Probiotics Supplementation During Pregnancy or Infancy for the Prevention of Atopic Dermatitis: A Meta-analysis

The impact of prebiotics, probiotics and synbiotics on the prevention and treatment of atopic dermatitis in children: an umbrella meta-analysis

Background

Studies have suggested that the administration of prebiotics, probiotics and synbiotics (pre-, pro-, and synbiotics) may potentially decrease the incidence of atopic dermatitis (AD) and alleviate its severity in children; however, recent studies have yielded inconclusive findings.

Objective

This umbrella meta-analysis aimed to comprehensively assess the effect of pre-, pro-, and synbiotics on AD among children.

Methods

A systematic search was carried out in the PubMed and Scopus databases up to April 2024 to identify relevant meta-analyses. Relative risks (RR) and weighted mean differences (WMD) along with their 95% confidence intervals (CI) were pooled using a random effects model to evaluate the impacts on both the incidence of AD and its severity, as assessed by the Scoring Atopic Dermatitis (SCORAD) index.

Results

This umbrella meta-analysis included 38 meta-analyses, with 127,150 participants. The analysis suggested that intervention with pre-, pro-, and synbiotics significantly reduced the incidence of AD (RR = 0.74, 95% CI: 0.70-0.79), which was confirmed by subgroup analyses. The treatment significantly reduced SCORAD score (WMD = -3.75, 95% CI: -5.08 to -2.42). In subgroup analysis, multi-strain probiotics, Lactobacillus, synbiotics, and pre-, pro-, and synbiotics mixtures were found to significantly decrease the SCORAD score, while, Bifidobacterium and prebiotics alone did not show a significant effect on the SCORAD score. The treatment resulted in a significant decrease in SCORAD score among children with moderate to severe AD, but not in subjects with mild AD.

Conclusions

Probiotics and synbiotics could be promising interventions to reduce the risk of developing AD and alleviate its severity in children.

Impact of Habitual Yogurt Intake in Mother-Child Dyads on Incidence of Childhood Otitis Media: The Japan Environment and Children's Study (JECS)

Otitis media, one of the most common childhood diseases, is characterized by inflammation or infection of the middle ear. Due to their ease of access, daily probiotics are recommended for the prevention of early childhood otitis media. This study aimed to assess the impact of probiotics on the incidence of otitis media using a dataset (n = 95,380) from the Japan Environment and Children's Study, a nationwide birth cohort study. After multiple imputations, the association between the incidence of otitis media in early childhood and the daily frequency of yogurt intake in children and mothers was examined using a generalized linear model after adjusting for several confounders. Repeated incidence of otitis media during the 2 years after birth was found in 14,874 participants (15.6%). Based on participants with the lowest frequency of yogurt intake ("almost never") as the reference group, risk ratios for otitis media incidence decreased with higher frequencies of yogurt intake in children at one year of age, but also independently in mothers during pregnancy. The lowest risk ratio (95% confidence interval) for otitis media incidence at six months of age was observed with the most frequent yogurt intake (once/day or more) (0.54 [0.46-0.63]). Additionally, although a similar association was observed in the subgroup of those with cleft lip and/or palate (CL/P), a high-risk group for severe recurrent otitis media, no statistical significance was observed. Thus, increased regular yogurt intake in both children and mothers was associated with a decrease of otitis media during early childhood.

The Role of Gut Microbiota and the Potential Effects of Probiotics in Heart Failure

Heart failure (HF) remains a significant global health challenge, affecting millions of individuals worldwide and posing a substantial burden on healthcare systems. HF is a syndrome of intricate pathophysiology, involving systemic inflammation, oxidative stress, metabolic perturbations, and maladaptive structural changes in the heart. It is influenced by complex interactions between cardiac function, systemic physiology, and environmental factors. Among these factors, the gut microbiota has emerged as a novel and intriguing player in the landscape of HF pathophysiology. The gut microbiota, beyond its role in digestion and nutrient absorption, impacts immune responses, metabolic processes, and, as suggested by evidence in the literature, the development and progression of HF. There is a bidirectional communication between the gut and the heart, often known as the gut-heart axis, through which gut microbiota-derived metabolites, immune signals, and microbial products exert profound effects on cardiovascular health. This review aims to provide a comprehensive overview of the intricate relationship between the gut microbiota and HF. Additionally, we explore the potential of using probiotics as a therapeutic strategy to modulate the gut microbiota's composition and attenuate the adverse effects observed in HF. Conventional therapeutic approaches targeting hemodynamic and neurohormonal dysregulation have substantially improved the management of HF, but emerging research is exploring the potential implications of harnessing the gut microbiota for innovative approaches in HF treatment.

Immunosuppressive and immunomodulating therapy for atopic dermatitis in pregnancy: an appraisal of the literature

Atopic dermatitis (AD) is the most common dermatological diagnosis during pregnancy. Treatment of AD during pregnancy can be challenging, due to the unpredictable course and the fact that the therapy needs to be safe for both the mother and the fetus. Here we present an up-to-date appraisal of the literature on the treatment options available for AD in patients planning pregnancy, during pregnancy, and during breastfeeding. All patients with AD are recommended to supplement any medical treatment with daily applications of emollients. The first step in the medical treatment for AD during pregnancy are topical corticosteroids, and/or topical tacrolimus. If required, UV-light therapy can also be considered. Treatment with systemic therapy during pregnancy should always rely on a careful risk-benefit assessment and be based on shared-decision making between the treating physician and patient. The first-line systemic treatment option is cyclosporine A, whereas azathioprine may be considered in patients already receiving this treatment prior to pregnancy. Systemic glucocorticoids may also be used. Treatment with systemic JAK inhibitors is not recommended, whereas treatment with mycophenolate mofetil and methotrexate is contraindicated. Targeted therapy with dupilumab is not generally recommended, due to lack of experience in human pregnancies, yet some case-reports on their use are emerging. These recommendations are based on the authors appraisal of existing literature and the current recommendation from the European Task Force on Atopic Dermatitis. It is always the responsibility of the treating physician to stay updated on the newest guidelines and literature when treating patients with AD during pregnancy.

Drug regulation of microRNA

The scientific review provides the mechanisms of drug regulation of microRNA in the human body. To write the article, information was searched using Scopus, Web of Science, MEDLINE, PubMed, Google Scholar, Embase, Global Health, The Cochrane Library databases. To restore the reduced functional activity of microRNAs, replacement therapy is used, with modified synthetic analogs of endogenous microRNAs, and drugs that enhance the production of the body’s own microRNAs. The authors state that numerous studies have confirmed the effectiveness of miRNA replacement therapy. It is known that there are several groups of drugs among miRNA inhibitors: anti-miRNA oligonucleotides, miRNA traps, miRNA mimics that prevent miRNA binding; peptide nucleic acids, small-molecule inhibitors. The authors suggest that the expression of drug-metabolizing enzymes is controlled by nuclear receptors and transcription factors, epigenetic regulation such as DNA methylation and histone acetylation, and post-translational modification. It is emphasized that ursodeoxycholic acid modulates the expression of some miRNAs. It is known that probiotic bacteria can modulate the expression level of miRNA genes. The use of probiotics is accompanied by a change in the expression of nume­rous genes of the body involved in the regulation of the inflammatory response, allergic reactions, metabolism and other biological processes. Thus, modern science is intensively studying the potential of using drugs that restore miRNA content or inhibit miRNA acti­vity for the therapy of miRNA-dependent conditions. The results of scientific research confirmed the therapeutic effect of ursodeoxycholic acid and probiotic preparations due to the effect on the acti­vity of miRNA generation in hepatobiliary diseases. Therefore, the introduction into clinical practice of drugs than can modulate the content and expression of specific miRNAs will certainly open new perspectives in the treatment of patients with hepatobiliary diseases.

The Saudi initiative for asthma - 2024 update: Guidelines for the diagnosis and management of asthma in adults and children

The Saudi Initiative for Asthma 2024 (SINA-2024) is the sixth version of asthma guidelines for the diagnosis and management of asthma for adults and children that was developed by the SINA group, a subsidiary of the Saudi Thoracic Society. The main objective of the SINA is to have guidelines that are up-to-date, simple to understand, and easy to use by healthcare workers dealing with asthma patients. To facilitate achieving the goals of asthma management, the SINA Panel approach is mainly based on the assessment of symptom control and risk for both adults and children. The approach to asthma management is aligned for age groups: adults, adolescents, children aged 5-12 years, and children aged <5 years. SINA guidelines have focused more on personalized approaches reflecting a better understanding of disease heterogeneity with the integration of recommendations related to biologic agents, evidence-based updates on treatment, and the role of immunotherapy in management. The medication appendix has also been updated with the addition of recent evidence, new indications for existing medication, and new medications. The guidelines are constructed based on the available evidence, local literature, and the current situation at national and regional levels. There is also an emphasis on patient-doctor partnership in the management that also includes a self-management plan.

