Yassin M. Alsaleh

Supervised by: Dr.Sameer Al Abdi

JOURNAL CLUB

بسم الله الرحمن الرحيم

)ال يكلف الله � إال وسعها( نفسا

2

3

• Infantile colic: paroxysmal, excessive crying without an identifiable cause in an otherwise healthy newborn infant.

Introduction

4

Infantile colic• Wessel’s criteria :• The classic definition is

based on the rule of threes:• crying that lasts for ≥3 hrs

per day.• for ≥ 3 days per week.• for a minimum of 3 weeks.

5

Infantile colic• It usually occurs in infants < 3 months.

• Colic affects 3% to 28% of infants.

• causing considerable stress and concern for parents.

6

Infantile colic• The etiology:

Not apparent

There is Theories

BUT

7

Theories

• swallowed air• Overfeeding .• some foods.

• The role of an aberrant intestinal microflora .

8

Theories

• Increased presence of hydrogen gas produced by anaerobic Gram-negative bacteria.

• Recently, coliform bacteria, particularly Escherichia coli, were found to be more abundant in the feces of colicky infants.

9

Infantile colic

• Treatments:• no treatment consistently provides

satisfactory relief.

• Carminatives before feedings are ineffective in preventing the attacks.

10

Old treatments

11

Carminatives

12

Probiotics

• Probiotics are live microorganisms thought to be healthy for the host organism.

• Probiotics are commonly consumed as part of fermented foods with specially added active live cultures; such as in yogurt, or as dietary supplements.

13

Probiotics

• Mechanism of action: • improving intestinal microbial balance,

thus inhibiting pathogens and toxin producing bacteria.

14

uses for probiotics• Managing lactose intolerance• Prevention of colon cancer• Lowering cholesterol• Lowering blood pressure• Improving immune function and

preventing infections• Antibiotic-associated diarrhea• Irritable bowel syndrome and colitis• constipation.

15

• in a prospective randomized study, supplementation with the probiotic Lactobacillus reuteri ATCC 55 730 improved colicky symptoms in breastfed infants within 1 week of treatment compared with treatment with simethicone.16

OBJECTIVES• To test the efficacy of Lactobacillus reuteri

on infantile colic .• to evaluate its relationship to the gut

microbiota.

17

18

METHODS• This randomized, controlled, double blind

Study.

• In general pediatricians and OPD at the Department of Pediatrics, University of Turin (Regina Margherita Children Hospital)

19

• between March 2008 and August 2009.

• All infants were diagnosed according to the modified Wessel’s criteria.

• All were born at term, AGA and aged 2 to 16 weeks at recruitment.

METHODS

20

Inclusion criteria• Only exclusively breastfed infants were

enrolled.

• At enrollment, mothers were encouraged to avoid cow’s milk in their diet.

21

Exclusion criteria• clinical evidence of chronic illness or GIT

disorders.• any intake of probiotics and/or antibiotics

in the week preceding recruitment.• any formula-feeding.• no acid blockers were used in any of the

infants who completed this study.

22

outcomes• Primary outcome was defined as a reduction of average

crying time to < 3 hours a day on day 21.

• Secondary outcome was defined as the number of responders in each group on days 7, 14, and 21.

• Responders were those who experienced a decrease in the daily average crying time of 50% from baseline.

23

• In addition, the intestinal microflora of the infants was analyzed to determine the effect of the by using (FISH).

METHODS

24

25

• Colicky infants were randomly assigned to groups by using a computer generated randomization list created by an independent departmental statistician.

• written informed consent was obtained from parents .

METHODS

26

• Active study product consisted of a suspension of freeze-dried L reuteri DSM 17 938 in a mixture of sunflower oil and medium-chain triglyceride oil .

• The placebo was identical in appearance and taste but without the live bacteria.

METHODS

27

• Both formulations were administered in 5 drops, once a day, 30 minutes before the feed in the morning, for 21 days.

METHODS

28

• At enrollment (day 0), history taken .• Medical examinations were performed.• growth parameters were recorded at baseline

and day 21.

• Parents were asked to fill in a structured diary to record:– the daily crying time (minutes),– stool characteristics and frequency,– any adverse effects

METHODS

29

Statistical Analysis• The sample size was calculated to find a

clinically relevant difference in the reduction in daily average crying .

• 20 patients were needed per group.• Data are shown as mean or median and

interquartile range (IQR)• differences were considered to be

significant when P<0.05.• All reported P values are 2-sided.

31

RESULTS32

Patient Enrollment

12650

25 25

25 21

433

RESULTS

• There were no significant differences between the groups regarding:

• type of delivery.• Gender.• age on entry.• Family history of gastrointestinal diseases • Atopy.• growth parameters

34

RESULTS

35

RESULTS

• At enrollment, there was no difference in median crying time (minutes/day) between the groups:

• 370 (IQR: 120) vs 300 (IQR: 150) in the L reuteri and placebo groups, respectively (P=0.127).

36

RESULTS

37

daily crying time• In probiotic group there was a significant

reduction in daily crying time at the end of the study (day 21) compared with placebo:

• 35 (IQR: 85) vs 90.0 (IQR: 148) minutes/day, respectively (P=0 .022)

min/day

90

35

placebo lactobacillus

38

Number of subject who cry for 3hrs

• By day 21, the number of subjects that had crying times 180 minutes (3hrs) was significantly lower in the L reuteri group compared with the placebo group (4 vs 12, respectively; P= 0.009

infant

12

4

placebo lactobacillus

39

number of responders• There was a significantly higher number of

responders in the probiotic group compared with placebo on days 7 (20 vs 8; P =0.006), 14 (24 vs 13; P =0.007), and 21 (24 vs 15; P =0.036).

