Guidance on the use of probiotics in clinical practice in children with selected clinical conditions and in specific vulnerable groups

Aim

The use of probiotics has been covered by many guidelines, position papers and evidence‐based recommendations, but few have referred to specific patient groups or clinical indications. This review summarises recommendations and scientifically credited guidelines on the use of probiotics for children with selected clinical conditions and provides practice points.

Methods

An expert panel was convened by the European Paediatric Association in June 2017 to define the relevant clinical questions for using probiotics in paediatric health care and review and summarise the guidelines, recommendations, position papers and high‐quality evidence.

Results

The panel found that specific probiotic strains were effective in preventing antibiotic‐associated and nosocomial diarrhoea, treating acute gastroenteritis and treating infantile colic in breastfed infants. However, special caution is indicated for premature infants, immunocompromised and critically ill patients and those with central venous catheters, cardiac valvular disease and short‐gut syndrome. This review discusses the safety of using probiotics in selected groups of paediatric patients and the quality of the available products providing practice points based on proved findings.

Conclusion

Efficacy of probiotics is strain specific. Their benefits are currently scientifically proven for their use in selected clinical conditions in children and not recommended for certain patient groups.     

Chronic actinic dermatitis treated with cyclosporine-A

Chronic actinic dermatitis (CAD) groups together all chronic photodermatosis with light photosensitivity. We report the case of a 69-year-old man who, for over one year, had presented a reddish-brown erythema and shedding, with thickened and hypo-elastic skin on the face, scalp, neck and on the back of the hands and forearms. Patch tests were positive to isoeugenolo 1% and photo-patch tests showed a positivity to phenotiazine 2%. After a short and ineffective treatment with beta-carotene and photo-protectors, the clinical picture was resolved with the administration of oral steroids but with a relapse of the dermatitis once the dosage was lowered. We therefore started treatment with cyclosporine-A (4.5 mg/kg/die), which resulted in a rapid improvement of the clinical picture, but with a reappearance of the manifestations when the dosage was lowered. The treatment was resumed and we observed that the dose of 1.5/mg/kg/die resulted morbus-static. The patient is still being treated with this drug at this dosage. The result is that the disease is under control and no side effects are present. As we consider CAD an invalidating disease it seems to us that Cy-A could be taken into consideration as an alternative to traditional treatments.     

Gynecomastia in type-1 neurofibromatosis with features of pseudoangiomatous stromal hyperplasia with giant cells. Report of two cases

We describe the histological finding in two cases of gynecomastia in patients with von Recklinghausen's disease. The histological and immunohistochemical features of the two cases were reviewed and compared with those of five cases of gynecomastia in men without clinical evidence of neurofibromatosis. In both patients bearing von Recklinghausen's disease, the breast stroma showed features consistent with pseudoangiomatous stromal hyperplasia (PASH). It was characterised by anastomosing empty spaces lined by spindle and multinucleated giant cells which were positive with CD34 and anti-vimentin antisera and negative with anti-FVIII and CD31 antisera. In two of five of the control cases without neurofibromatosis, the mammary stroma showed focal areas with features of PASH, but no multinucleated giant cells were present in any case. PASH with giant cells should be recognised as a feature of gynecomastia in von Recklinghausen's disease. The presence of multinucleated giant cells is very unusual and, although more cases have to be studied, these cells seem to be a feature of PASH occurring in patients with von Recklinghausen's disease.     