Atopic March or Atopic Multimorbidity-Overview of Current Research

The atopic march encompasses a sequence of allergic conditions, including atopic dermatitis, food allergy, allergic rhinitis, and asthma, that frequently develop in a sequential pattern within the same individual. It was introduced as a conceptual framework aimed at elucidating the developmental trajectory of allergic conditions during childhood. Following the introduction of this concept, it was initially believed that the atopic march represented the sole and definitive trajectory of the development of allergic diseases. However, this perspective evolved with the emergence of new longitudinal studies, which revealed that the evolution of allergic diseases is far more intricate. It involves numerous immunological pathological mechanisms and may not align entirely with the traditional concept of the atopic march. The objective of our review is to portray the atopic march alongside other patterns in the development of childhood allergic diseases, with a specific emphasis on the potential for a personalized approach to the prevention, diagnosis, and treatment of atopic conditions.

Low-dose perinatal supplementation with Enterococcus faecalis increases concentrations of short-chain fatty acids in the offspring but does not protect against allergic asthma

Childhood allergic asthma is associated with a dysbiotic gut microbiome in early life, and maternal perinatal treatment with probiotics is a potential way alter the infant microbiome, which may improve asthma outcomes. This study used a mouse model to examine the effect of maternal supplementation with the probiotic Enterococcus faecalis on faecal short-chain fatty acid (SCFA) concentrations and asthma risk in the offspring. Pregnant/lactating mice were treated daily, from gestation day 6 to postnatal day 21, with an oral suspension of 106, 107 or 108 colony-forming units of a live preparation of the probiotic E. faecalis (Symbioflor®1). At weaning, offspring were subjected to an ovalbumin-induced experimental asthma protocol. Faeces were collected from the mothers and offspring at several different time points to determine SCFA concentrations. It was found that maternal supplementation with E. faecalis did not alter litter size, sex ratio or offspring weight, and was associated with an increase in SCFAs in offspring faeces at weaning and after allergy induction. However, allergic offspring from E. faecalis supplemented mothers showed no difference in asthma severity when compared with allergic offspring from control mothers. In conclusion, although maternal perinatal supplementation with low-dose E. faecalis was associated with increased faecal SCFAs in the offspring, it did not protect against offspring asthma. This is may be because SCFA concentrations were not increased to an immunoprotective level. We recommend that future studies concentrate on probiotic supplementation in high-risk cases, for instance, to repair gut dysbiosis resulting from antibiotic use in pregnant mothers or their infants.

Strategies for applying probiotics in the antibiotic management of Clostridioides difficile infection

The vital role of probiotics in the food field has been widely recognized, and at the same time, probiotics are gradually exhibiting surprising effects in the field of nutraceuticals, especially in regulating gut inflammation and the nutritional environment. As a dietary supplement in clinical nutrition, the coadministration of probiotics with antibiotics model has been applied to prevent intestinal infections caused by Clostridioides difficile. However, the mechanism behind this "bacteria-drug combination" model remains unclear. In particular, the selection of specific probiotic strains, the order of probiotics or antibiotics, and the time interval of coadministration are key issues that need to be further explored and clarified. Here, we focus on the issues mentioned above and give reasonable opinions, mainly including: (1) probiotics are safer and more effective when they intervene after antibiotics have been used; (2) the choice of the time interval between coadministration should be based on the metabolism of antibiotics in the host, differences in probiotic strains, the baseline ecological environment of the host's intestine, and the host immune level; in addition, the selection of the coadministration regime should also take into account factors such as the antibiotic sensitivity of probiotics and dosage of probiotics; and (3) by encapsulating probiotics, combining probiotics with prebiotics, and developing next-generation probiotics (NGPs) and postbiotic formulations, we can provide a more reasonable reference for this type of "bacteria-drug combination" model, and also provide targeted guidance for the application of probiotic dietary supplements in the antibiotic management of C. difficile infection.

Metaanalyse zu präventiven und therapeutischen Effekten probiotischer Supplementierung bei Kindern mit atopischer Dermatitis

Trotz zahlreicher wissenschaftlicher Untersuchungen gibt es zur Wirkung von Probiotika auf die Inzidenz und Schwere der atopischen Dermatitis (AD) widersprüchliche Ergebnisse. Wir untersuchten, ob die Supplementierung mit Probiotika diese Parameter verringern. Dazu wurden drei Datenbanken systematisch durchsucht. In der Probiotika‐Gruppe war die AD‐Inzidenz um 22% geringer. Bei Verabreichung der Probiotika an schwangere und stillende Mütter betrug die Verringerung der Inzidenz 49% und bei Verabreichung an schwangere Mütter und Kinder 27%. Bei Verabreichung an schwangere und stillende Mütter sowie Kinder wurde eine 39%ige Verringerung der AD‐Inzidenz erreicht. Es wurden signifikante Unterschiede beim SCORAD (SCORing Atopic Dermatitis) zugunsten der Probiotika beobachtet, die IDLQI blieb jedoch unverändert. Lactobacillus (L.) rhamnosus war der am häufigsten dokumentierte Stamm, erwies sich jedoch bezüglich der Verringerung des SCORAD als unwirksam. Im Gegensatz dazu zeigte sich bei L. paracasei und L. sakei eine signifikante Verringerung des SCORAD. Während Probiotika bei der Prävention einer AD effektiv sind, ist die Wirkung bei der Behandlung einer AD weniger eindeutig, insbesondere bei Kindern <1 Jahr. Die Einnahme von Probiotika durch stillende Mütter ist eine wichtige Maßnahme und kann eine neue prophylaktische Strategie darstellen. Der präventive Effekt von Probiotika bei AD ist nicht mit dem familiären Hintergrund oder dem AD‐Risiko assoziiert. Bei L. paracasei und L. sakei zeigte sich die größte Verringerung des SCORAD.

Meta-analysis on preventive and therapeutic effects of probiotic supplementation in infant atopic dermatitis

Despite a large body of research, the effect of probiotic administration on the incidence and severity of atopic dermatitis (AD) shows conflicting results. We aimed to investigate whether probiotic supplementation reduces the incidence and severity of AD. Three databases were systematically searched. A 22% lower incidence of AD was found in the probiotic group. The reduction in incidence was 49% when probiotics were given to pregnant and lactating mothers, and 27% when they were given to pregnant mothers and infants. A 39% reduction of AD incidence was achieved when administered to pregnant-breastfeeding mothers and infants. Significant differences in SCORAD (SCORing Atopic Dermatitis) favoring probiotics were observed, but the IDLQI remained unchanged. Lactobacillus (L.) rhamnosus was the most documented strain, but it turned out to be ineffective in reducing SCORAD. Conversely, L. paracasei and L. sakei showed a significant decrease in SCORAD. Probiotics are effective in the prevention of AD, but the effect is less conclusive for the treatment of AD, especially in infants <1 year. The intake of probiotics by breastfeeding mothers is an important measure and may become a novel preventive strategy. The preventive effect of probiotics against AD is not associated with family background or AD risk. L. paracasei and L. sakei show the greatest reduction in SCORAD.

Microbiome-Induced Autoimmunity and Novel Therapeutic Intervention

Microorganisms' flora, which colonize in many parts of our body, stand out as one of the most important components for a healthy life. This microbial organization called microbiome lives in integration with the body as a single and whole organ/system. Perhaps, the human first encounters the microbial activity it carries through the immune system. This encounter and interaction are vital for the development of immune system cells that protect the body against pathogenic organisms and infections throughout life. In recent years, it has been determined that some disruptions in the host-microbiome interaction play an important role in the physiopathology of autoimmune diseases. Although the details of this interaction have not been clarified yet, the focus is on leaky gut syndrome, dysbiosis, toll-like receptor ligands, and B cell dysfunction. Nutritional regulations, prebiotics, probiotics, fecal microbiota transplantation, bacterial engineering, and vaccination are being investigated as new therapeutic approaches in the treatment of problems in these areas. This article reviews recent research in this area.

