beneficial effects. Effects are dependent upon the specific bacteria and characteristics of the study population. One study reported beneficial effects for prebiotics in the prevention of eczema in high-risk infants, however, further studies are required to confirm this.

The use of probiotics in the treatment of allergic disease is less promising. A Cochrane meta-analysis concluded that probiotics are not effective for the treatment of atopic dermatitis. Probiotic effects in the treatment of asthma and allergic rhinitis are conflicting. Probiotics, prebiotics and synbiotics offer potential treatments for the prevention of atopic eczema; however, there is currently insufficient evidence to recommend their use in clinical practice. Studies to clarify the optimal dose, bacterial species/strains, whether there is added benefit with synbiotics, the optimal timing for intervention, and the patient populations who would benefit most from such therapies are warranted.

The composition of the intestinal microflora may be different in individuals with atopic eczema from those without this condition, and such differences may precede the development of eczema. Probiotics are live bacteria that colonize the gastrointestinal tract and provide a health benefit to the host. Probiotics added to infant feeds have the potential to prevent sensitisation of infants to dietary allergens.

Less microbial exposure in early childhood is associated with more allergic disease later. Allergic children have a different fecal microflora, with less lactobacilli and bifidobacteria. Beneficial effects regarding the development of allergy have been suggested to come through probiotic supplementation.

In the international literature, there are few studies that evaluated the probiotic effect on allergic rhinitis, and authors reported that probiotics might have a beneficial effect in AR by reducing symptom severity and medication use. Another major potential benefit of probiotics has been suggested in patients with asthma. On this topic, several studies have been carried out using different probiotics and the results have not been univocal. Indeed, probiotics seems to be able to offer protection about common cold and respiratory infections in healthy and hospitalized children.

In a double-blinded, placebo-controlled study mothers with infants at high risk for allergy to receive a probiotic mixture (2 lactobacilli, bifidobacteria, and propionibacteria) or placebo during the last month of pregnancy and their infants to receive it from birth until age 6 months. Infants also received a prebiotic galacto-oligosaccharide or placebo. At 5 years, the studies was evaluated the cumulative incidence of allergic diseases (eczema, food allergy, allergic rhinitis, and asthma) and IgE sensitization.

Frequencies of allergic and IgE-associated allergic disease and sensitization in the probiotic and placebo groups were similar. No significant difference appeared in frequencies of eczema, atopic eczema, allergic rhinitis, or asthma between groups. However, less IgE-associated allergic disease occurred in cesarean-delivered children receiving probiotics.

No allergy-preventive effect that extended to age 5 years was achieved with perinatal supplementation of probiotic bacteria to high-risk mothers and children. It conferred protection only to cesarean-delivered children.

Other studies was studied the effect of a mixture of 4 probiotic bacterial strains along with prebiotic galacto-oligosaccharides in preventing allergic diseases. These studies randomized 1223 pregnant women carrying high-risk children to use a probiotic preparation or a placebo for 2 to 4 weeks before delivery. Their infants received the same probiotics plus galacto-oligosaccharides or a placebo for 6 months. At 2 years, we evaluated the cumulative incidence of allergic diseases (food allergy, eczema, asthma, and allergic rhinitis) and IgE sensitization (positive skin prick test response or serum antigen-specific IgE level >0.7 kU/L). Fecal bacteria were analyzed during treatment and at age 2 years.

Probiotic treatment compared with placebo showed no effect on the cumulative incidence of allergic diseases but tended to reduce IgE-associated (atopic) diseases. Probiotic treatment reduced eczema and atopic eczema. Lactobacilli and bifidobacteria more frequently colonized the guts of supplemented infants.

Probiotic treatment showed no effect on the incidence of all allergic diseases by age 2 years but significantly prevented eczema and especially atopic eczema. The results suggest an inverse association between atopic diseases and colonization of the gut by probiotics. The prevention of atopic eczema in high-risk infants is possible by modulating the infant’s gut microbiota with probiotics and prebiotics.

Assessment of trial quality, data extraction and synthesis of data were performed using standard methods of the Cochrane Neonatal Review Group. Meta-analysis of five studies reporting the outcomes of 1477 infants found a significant reduction in infant eczema. However, there was significant and substantial heterogeneity between studies. One study reported that the difference in eczema between groups persisted to 4 years age. When the analysis was restricted to studies reporting atopic eczema (confirmed by skin prick test or specific IgE), the findings were no longer significant. All studies reporting significant benefits used probiotic supplements containing L. rhamnosus and enrolled infants at high risk of allergy. No other benefits were reported for any other allergic disease or food hypersensitivity outcome.

There is insufficient evidence to recommend the addition of probiotics to infant feeds for prevention of allergic disease or food hypersensitivity. Although there was a reduction in clinical eczema in infants, this effect was not consistent between studies and caution is advised in view of methodological concerns regarding included studies. Further studies are required to determine whether the findings are reproducible.

Rhinitis Allergy

PubMed was searched to identify randomized controlled trials (RCTs) that studied the effects of probiotics on AR and asthma. RCTs that studied the effects of probiotics administration on the treatment but not the prevention of AR and asthma were selected for inclusion in this review.

Nine of the 12 RCTs that evaluated clinical outcomes in AR showed an improvement due to the use of probiotics. All the RCTs that studied perennial AR showed lower symptom scoring and medication use with the use of probiotics compared with placebo. Also, 5 of the 8 RCTs that referred to seasonal AR suggested an improvement in clinical outcomes. Nine RCTs that reported various immunologic measurements of allergy found no significant probiotic effects. The RCTs that studied the effect of probiotic administration on the treatment of asthma showed no positive effects. Probiotics may have a beneficial effect in AR by reducing symptom severity and medication use. Many more good-quality studies are needed to resolve this issue.

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Kukkonen K, et al. Probiotics and prebiotic galacto-oligosaccharides in the prevention of allergic diseases: a randomized, double-blind, placebo-controlled trial. J Allergy Clin Immunol. 2007 Jan;119(1):192-8. Epub 2006 Oct 23.

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