Oxaliplatin/rituximab combination in the treatment of intermediate-low grade non-Hodgkin's lymphoma of elderly patients

High and intermediate grade non-Hodgkin's lymphomas (NHL) require treatments with aggressive chemotherapy schedules. However, low grade NHLs display a low chemoresponsiveness and patients aged >65 years often do not tolerate anthracycline and corticosteroid-containing chemotherapy regimens. Therapeutic options in this subset of patients are watchful waiting, oral alkylating agents, purine nucleoside analogues, combination chemotherapy, interferon and monoclonal antibodies. The approval of rituximab, an unconjugated chimeric antibody against the CD20 antigen for the treatment of B-cell NHL marked a milestone in the development of antibody treatment. Moreover, promising results have also been found with oxaliplatin in patients with NHL and reversible, cumulative, peripheral sensory neuropathy is the principle dose-limiting factor of oxaliplatin therapy. On the basis of these considerations we have performed a feasibility study in NHL in patients aged >65 years using as schedule: 130 mg/m2 oxaliplatin every 21 days and 375 mg/m2 rituximab weekly. We have enrolled 8 patients, 2 males and 6 females (mean age 69.2+/-3.1 years; median, 67 years) affected by intermediate or high grade stage III/IV NHL. Six patients have cardiac abnormalities (myocardial function between 45 and 50%) and 1 increase of transaminasemia due to active chronic hepatitis. All the patients included in the study were treated for at least 3 cycles and 31 cycles were completed. We have recorded grade I/II (CTC) neurotoxicity in 30%, grade I anemia in 25% and grade I neutropenia in 20% of the patients. No infusional reactions, liver or renal toxicity neither nausea and/or vomiting were recorded. One complete response, 3 partial response and 3 minimal response were obtained at 11 months of median time follow-up. These results demonstrate the feasibility of this schedule which offers a suitable alternative regimen to treat elderly patients with NHL and shows a good efficacy and an acceptable toxicity profile.     

Thymus tuberculosis poorly responding to anti-mycobacterial therapy in a young girl with primary infection

Tuberculous infection of the thymus is a rare condition, previously described only in young adults. A case of a young girl with primary pulmonary tuberculosis, hilar and mediastinal lymph node enlargement and a partially necrotic mass in antero-superior mediastinum is described. Treatment with three anti-mycobacterial drugs was started, effective in markedly reducing all the intrathoracic abnormalities with the exception of the antero-superior mediastinal mass. Since the radiographic and ultrasonographic appearance of the thymus tuberculous infection may be indistinguishable from other serious conditions, including lymphoma and thymoma, a diagnostic procedure was performed. Evaluation of the resected specimen showed foci of caseation and multiple granulomas with extensive central necrosis within the thymic tissue.     

Focal nodular hyperplasia in normal and fatty liver: a qualitative and quantitative evaluation with contrast-enhanced ultrasound

The aim of this study was to describe gray-scale appearance of liver parenchyma and focal nodular hyperplasia (FNH) by pulse inversion (PI) ultrasound (US) at baseline and after contrast agent administration in patients with normal and fatty liver. Sixteen consecutive patients (12 women, 4 men) with 29 previously diagnosed FNHs (15 of 29 located in normal liver and 14 of 29 in fatty liver) underwent PI US before and after SH U 508A (Levovist) injection. Signal intensity values were measured within the FNHs and the adjacent liver parenchyma in selected images. Baseline echogenicity of fatty liver was higher (15.19±2.90 dB±SD) than normal liver (10.91±3.15 dB±SD; p<0.001). After Levovist administration, normal livers (7 of 16) showed a statistically significant increase of echogenicity (16.59±3.81 dB±SD; p<0.001) in comparison with fatty livers (9 of 16; 15.75±3.12 dB±SD). The FNHs located in normal liver showed baseline echogenicity higher (12.29±3.22 dB±SD) than that of FNHs arising in fatty liver (7.06±2.43 dB±SD; p<0.001). After Levovist administration, FNHs located in normal liver showed a statistically significant increase of echogenicity (25.30±4.62 dB±SD) in comparison with FNHs located in fatty liver (13.58±3.54 dB±SD; p<0.001); the latter always showed mean values of echogenicity lower than surrounding liver parenchyma. In our series decreased contrast-enhancement pattern of both fatty liver and FNHs located in fatty liver was the most prominent finding when Levovist is administered. Contrast washout was a distinctive feature of FNH arising from the fatty liver.This paper has been accepted for presentation as a scientific paper at the Scientific Assembly and Annual Meeting of the ECR 2003.