Using probiotics in paediatric populations

This statement defines probiotics and reviews the most recent literature on their use in paediatrics. Many studies have examined the potential benefit of probiotics, but significant variation in the strains and doses of probiotics used, the patient populations studied, and in study design, have led to heterogeneous results. Present evidence suggests that probiotics can decrease mortality and lower incidence of necrotizing enterocolitis in preterm and low birth weight neonates. Probiotics may also be beneficial in reducing feeding intolerance. In infants, probiotics may be considered to reduce symptoms of colic. In older children, probiotics can be considered to prevent antibiotic-associated diarrhea and Clostridium difficile -associated diarrhea. Probiotic supplements used in conjunction with standard therapy can help with Helicobacter pylori eradication and decrease the side effects of treatment. Lactobacillus species can be considered to treat irritable bowel syndrome. Probiotics can also be considered to help prevent atopic dermatitis and eczema. To optimize paediatric policy and practice, large, quality studies are needed to determine what types and combinations of probiotics are most efficacious.

L’utilisation des probiotiques dans la population pédiatrique

Le présent document de principes définit les probiotiques et fournit une analyse des publications scientifiques les plus récentes sur leur utilisation en pédiatrie. De nombreuses études ont évalué les avantages potentiels des probiotiques, mais en raison des variations importantes dans les souches et les doses utilisées, des populations de patients étudiées et des méthodologies privilégiées, les résultats sont hétérogènes. Selon les données probantes à jour, les probiotiques peuvent réduire le taux de mortalité et l’incidence d’entérocolite nécrosante chez les nouveau-nés prématurés et de petit poids à la naissance. Ils peuvent également être bénéfiques pour réduire l’intolérance alimentaire. Chez les nourrissons, on peut envisager de les utiliser pour limiter les symptômes de coliques, et chez les enfants plus âgés, pour prévenir la diarrhée associée aux antibiotiques ou au Clostridium difficile . Les suppléments de probiotiques utilisés conjointement avec un traitement standard peuvent contribuer à éradiquer l’Helicobacter pylori et à atténuer les effets secondaires du traitement. On peut envisager d’utiliser des espèces de Lactobacillus pour traiter le syndrome du côlon irritable ou de recourir à des probiotiques pour contribuer à prévenir la dermatite atopique et l’eczéma. Afin d’optimiser les politiques et les pratiques en pédiatrie, de vastes études de qualité devront être réalisées pour déterminer les types et les combinaisons de probiotiques les plus efficaces.

Biotics in atopic diseases: state of the art and future perspectives

Prevalence of allergic diseases has growing in recent decades, being a significant burden for patients and their families. Different environmental factors, acting in early life, can significantly affect the timing and diversity of bacterial colonization and the immune system development. Growing evidence points to a correlation between early life microbial perturbation and development of allergic diseases. Besides, changes in the microbiota in one body site may influence other microbiota communities at distance by different mechanisms, including microbial-derived metabolites, mainly the short chain fatty acids (SCFA). Hence, there has been an increasing interest on the role of "biotics" (probiotics, prebiotics, symbiotics and postbiotics) in shaping dysbiosis and modulating allergic risk. Systemic type 2 inflammation is emerging as a common pathogenetic pathway of allergic diseases, intertwining communication with the gut mcirobiota. The aim of this review was to provide an update overview of the current knowledge of biotics in prevention and treatment of allergic diseases, also addressing research gaps which need to be filled.

Efficacy and Safety of Fig (Ficus carica L.) Leaf Tea in Adults with Mild Atopic Dermatitis: A Double-Blind, Randomized, Placebo-Controlled Preliminary Trial

Atopic dermatitis (AD) is a chronic, recurrent pruritic skin disease with repeated remissions and exacerbations. Various factors, such as allergies, skin conditions and lifestyle, combine to cause AD, making it difficult to cure completely. Although AD symptoms are suppressed with medications, this is a long-term effort and burden on patients. Thus, safer drugs and alternatives are needed. We previously found that consumption of tea prepared from fig (Ficus carica L.) leaves alleviated allergy and AD symptoms in cultured cells and animals. Therefore, here, we conducted a double-blind, randomized, controlled study in patients with mild AD to evaluate the safety and AD-relieving effects of prolonged consumption of fig leaf tea. Positive effects of fig leaf tea consumption were confirmed in 14 of 15 participants. Eczema Area and Severity Index values were significantly lowered in the fig leaf tea-treated group than in the placebo-treated group. The effect weakened 4 weeks after the end of the intervention, suggesting that continued intake of fig leaf tea was effective. Further assessments confirmed the safety of fig leaf tea consumption and revealed no variations that might pose a health hazard. Therefore, we postulate that fig leaf tea is a natural and safe therapeutic option for AD.

Transplantation of maternal intestinal flora to the newborn after elective cesarean section (SECFLOR): study protocol for a double blinded randomized controlled trial

Background

A complication of elective cesarean section (CS) delivery is its interference with the normal intestinal colonization of the infant, affecting the immune and metabolic signaling in early life— a process that has been associated with long-term morbidity, such as allergy and diabetes. We evaluate, in CS-delivered infants, whether the normal intestinal microbiome and its early life development can be restored by immediate postnatal transfer of maternal fecal microbiota (FMT) to the newborn, and how this procedure influences the maturation of the immune system.

Methods

Sixty healthy mothers with planned elective CS are recruited and screened thoroughly for infections. A maternal fecal sample is taken prior to delivery and processed according to a transplantation protocol. After double blinded randomization, half of the newborns will receive a diluted aliquot of their own mother’s stool orally administered in breast milk during the first feeding while the other half will be similarly treated with a placebo. The infants are clinically followed, and fecal samples are gathered weekly until the age of 4 weeks, then at the ages of 8 weeks, 3, 6, 12 and 24 months. The parents fill in questionnaires until the age of 24 months. Blood samples are taken at the age of 2–3 days and 3, 6, 12 and 24 months to assess development of major immune cell populations and plasma proteins throughout the first years of life.

Discussion

This is the first study to assess long-time effects on the intestinal microbiome and the development of immune system of a maternal fecal transplant given to term infants born by CS.

Trial registration

ClinicalTrials.gov NCT04173208, registration date 21.11.2019.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-022-03609-3.

Hygienic behaviors during the COVID-19 pandemic may decrease immunoglobulin G levels: Implications for Kawasaki disease

Background

Due to the coronavirus disease 2019 (COVID-19) pandemic, hygienic behaviors became a new norm since January 2020. The hygiene hypothesis predicts that an excessively hygienic environment may adversely affect human health.

Objective

We quantified the effect of COVID-19 on immunological parameters linked to the hygiene hypothesis.

Methods

We examined age-specific levels of total nonspecific immunoglobulin G (IgG) and IgE in individuals who visited Fukuoka Tokushukai Hospital between 2010 and 2021. Pre-COVID (2010–2019) and COVID (2020–2021) periods were compared.

Results

IgG levels steadily decreased throughout Pre-COVID period. IgG levels fell abruptly from the pre-COVID period to the COVID period in all age groups (P = 0.0271, < 0.3 years; P = 0.0096, 0.3–5 years; P = 0.0074, ≥ 5 years). The declines in IgG in < 0.3 years and that in ≥ 5 years accelerated during the COVID period. IgE levels were seasonal, but did not change noticeably from the pre-COVID to COVID period. IgG levels recorded for patients with Kawasaki disease (KD) (mean 709 mg/dL) were significantly lower than for matched control subjects (826 mg/dL) (P<0.0001).

Discussion

Hygienic behaviors during the COVID-19 outbreak decreased the chance of infection, which may explain the decreases in IgG levels in children and adults. Neonatal IgG declined, possibly because of the decrease in maternal IgG.

Conclusion

Hygienic behaviors decreased the IgG levels in all age groups, from neonates to adults. This downturn in IgG may lead to vulnerability to infections as well as to KD.

Lactobacillus rhamnosus Used in the Perinatal Period for the Prevention of Atopic Dermatitis in Infants: A Systematic Review and Meta-Analysis of Randomized Trials

Background

Numerous systematic reviews and meta-analyses have examined the effects of probiotics used perinatally on prevention or treatment of atopic disease in infants and children. However, to date, no review has examined randomized controlled trials of Lactobacillus rhamnosus, specifically, administered both prenatally and postnatally and its effect over a long period of time.