40

41

Microbiologic Analysis of Fecal Cultures

• Fecal counts of Lactobacillus, bifidobacteria,and Clostridium butyricum species were similar between the groups.

• the levels of E coli were higher in the L reuteri group at the beginning of the study

42

reduction in E coli

• There was a significant reduction in E coli in the probiotic group compared with the placebo group (-6.55 x107 [IQR: 4.87 x108] vs 4.30 x 105 [IQR: 4.35 x 107], respectively P =0.001) .

43

Lactobacilli level increament

• Lactobacilli were found to be significantly increased in the L reuteri versus placebo group (4.07x105 [IQR: 4.98x106] vs 0 [IQR: 3.27x104]( P=0.002).

44

GIT function

• Gastrointestinal function was similar between the groups

45

Adverse events • reported during the study were:

– rhinitis (L reuteri group, n 1).–eczema (placebo group, n1).– fever (placebo group, n 1).–otalgy (placebo group,n 1).–GER (placebo group, n 1).

46

placebo lactobacillus

responders

median crying time

reduction in E coli

Lactobacilli level increament

Adverse events

47

48

Critical appraisal

49

PICO• Population: colicky infant

aged 2 to 16 weeks

• Intervention: probiotic

• Control: placebo.

• Out come: improvement of colic.

50

Relevance1. Does the study address a common

problem in your practice? YES2. Does the study address an important

outcome to you or to your patient? (DOE vs. POEM).

YES3. Assuming that the study conclusion is true would it lead to a change in your practice? YES

51

Validity1. Was the assignment of patients to

treatment randomized?

Yes

2- Was the assignment concealed?

Yes

52

Validity3- Were patients analyzed in the groups to

which they were randomized (intention to treat analysis)?

YES• Was follow-up complete& long enough? YES

53

Validity3. Were the groups similar at the start of the

trial? Baseline prognostic factors (demographics, co-morditity, disease severity, other known confounders) balanced?

YES4. Were patients, their clinicians, and study

personnel 'blind' to treatment? YES

54

Validity5. Aside from the experimental intervention,

were the groups treated equally?

• Co-intervention?

• Contamination?

• Compliance?

yes

55

Validity6. Were all clinically important outcomes

considered?

YES

56

Results clinical significance

• Precision of the effect: • Confidence intervals?

• no

57

Calculation

• Absolute Risk Reduction = |EER-CER| = • a/n1 - c/n0 =0.04 - 0.28 = -0.24 = 24%• NNT number need to treat = 1/absolute

risk reduction = 1/0.24=4.158

colic

N Y

25 n1 24 (96%) b 1 a Lactobacillus treatment

25 n0 18 (71%) d 7 c placebo

50 42 8

59

Applicability

1. Can you do the Intervention exactly as it is described in the paper

YES

2. Is your Patient is similar to the population of the study? YES

3. Are the likely treatment benefits worth the potential harms and costs?

???????

60

product

61

62

CONCLUSION• L. reuteri DSM 17 938 at a dose of 108

colony-forming units per day in early breastfed infants improved symptoms of infantile colic .

• well tolerated and safe.• Gut microbiota changes induced by the

probiotic could be involved in the observed clinical improvement.

63

Points• those who received placebo thrived and

had reduced crying time by the end of the study.

• They include patient at age of 2 weeks and (16 weeks) 4 months

• This study was funded by BioGaia AB (Stockholm, Sweden).

64

Appendages

65

66

Lactobacillus reuteri

• Lactobacillus reuteri is a Gram-positive bacterium that naturally inhabits the gut of mammals and birds.

67

History

• Discovery• As early as the turn of the 20th century, L. reuteri

was recorded in scientific classifications of lactic acid bacteria[1], though at this time it was mistakenly grouped as a member of Lactobacillus fermentum. In the 1960s, further work by German microbiologist Gerhard Reuter – for whom the species eventually would be named – began to distinguish L. reuteri from L. fermentum. Reuter re-classified the species as "Lactobacillus fermentum biotype II".[2]

68

History

• L. reuteri was eventually identified as a distinct species in 1980 by Kandler et al.[3] This group found significant differences between L. reuteri and other biotypes of L. fermentum, and thus proposed that it be given formal species identity. They chose the species name "reuteri", after discoverer Gerhard Reuter, and L. reuteri has since been recognized as a separate species within the Lactobacillus genus. 69

level of evidence

70

GLOSSARY• Randomization: Ideally, a process that

ensures every member of a population has an equal chance to be included in the study's sample.

• Randomized Controlled Trial (RCT): A true experiment, in which the researcher randomly assigns some patients to at least one maneuver (treatment) and other patients to a placebo, or usual treatment. 71

GLOSSARY• Intention-to-treat Analysis: analyzed for

according to the groups for which they were originally assigned .

72

Interquartile range

• also called the midspread or middle fifty, is a measure of statistical dispersion, being equal to the difference between the third and first quartiles.

• the distance between the 75th percentile and the 25th percentile. The IQR is essentially the range of the middle 50% of the data. Because it uses the middle 50%, the IQR is not affected by outliers or extreme values. 73

Interquartile range

• Example• Compute the interquartile range for the

sorted Cotinine data: • 18, 33, 58, 67, 73, 93, 147• The 25th and 75th percentiles are

the .25*(7+1) and .75*(7+1) = 2nd and 6th observations, respectively.

• IQR = 93-33 = 60.

74

THANK YOU 75