Objective

The objective was to determine if L. rhamnosus either used solely or in conjunction with other probiotics demonstrates a long-term preventive effect on atopic disease in pediatric patients when used perinatally.

Methods

A systematic review was undertaken to identify those studies where L. rhamnosus was used (either solely or in conjunction with other probiotics). The following databases were searched from the year 2000 through December 8, 2021: PubMed, Cochrane Reviews and Cochrane Central Database of Controlled Trials; systematic reviews were hand searched to identify randomized controlled trials (RCTs). Meta-analytic statistical techniques were then employed. Evaluation of the incidence of atopic eczema was also examined longitudinally based on timeframe. Grading of Recommendations, Assessment, Development and Evaluations (GRADE) assessments were employed to determine the quality of the evidence.

Results

Eleven randomized controlled trials were identified which examined L. rhamnosus in its effect on atopy. Risk of bias was low on the majority of the domains assessed. Meta-analysis of the timeframes ≤ 2 years (RR 0.60, 95% CI 0.47–0.75; p < 0.00001) and 6–7 years (RR 0.62, 95% CI 0.50–0.75; p < 0.00001) demonstrated statistically significant reductions in atopic eczema with use of L. rhamnosus. For the 4 to 5-year (RR 0.74, 95% CI 0.55–1.00; p = 0.05) and 10–11-year (RR 0.68, 95% CI 0.37–1.27; p = 0.23) timeframes there was no statistically significant reduction. GRADE assessment for each timeframe was considered moderate in two, owing to high attrition rates in all of the studies, and low in two due to imprecision.

Conclusion

Based on the meta-analysis and GRADE assessments, the use of L. rhamnosus with or without other probiotics appears to have a positive effect in reducing the incidence of atopic eczema in pediatric patients at least out to 7 years. Attrition rates temper these findings.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40257-022-00723-x.

Probiotics for the prevention of atopic dermatitis in infants from different geographic regions: a systematic review and meta-analysis

BackgroundAtopic dermatitis (AD) is a common skin disease during infancy, but the preventive effect of probiotics on AD remains unclear.AimTo evaluate the efficacy of probiotic supplementation for the prevention of AD in infants.MethodsPubMed, Cochrane Library, and Embase databases were reviewed for relevant randomized controlled trials (RCTs). Two authors independently extracted the data. The primary endpoint was the risk of AD in infants. Risk ratio (RR) and 95% confidence interval (CI) were calculated.ResultsA total of 20 related articles including 22 studies were included. A significant reduction in AD risk was revealed for the probiotic group compared to the control group (RR 0.76; 95% CI 0.67-0.87). Subgroup analyses by participant receiving intervention revealed that not only probiotics given to mother (RR 0.70; 95% CI 0.57-0.85) or given to mother and infant (RR 0.76; 95% CI 0.61-0.95) were effective in preventing AD in infants, and probiotics given to infants alone (RR 0.76; 95% CI 0.60-0.96) still effectively decreased the risk of AD.ConclusionProbiotic supplementation reduced the risk of developing AD in infants. Furthermore, probiotic supplementation given to mother or to mother and infant could effectively prevent AD in infants.

The effect of probiotics on the clinical status of adult patients with atopic dermatitis: a systematic review

OBJECTIVES

To describe, through a literature review, the results and benefits of oral and topical probiotics for adult patients with atopic dermatitis.

DESIGN

A systematic review of articles published over a 13-year period was conducted to answer the following questions: (1) what information is given in the scientific literature concerning the use of probiotics in adult patients with atopic dermatitis? (2) Was there an improvement in the clinical status of the patients? (3) Was there a change in the microbial profile in patients after using such approaches? (4) Among the probiotics used, which was the most used in adult AD patients? (5) What was the average time of these interventions? (6) What were the outcomes?

RESULTS

Seven studies with different sample sizes, ranging from 16 to 109 patients, were included in this review. These studies were all clinical trials (7/7), and probiotics (7/7) was the model of intervention chosen. Probiotics showed a potential to relieve the symptoms of the study groups with a reduction of pruritus and SCORAD when compared to the placebo groups. However, their effectiveness varied according to the strain, period, and form of administration.

CONCLUSIONS

Many studies have demonstrated that probiotics improve the symptoms of atopic dermatitis and even its prevention. However, there is still much controversy and divergence concerning the real benefits. Despite this, probiotics have demonstrated a fair ability in improving AD adult patients' symptoms in terms of decreasing pruritus and severity related to SCORAD.

Manipulating Microbiota to Treat Atopic Dermatitis: Functions and Therapies

Atopic dermatitis (AD) is a globally prevalent skin inflammation with a particular impact on children. Current therapies for AD are challenged by the limited armamentarium and the high heterogeneity of the disease. A novel promising therapeutic target for AD is the microbiota. Numerous studies have highlighted the involvement of the skin and gut microbiota in the pathogenesis of AD. The resident microbiota at these two epithelial tissues can modulate skin barrier functions and host immune responses, thus regulating AD progression. For example, the pathogenic roles of Staphylococcus aureus in the skin are well-established, making this bacterium an attractive target for AD treatment. Targeting the gut microbiota is another therapeutic strategy for AD. Multiple oral supplements with prebiotics, probiotics, postbiotics, and synbiotics have demonstrated promising efficacy in both AD prevention and treatment. In this review, we summarize the association of microbiota dysbiosis in both the skin and gut with AD, and the current knowledge of the functions of commensal microbiota in AD pathogenesis. Furthermore, we discuss the existing therapies in manipulating both the skin and gut commensal microbiota to prevent or treat AD. We also propose potential novel therapies based on the cutting-edge progress in this area.

Probiotics Function in Preventing Atopic Dermatitis in Children

Atopic dermatitis (AD) is a chronic inflammatory skin disorder characterized by relapsing eczematous injuries and severe pruritus. In the last few years, the AD prevalence has been increasing, reaching 20% in children and 10% in adults in high-income countries. Recently, the potential role of probiotics in AD prevention has generated considerable interest. As many clinical studies show, the gut microbiota is able to modulate systemic inflammatory and immune responses influencing the development of sensitization and allergy. Probiotics are used increasingly against AD. However, the molecular mechanisms underlying the probiotics mediated anti-allergic effect remain unclear and there is controversy about their efficacy. In this narrative review, we examine the actual evidence on the effect of probiotic supplementation for AD prevention in the pediatric population, discussing also the potential biological mechanisms of action in this regard.

Targeting therapeutic approaches and highlighting the potential role of nanotechnology in atopic dermatitis

Atopic dermatitis is a chronic as well as widespread skin disease which has significant influence on the life attributes of affected people and their families. Systemic immunosuppressive drugs can be utilised for effective care of disease, although they are often prescribed for rigorous disruption or disease that is complicated to manage. Therefore, topical applications of corticosteroids are considered the primary pharmacologic therapies for atopic dermatitis, and research recommends that these medications might be helpful in preventing disease flare-ups. However, topical medicine administration to deeper layers of skin is challenging because of the skin anatomic barrier that restricts deeper drug permeation, and also due to barrier function abnormalities in atopic dermatitis skin, which might result in systemic drug absorption, provoking systemic consequences. Hence, effective management of atopic dermatitis needs new, effective, safe and targeted treatments. Therefore, nanotechnology-based topical therapeutics have attracted much interest nowadays because of their tendency to increase drug diffusion and bioavailability along with enormous drug targeting potential to affected cells, and, thereby, reducing the adverse effects of medications. In this review, we mention different symptoms of atopic dermatitis, and provide an overview of the different triggering factors causing atopic dermatitis, with emphasis on its epidemiology, pathophysiology, clinical features and diagnostic, and preventive measures. This review discusses existing therapeutics for treating atopic dermatitis, and the newer approaches as well as the current classical pharmacotherapy of atopic dermatitis against new nanoparticle skin delivery systems. This review has also briefly summarised the recent patents and clinical status of therapeutic modalities for atopic dermatitis.

Probiotics Properties: A Focus on Pregnancy Outcomes

A healthy microbiome plays an important role in the prevention of illness and maintenance of overall health, including reproductive health. Although the therapeutic advantages of probiotics have been shown to run across multiple organ systems, their role in pregnancy is not well explored. The aim of this review is to highlight the potential advantages and adverse effects of probiotics in pregnancy. Data were collected from the literature over the past decade using PubMed, Medline, Google Scholar, Ovid, Scopus, and Science Direct. A total of 40 articles were utilized in this review. Collected data indicated that prenatal and post-natal supplementation with lactobacilli alone or lactobacilli with Bifidobacterium spp. seems to be protective. Probiotics may improve insulin resistance and consequently reduce the risk of gestational diabetes. Probiotics may also reduce anxiety and depression by influencing brain activity. Additionally, they interfere with vaginal flora to make it friendlier to beneficial bacteria, and enhance anti-inflammatory or reduce pro-inflammatory cytokines. They may also decrease eczema in breastfed infants and prevent allergic reactions by downregulating Th2 responses to specific allergens from mid to late gestation. Leveraging the cervicovaginal microbiota could promote a number of positive pregnancy-related health outcomes. Caution should be exercised in the selection, dosing, and monitoring of probiotics administration. More comprehensive randomized clinical trials are needed to reach a more meaningful evidence-based clinical knowledge.

Intestinal dysbiosis featuring abundance of Streptococcus associates with Henoch-Schönlein purpura nephritis (IgA vasculitis with nephritis) in adult

Background

The pathogenesis of Henoch-Schönlein purpura nephritis (HSPN) is closely associated with mucosal infection. But whether intestinal microbiota dysbiosis plays a role in it is not clear.

Methods

A total of 52 participants including 26 HSPN patients and 26 healthy controls were included. By using 16S ribosomal RNA gene sequencing, the intestinal microbiota composition between HSPN and healthy controls was compared. The diagnostic potency was evaluated by Receiver operating characteristic (ROC) with area under curves (AUC). Meanwhile, correlation analysis was also performed.

Results

The lower community richness and diversity of fecal microbiota was displayed in HSPN patients and the structure of gut microbiota was remarkedly different. A genus-level comparison indicated a significant increase in the proportions of g-Bacteroides, g-Escherichia–Shigella and g-Streptococcus, and a marked reduction of g-Prevotella_9 in HSPN patients, suggesting that the overrepresentation of potential pathogens and reduction of profitable strains were the main feature of the dysbiosis. The differential taxonomic abundance might make sense for distinguishing HSPN from healthy controls, with AUC of 0.86. The relative abundance of the differential bacteria was also concerned with clinical indices. Among them, Streptococcus spp. was positively associated with the severity of HSPN (P < 0.050). It was found that HSPN patients with higher level of Streptococcus spp. were more likely to suffering from hematuria and hypoalbuminemia (P < 0.050).

Conclusions

The dysbiosis of gut microbiota was obvious in HSPN patients, and the intestinal mucosal streptococcal infection was distinctive, which was closely related to its severity.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12882-021-02638-x.

Clinical outcomes following pre-, pro- and synbiotic supplementation after caesarean birth or antibiotic exposure in the first week of life in term born infants: A systematic review of the literature

BACKGROUND

Caesarean section and early exposure to antibiotics disrupt the developing gastrointestinal microbiome, which is associated with long-term health effects.

OBJECTIVE

The aim of this systematic review was to summarise the impact of prebiotics, probiotics, or synbiotics supplementation on clinical health outcomes of term infants born by caesarean section or exposed to antibiotics in the first week of life.

DESIGN

A systematic search was performed in Medline and Embase from inception to August 2021. Title and abstract screening (n = 11,248), full text screening (n = 48), and quality assessment were performed independently by two researchers.

RESULTS

Six RCTs studying caesarean born infants were included, group sizes varied between 32-193 with in total 752 children. No studies regarding supplementation after neonatal antibiotic exposure were found. Three studies administered a probiotic, one a prebiotic, one a synbiotic, and one study investigated a prebiotic and synbiotic. Several significant effects were reported at follow-up varying between 10 days and 13 years: a decrease in atopic diseases (n = 2 studies), higher immune response to tetanus and polio vaccinations (n = 2), lower response to influenza vaccination (n = 1), fewer infectious diseases (n = 2), and less infantile colic (n = 1), although results were inconsistent.

CONCLUSIONS

Supplementation of caesarean-born infants with prebiotics, probiotics, or synbiotics resulted in significant improvements in some health outcomes as well as vaccination responses. Due to the variety of studied products and the paucity of studies, no recommendations can be given yet on the routine application of prebiotics, probiotics, or synbiotics to improve health outcomes after caesarean section or neonatal antibiotic exposure.

Atopic dermatitis: Current standards of diagnosis and treatment, including the latest methods of management

Atopic dermatitis (AD) is a chronic relapsing disease which causes characteristic eczematous skin lesions. The most common symptoms of atopic dermatitis are persistent pruritus, xerosis, and skin lesions with a typical location and appearance that changes with the patient’s age. The prevalence of the disease in the pediatric population is estimated at 10% to 30%, while in adults it ranges from 1% to 3%. The number of people who suffer from AD is rising every year. The pathophysiology of the disease is complex and multifactorial. It involves elements of epidermal barrier dysfunction, alterations in cellular immune response, IgE hypersensitivity, and environmental factors. AD significantly reduces the quality of life of both patients and their families. Patients with AD are at higher risk for neuropsychiatric disorders such as depression, attention-deficit/hyperactivity disorder, and headaches. The decreased quality of life of AD patients and their families is associated with the discomfort of recurrent and chronic inflammatory skin lesions, persistent pruritus, and the inconvenience of long-term therapy. It also affects the psychological development of children, contributes to behavioral disorders (hyperactivity, hypersensitivity) and impacts many areas of family life such as sleep, leisure activities, and relationships between family members. The basic treatment of AD is avoidance of potential harmful factors, proper care in the treatment of exacerbations, topical corticosteroids, and calcineurin inhibitors in proactive therapy. In some patients who meet age criteria, phototherapy and cyclosporine should be considered. In individuals with severe AD who do not respond to topical treatment and who will not benefit from general therapy, dupilumab, a biologic drug, is the treatment of choice. Biologic treatment has an increasingly important place in the effective and modern therapy of AD. Currently, new biologic drugs are being researched, which may bring a therapeutic revolution in AD in the future. Allergen immunotherapy in patients with AD should be carefully evaluated on an individual basis, as proper selection of patients with documented IgE-dependent sensitization is important for the success of this therapy. Close collaboration with the patient and their caregivers, education, and psychological support as appropriate are integral to the treatment.

A New Formulation of Probiotics Attenuates Calcipotriol-Induced Dermatitis by Inducing Regulatory Dendritic Cells

Atopic dermatitis (AD) is a recurrent chronic inflammatory skin disease affecting up to 30% of the children population, and immuno-regulatory therapy that could modify the course of disease is urgently needed. Probiotics have demonstrated therapeutic effects on AD and could potentially regulate the disease process. However, the efficacy of probiotics for AD is inconsistent among different studies, which is mainly due to the elusive mechanism and different species and (or) strains used. In this study, we designed a mixture of five strains of probiotics (named IW5) and analyzed the effect and mechanism of IW5 on calcipotriol (MC903)-induced AD-like dermatitis. We found that IW5 significantly alleviated skin inflammation of the MC903-induced AD in mice. Administration with IW5 induced increased production of regulatory T cells and regulatory dendritic cells (DCregs) in the mesenteric lymph nodes. We also found that the diversity of the gut microbiota in the mice with MC903-induced dermatitis was increased after IW5 administration, and the level of butyrate in the gut was elevated. In cell culture, butyrate induced the production of DCregs. Our study revealed the therapeutic effects of a newly designed probiotics mixture and uncovered a possible mechanism, providing a foundation for future clinical studies.

What are the highest yielding search strategy terms for systematic reviews in atopic dermatitis? A systematic review

The impact of search strategies on systematic reviews (SR) of atopic dermatitis (AD) is unknown. The purpose of this review was to evaluate search strategies used in SR of AD and their impact on the frequency of manuscripts identified. MEDLINE and EMBASE were searched for SR related to AD. Simulations were performed by running combinations of search terms in MEDLINE and EMBASE. Overall, 250 SR met inclusion criteria, of which 225 specified search strategies. SR using 5-6 terms (20.0% to 12.1%) or ≥ 7 (40.0% to 18.8%) terms decreased, whereas SR using 3-4 terms numerically increased (18.8% to 30.2%) and 1-2 terms remained similar (37.5% to 38.9%) from 1999-2009 to 2015-2019. The most commonly searched terms were "atopic dermatitis" (n = 166), followed by "eczema" (n = 156), "dermatitis atopic'" (n = 81), "atopic eczema" (n = 74), "neurodermatitis" (n = 59), "Besniers prurigo" (n = 29), "infantile eczema" (n = 27), and "childhood eczema" (n = 19). Simulations revealed that "eczema" and "atopic dermatitis" yielded the most hits. The number of search terms that maximized hits in MEDLINE and EMBASE was 5 and 4, respectively. Search strategies for AD were heterogeneous, with high proportions of search strategies providing few search hits. Future studies should use standardized and optimized search terms.

Atopic dermatitis and nutrition

Atopic dermatitis, a common chronic and pruritic inflammatory skin disorder, can create significant disruptions in sleep and quality of life. Atopic dermatitis is especially common in infants and children; therefore, safe and natural therapeutic options have considerable appeal. Over the past several decades, there has been an increase in the prevalence of atopic dermatitis in industrialized nations. Also, there is variability in the prevalence of atopic dermatitis in the United States, both across and within states. Environmental factors including diet are believed to be associated with this increased risk. Dietary interventions continue to be an area of keen interest and have been studied extensively, albeit with variable results. Maternal dietary restrictions during pregnancy and lactation, hydrolyzed or partially hydrolyzed formulas, delaying the introduction of solid foods, and omega-3 or omega-6 fatty acids supplementation do not appear to have a beneficial effect on the treatment and prevention of atopic dermatitis. Exclusive breastfeeding for 3 to 4 months, a diet high in fruits and vegetables, and prebiotics might have a beneficial effect. Because environmental triggers, including dietary exposures, are thought to play a role in the pathogenesis of atopic dermatitis, we herein review the current literature on the role of dietary habits, vitamin and mineral supplementation, and probiotics on the treatment and prevention of atopic dermatitis.

Comparative effectiveness of probiotic strains on the prevention of pediatric atopic dermatitis: A systematic review and network meta-analysis

BACKGROUND

Atopic dermatitis is the most common chronic skin disease affecting the pediatric population. Probiotics have been proposed to be effective in preventing the development of pediatric atopic dermatitis. Although studies show promise for the use of probiotics, the evidence is still inconclusive due to significant heterogeneity and imprecision.

OBJECTIVE

To determine the comparative effectiveness of the different types of probiotic strains in preventing the development of atopic dermatitis among pediatric patients.

METHODOLOGY

A systematic search of Cochrane Library, MEDLINE, TRIP Database, and Centre for Research and Dissemination was conducted. Manual search of the reference lists and search for unpublished articles were also done. All randomized controlled trials available from inception until April 12, 2020, on the use of probiotics in the prevention of atopic dermatitis among children were included. The comparator groups considered are other probiotic strains and placebo. The primary outcome of interest was the development of atopic dermatitis. Two authors independently searched for articles, screened the articles for inclusion, appraised the articles using the Cochrane risk of bias tool version 2, and extracted the data. In case of disagreement, the two authors discussed the source of disagreement until consensus was reached. If consensus was not reached, an independent third party reviewer was consulted. Frequentist network meta-analysis was conducted using STATA 14 software. The ranking probabilities and surface under the cumulative ranking curve (SUCRA) values were obtained to determine ranking of the different probiotic strains based on efficacy and safety data.

RESULTS

We included 21 original studies represented by 35 records and a total of 5406 children with atopic dermatitis as diagnosed by clinicians or fulfillment of validated diagnostic criteria. All studies were randomized placebo-controlled trials. The top 3 probiotic preparations in terms of efficacy in reducing the risk of atopic dermatitis are Mix8 (Lactobacillus paracasei ST11, Bifidobacterium longum BL999), LP (Lactobacillus paracasei ssp paracasei F19) and Mix3 (Lactobacillus rhamnosus GG, Bifidobacterium animalis ssp lactis Bb-12). Mix8 compared with placebo probably reduces the risk of atopic dermatitis based on low-quality evidence (RR = 0.46, 95% CI 0.25-0.85). Mix3 compared with placebo also probably reduces the risk of atopic dermatitis based on low-quality evidence (RR = 0.50, 95% CI 0.27-0.94). It is uncertain whether LP compared with placebo reduces the risk of atopic dermatitis due to very-low-quality certainty of evidence (RR = 0.49, 95% CI 0.20-1.19). In terms of adverse events, LGG may slightly lead to less adverse events compared with placebo based on low-quality evidence (RR = 0.70, 95% CI 0.32-1.52). Mix4 may slightly lead to more adverse events compared with placebo based on low-quality evidence (RR = 1.06, 95% CI 0.02-51.88). Based on subgroup analysis of studies involving infants, Mix3 compared with placebo probably reduces the risk of atopic dermatitis based on low-quality evidence (RR = 0.46, 95% CI 0.22-0.97). In the subgroup analysis of studies where probiotics were administered to pregnant women and to infants, LRH compared with placebo probably reduces the risk of atopic dermatitis based on moderate-quality evidence (RR = 0.54, 95% CI 0.26-1.11).

CONCLUSION

Certain probiotic preparations demonstrate efficacy in reducing the risk of developing atopic dermatitis when administered to pregnant women, infants, or both.

Current Insights into Immunology and Novel Therapeutics of Atopic Dermatitis

Atopic dermatitis (AD) is one of the most prevalent inflammatory disease among non-fatal skin diseases, affecting up to one fifth of the population in developed countries. AD is characterized by recurrent pruritic and localized eczema with seasonal fluctuations. AD initializes the phenomenon of atopic march, during which infant AD patients are predisposed to progressive secondary allergies such as allergic rhinitis, asthma, and food allergies. The pathophysiology of AD is complex; onset of the disease is caused by several factors, including strong genetic predisposition, disrupted epidermal barrier, and immune dysregulation. AD was initially characterized by defects in the innate immune system and a vigorous skewed adaptive Th2 response to environmental agents; there are compelling evidences that the disorder involves multiple immune pathways. Symptomatic palliative treatment is the only strategy to manage the disease and restore skin integrity. Researchers are trying to more precisely define the contribution of different AD genotypes and elucidate the role of various immune axes. In this review, we have summarized the current knowledge about the roles of innate and adaptive immune responsive cells in AD. In addition, current and novel treatment strategies for the management of AD are comprehensively described, including some ongoing clinical trials and promising therapeutic agents. This information will provide an asset towards identifying personalized targets for better therapeutic outcomes.

The evidence for interventions in early childhood allergy prevention - towards a living systematic review: protocol

Background: Research in early childhood allergy prevention (ECAP) is flourishing and new intervention strategies have proven to be promising. Due to the dynamic nature of ECAP, gaps between what is known and how guidelines inform practice are likely. A living systematic review (LSR) can narrow this gap by incorporating new evidence as it becomes available. No efficacy comparisons across various ECAP interventions for similar outcomes have been carried out. Networks of randomised clinical trials can be evaluated in the context of a network meta-analysis (NMA). We aim to establish a LSR on the efficacy and safety of any intervention investigated in randomised controlled trials (RCT) to prevent the occurrence of allergic sensitisation (AS), symptoms or diagnoses of allergic diseases in infancy and early childhood (0-3 years). Methods: A baseline SR will synthesise the evidence from existing SRs of RCTs as well as RCTs not yet considered in these. After completion of the baseline SR we propose to conduct a LSR. Using this methodology, we aim to undertake constant evidence surveillance, three-monthly search updates, and review updates every three months, should new evidence emerge. Conclusions: The ECAP evidence landscape has undergone dramatic transformations and this process is likely to continue. As a response to this, a LSR offers the potential to allow more timely synthesis of new evidence as it emerges. Long gaps between updates of SRs makes it harder for guidelines and recommendations to be up to date. Users of information, such as parents, may be confused if they encounter new evidence that is not part of a trusted guideline. A LSR approach allows us to continuously search the literature and update the evidence-base of existing ECAP interventions resulting in a decreased timespan from evidence accrual to informing clinical practice.

The evidence for interventions in early childhood allergy prevention - towards a living systematic review: protocol

Background: Research in early childhood allergy prevention (ECAP) is flourishing and new intervention strategies have proven to be promising. Due to the dynamic nature of ECAP, gaps between what is known and how guidelines inform practice are likely. A living systematic review (LSR) can narrow this gap by incorporating new evidence as it becomes available. No efficacy comparisons across various ECAP interventions for similar outcomes have been carried out. Networks of randomised clinical trials can be evaluated in the context of a network meta-analysis (NMA). We aim to establish a LSR on the efficacy and safety of any intervention investigated in randomised controlled trials (RCT) to prevent the occurrence of allergic sensitisation (AS), symptoms or diagnoses of allergic diseases in infancy and early childhood (0-3 years). Methods: A baseline SR will synthesise the evidence from existing SRs of RCTs as well as RCTs not yet considered in these. After completion of the baseline SR we propose to conduct a LSR. Using this methodology, we aim to undertake constant evidence surveillance, three-monthly search updates, and review updates every three months, should new evidence emerge. Conclusions: The ECAP evidence landscape has undergone dramatic transformations and this process is likely to continue. As a response to this, a LSR offers the potential to allow more timely synthesis of new evidence as it emerges. Long gaps between updates of SRs makes it harder for guidelines and recommendations to be up to date. Users of information, such as parents, may be confused if they encounter new evidence that is not part of a trusted guideline. A LSR approach allows us to continuously search the literature and update the evidence-base of existing ECAP interventions resulting in a decreased timespan from evidence accrual to informing clinical practice.

Mothers' knowledge, attitudes and practices regarding probiotic use during pregnancy and for their infants in Turkey

OBJECTIVE

The current study was conducted to determine mothers' knowledge, attitudes and practices regarding probiotic use during pregnancy and for infants between 6 months and 2 years old.

DESIGN

The study had a cross-sectional design, and the data were collected using a Socio-demographic Information Form and a Probiotic Information and Attitude Form. The data were evaluated using frequency, percentage and χ2 tests.

SETTING

Two hospitals of one province in the central Black Sea Region, Turkey.

PARTICIPANTS

519 mothers with infants between 6 months and 2 years old who had been hospitalised in paediatric clinics participated in the study.

RESULTS

20·2 % of the mothers knew what a probiotic was, 33·1 % of them had knowledge of specific probiotic products and 49·7 % of them knew that breast milk contains probiotics. A statistically significant difference was found between mothers' knowledge of probiotics and probiotic products, and their ages, education, employment, income, family structure and whether they were actively breast-feeding (P < 0·05). A statistically significant difference was found between the mothers' knowledge that breast milk contains probiotics and their ages, education, employment, income, family structure, age of children and actively breast-feeding (P < 0·05).

CONCLUSION

The study found that the mothers' knowledge and practices regarding probiotics were inadequate, and that they traditionally used natural products in their daily lives. Evidence-based educational activities should be designed which include information about the definition of probiotics, and their benefits and disadvantages for mothers. Further studies are needed to determine the knowledge and attitudes of health professionals regarding the use of probiotics by mothers with infants and pregnant women.

Effect of probiotics on thymus size and markers of infection in late infancy: a randomized controlled trial

BACKGROUND

Probiotics are known to stimulate the immune system but the effect on thymus size in late infancy is unknown. We examined the effect of probiotics on thymus size and C-reactive protein (CRP) in healthy Danish infants starting daycare. We further examined associations between thymus size, CRP and recent infections.

METHODS

The study included 186 children randomized to a combination of Lactobacillus rhamnosus, LGG® and Bifidobacterium animalis spp. lactis, BB-12® or placebo for 6 months. Thymus size, assessed as thymus index (TI) and thymus weight index (TWI), was measured by ultrasound at baseline and at endpoint. Blood samples were drawn to measure CRP. Infections were parent-reported.

RESULTS

There was no significant difference in thymus size between the probiotic group and placebo (p ≥ 0.248) but TWI tended to be higher in the probiotic group corresponding to 5% higher than placebo (p = 0.068) in an adjusted model. There was no effect of probiotics on CRP (p = 0.331). At the endpoint, thymus size was inversely associated with CRP (p ≤ 0.040), diarrhea (p ≤ 0.050), and TI was also associated with the absence from daycare due to respiratory or gastrointestinal infections (p = 0.010).

CONCLUSION

The probiotic intervention had no effect on thymus size or CRP in Danish children at the age of starting daycare.

IMPACT

Overall there was no effect on thymus size of a combination of Lactobacillus rhamnosus, LGG® and Bifidobacterium animalis spp. lactis, BB-12® administered to Danish children starting daycare. This study examines the effect of probiotics on thymus size in healthy children when they start daycare thus exposed for infections while their immune system is still developing. This has to our knowledge not been described before. We found no significant difference in thymus size between the probiotic and placebo groups, but for thymus weight index, there was a trend. This should be investigated further in studies designed for this as primary outcome.

Revisiting the Hygiene Hypothesis in the Context of Autoimmunity

Initially described for allergic diseases, the hygiene hypothesis was extended to autoimmune diseases in the early 2000s. A historical overview allows appreciation of the development of this concept over the last two decades and its discussion in the context of evolution. While the epidemiological data are convergent, with a few exceptions, the underlying mechanisms are multiple and complex. A major question is to determine what is the respective role of pathogens, bacteria, viruses, and parasites, versus commensals. The role of the intestinal microbiota has elicited much interest, but is it a cause or a consequence of autoimmune-mediated inflammation? Our hypothesis is that both pathogens and commensals intervene. Another question is to dissect what are the underlying cellular and molecular mechanisms. The role of immunoregulatory cytokines, in particular interleukin-10 and TGF beta is probably essential. An important place should also be given to ligands of innate immunity receptors present in bacteria, viruses or parasites acting independently of their immunogenicity. The role of Toll-Like Receptor (TLR) ligands is well documented including via TLR ligand desensitization.

BCG immunomodulation: From the 'hygiene hypothesis' to COVID-19

The century-old tuberculosis vaccine BCG has been the focus of renewed interest due to its well-documented ability to protect against various non-TB pathogens. Much of these broad spectrum protective effects are attributed to trained immunity, the epigenetic and metabolic reprogramming of innate immune cells. As BCG vaccine is safe, cheap, widely available, amendable to use as a recombinant vector, and immunogenic, it has immense potential for use as an immunotherapeutic agent for various conditions including autoimmune, allergic, neurodegenerative, and neoplastic diseases as well as a preventive measure against infectious agents. Of particular interest is the use of BCG vaccination to counteract the increasing prevalence of autoimmune and allergic conditions in industrialized countries attributable to reduced infectious burden as described by the 'hygiene hypothesis.' Furthermore, BCG vaccination has been proposed as a potential therapy to mitigate spread and disease burden of COVID-19 as a bridge to development of a specific vaccine and recombinant BCG expression vectors may prove useful for the introduction of SARS-CoV-2 antigens (rBCG-SARS-CoV-2) to induce long-term immunity. Understanding the immunomodulatory effects of BCG vaccine in these disease contexts is therefore critical. To that end, we review here BCG-induced immunomodulation focusing specifically on BCG-induced trained immunity and how it relates to the 'hygiene hypothesis' and COVID-19.

Brief Academic Review and Clinical Practice Guidelines for Pediatric Atopic Dermatitis

In this clinical guidelines article, we first include a brief review of the epidemiology, pathogenesis, clinical diagnoses, and scoring-scales for pediatric atopic dermatitis (AD). We then offer a set of pharmacologic treatment guidelines for infants and toddlers (<2 years), children (2-12 years), and adolescents (>12 years). We recommend irritant avoidance and liberal emollient usage as the cornerstone of treatment in all age-groups. In infants <2 years, we recommend topical corticosteroids as first-line medication-based therapy. In infants as young as 3 months, pimecrolimus, a topical calcineurin inhibitor, may also be used. As a last resort in patients <2 years, non-traditional therapies, such as the Aron regime, may be a safer option for refractory or resistant AD before off- label medications are considered. In children and adolescents >2 years, topical corticosteroids are still considered first-line therapies, but there is sufficient safety data to utilize topical calcineurin inhibitors and topical PDE4 inhibitors as well. In children ages 2-12 years whose atopic dermatitis fails to respond to prior treatments, oral systemic immunosuppressants can be used. For adolescents >12, the biologic, dupilumab, is an additional therapeutic option. A trial of phototherapy may also be utilized in children, particularly in adolescents >12 years, if they have access to treatment. Although not currently approved for the treatment of AD, Janus-kinase (JAK) inhibitors represent a promising new class of biologics with recently completed phase III clinical trials (JADE-- MONO1/2).

Allergy Prevention: An Overview of Current Evidence

Background: There has been a rapid rise in allergic disorders across the globe. This has increased research into the determinants of allergy development, to identify factors that may be manipulated to mitigate risk. An opportune window in immunological development appears to exist in early life whereby certain exposures may promote or prevent the development of an allergic disposition. Furthermore, factors that affect the composition and diversity of the microbiome in early life have been explored. In this review, we discuss current literature and recommendations relating to exposures that may prevent allergy development or promote tolerance. Risk factors and recommendations: Delivery by caesarean section, omission of breastfeeding, vitamin D insufficiency, and environmental exposures, such as cigarette smoke exposure, all increase the risk of an allergic predisposition. Dietary diversity during pregnancy, lactation, and in infancy is protective. Breastfeeding for at least 4 months reduces the risk of eczema. Recommendations for food-allergen exposure has shifted from delayed introduction to early introduction as a tolerance-inducing strategy. Supplements such as probiotics and vitamins during pregnancy and infancy have yet to produce conclusive results for allergy prevention. Emollient use in infancy has not been shown to be protective against eczema or food allergy.

Dietary factors during pregnancy and atopic outcomes in childhood: A systematic review from the European Academy of Allergy and Clinical Immunology

RATIONALE

Allergic diseases are an increasing public health concern, and early life environment is critical to immune development. Maternal diet during pregnancy has been linked to offspring allergy risk. In turn, maternal diet is a potentially modifiable factor, which could be targeted as an allergy prevention strategy. In this systematic review, we focused on non-allergen-specific modifying factors of the maternal diet in pregnancy on allergy outcomes in their offspring.

METHODS

We undertook a systematic review of studies investigating the association between maternal diet during pregnancy and allergic outcomes (asthma/wheeze, hay fever/allergic rhinitis/seasonal allergies, eczema/atopic dermatitis (AD), food allergies, and allergic sensitization) in offspring. Studies evaluating the effect of food allergen intake were excluded. We searched three bibliographic databases (MEDLINE, EMBASE, and Web of Science) through February 26, 2019. Evidence was critically appraised using modified versions of the Cochrane Collaboration Risk of Bias tool for intervention trials and the National Institute for Clinical Excellence methodological checklist for cohort and case-control studies and meta-analysis performed from RCTs.

RESULTS

We identified 95 papers: 17 RCTs and 78 observational (case-control, cross-sectional, and cohort) studies. Observational studies varied in design and dietary intakes and often had contradictory findings. Based on our meta-analysis, RCTs showed that vitamin D supplementation (OR: 0.72; 95% CI: 0.56-0.92) is associated with a reduced risk of wheeze/asthma. A positive trend for omega-3 fatty acids was observed for asthma/wheeze, but this did not reach statistical significance (OR: 0.70; 95% CI: 0.45-1.08). Omega-3 supplementation was also associated with a non-significant decreased risk of allergic rhinitis (OR: 0.76; 95% CI: 0.56-1.04). Neither vitamin D nor omega-3 fatty acids were associated with an altered risk of AD or food allergy.

CONCLUSIONS

Prenatal supplementation with vitamin D may have beneficial effects for prevention of asthma. Additional nutritional factors seem to be required for modulating the risk of skin and gastrointestinal outcomes. We found no consistent evidence regarding other dietary factors, perhaps due to differences in study design and host features that were not considered. While confirmatory studies are required, there is also a need for performing RCTs beyond single nutrients/foods.

The Role of Probiotics in the Prevention and Treatment of Atopic Dermatitis in Children: An Updated Systematic Review and Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Atopic dermatitis (AD) is a chronic inflammatory skin disease common among infants and children. It is associated with a high risk of allergies, asthma, and mental health problems. Attempts have been made to use probiotics in clinical interventions for AD.

OBJECTIVE

Our objective was to perform an updated meta-analysis of recently published studies to evaluate the effect of probiotics in the prevention and treatment of AD in children and to further understand the role of probiotics in AD interventions in the clinic.

METHOD

We searched the PubMed/MEDLINE, Embase, Cochrane Central Register of Controlled Trials, China National Knowledge Infrastructure, and Wanfang databases with prespecified selection criteria from inception of each database to 11 January 2020. No language restrictions were applied.

RESULTS

A total of 25 studies were included in our meta-analysis. Of these, 14 were prevention studies (with 3049 children enrolled) and 11 were treatment studies (with 816 children enrolled). One treatment study was excluded after the sensitivity analysis. From the 14 prevention studies included, the pooled relative risk ratio of AD in those treated with probiotics versus placebo was 0.70 [95% confidence interval (CI) 0.57-0.84; P = 0.0002]. Subgroup analyses showed that only mixed strains of probiotics had a significant effect on lowering the incidence of AD. Probiotics administered solely to infants did not prevent the development of AD, but effects were significant when probiotics were administered to both pregnant mothers and their infants or solely to pregnant mothers. In studies with treatment durations > 6 months, the incidence of AD decreased significantly; a similar effect was achieved when the treatment duration was < 6 months. Meta-analysis of the ten treatment studies showed a significant decrease in the weighted mean difference (WMD) in Scoring Atopic Dermatitis (SCORAD) index values in the probiotics group compared with the control group (WMD, - 7.23; 95% CI - 10.59 to - 3.88; P < 0.0001). Subgroup analyses showed that both single-strain and mixed-strain probiotics had a significant effect on improving SCORAD values. Studies with participants aged < 1 year (P = 0.07) reported no significant results. In studies with treatment periods > 8 weeks, SCORAD values seemed to decrease more than in studies with treatment periods < 8 weeks. However, the subgroup difference was only statistically significant when the analysis was performed according to participant age in prevention studies.

CONCLUSION

Our updated meta-analysis demonstrates that interventions with probiotics potentially lower the incidence of AD and relieve AD symptoms in children, particularly when treating infants and children aged ≥ 1 year with AD. Interventions with mixed-strain probiotics tended to have better preventive and curative effects. Probiotics administered solely to infants appeared to produce negative preventive effects. Different intervention durations might also affect clinical outcomes. However, given the insignificant subgroup differences, except for treatment by participant age, and the moderate heterogeneity among the studies, these conclusions should be interpreted with caution, and more powerful randomized controlled trials using standardized measurements should be conducted to assess the long-term effects of probiotics.

Safety of Probiotics: Functional Fruit Beverages and Nutraceuticals

Over the last decade, fruit juice consumption has increased. Their rise in popularity can be attributed to the belief that they are a quick way to consuming a dietary portion of fruit. Probiotics added to fruit juices produce various bioactive compounds, thus probiotic fruit juices can be considered as a new type of functional foods. Such combinations could improve nutritional properties and provide health benefits of fruit juices, due to delivering positive health attributes from both sources (fruit juices and probiotics). However, this review discusses the other side of the same coin, i.e., the one that challenges general beliefs that probiotics are undoubtedly safe. This topic deserves more acknowledgments from the medical and nutritional literature, as it is highly important for health care professionals and nutritionists who must be aware of potential probiotic issues. Still, clinical trials have not adequately questioned the safety of probiotics, as they are generally considered safe. Therefore, this reviews aims to give an evidence-based perspective of probiotic safety, focusing on probiotic fruit beverages and nutraceuticals, by providing documented clinical case reports and studies. Finally, the paper deals with some additional insights from the pharmacological and toxicological point of views, such as pharmacological repercussions of probiotics on health.

The effect of multistrain synbiotic and vitamin D3 supplements on the severity of atopic dermatitis among infants under 1 year of age: a double-blind, randomized clinical trial study

Background: Atopic dermatitis (AD) is the most common chronic and recurrent skin disease during infancy.Objective: This study was aimed at evaluating the effect of synbiotic and vitamin D3 supplements on the severity of AD among infants under 1 year of age.Methods: This double-blind, randomized clinical trial study was conducted on 81 subjects with AD in Sabzevar, Iran in 2018. Subjects were randomly assigned to three groups. Synbiotic group was administered a dose of five drops/day of synbiotic in addition to routine treatment. Vitamin D3 group was administered 1000 units (IU) of vitamin D3 daily in addition to routine treatment. Control group just received routine treatments. The severity of AD was evaluated using SCORing Atopic Dermatitis (SCORAD) at baseline and two months' follow-up.Results: The mean age of subjects was 4.87 ± 3.5 and 59.26% (n = 48) were male. The mean SCOARD scores were substantially decreased in the synbiotic (b_xy: -13.90, 95% CI, -20.99, -6.81; p < .001) and vitamin D3 (b_xy: -12.38, 95% CI, -19.33, -5.43; p = .001) groups as compared to control one by the end of two months.Conclusions: Findings suggest that multistrain synbiotic and vitamin D3 supplements administration along with routine treatments, as complementary therapies, may be effective in reducing the severity of AD in infants.