Probiotics |
I have been wanting to tackle the probiotics conversation for years because I get a lot of questions from parents that go like this:
The list goes on and on. I love collaborating with Dr. Ted so I asked him to help me out. Usually, we pick a topic and look at the current data. We go down lots of rabbit holes. I pepper in some of the more anecdotal experiences (put breastmilk on everything) and then voila, I have a post. Finding straightforward and simple answers should be easy right? Alas that wasn’t quite the case with this subject. We ended up working on this topic for months. The one thing that stood out from our digging is that the importance of gut health is becoming more and more documented. As an increasing amount of research is being done in this area, probiotics are often billed as the future of gut medicine. A panacea for all your poop woes. Unfortunately, research on how to modulate gut health is lagging. While we know more now than we used to, there is still so much emerging knowledge. So Dr. Ted and I did a deep dive into the available information and came up with the glaring conclusion: “...we still don’t know sh*t” That said, we’ll try to get you answers some of the more common questions. What is the microbiome? A wide array of bacteria and other organisms live in and on the human body. We know that these microbes do things, such as break down the food we eat, and release chemicals that have impacts on our health. There is a complex dynamic between hundreds if not thousands of strains of bacteria, viruses, and fungi that live in our microbiome, and they live in symbiosis with each other. There are times where the good bacteria keep bad bacteria at bay, and there are times where the bad bacteria become dominant and harm the good bacteria. I am always a fan of finding ‘balance.’ Never is this more important than in our guts. High-level patterns we know for sure: The difference between probiotics and prebiotics. There are two common ways that humans can choose to support the microbiome directly - probiotics and prebiotics. The World Health Organization defines probiotics as “live microorganisms, which when administered in adequate amounts confer a health benefit on the host.” Prebiotics can simply be thought of as the food/fuel for organisms in the microbiome to confer a health benefit. The most commonly used prebiotic example is fiber, which is passed through the intestines undigested to feed healthy bacteria. Even though it sounds like prebiotics should “come before” your probiotics, the timing doesn’t matter, and you don’t always need to take both. Our gut always has some natural probiotic strains that will benefit from prebiotics, and supplemental probiotics can thrive without specific prebiotics.
Variety is important. Time and time again, when we look at samples of human microbiomes, having diversity is correlated with better health. To that end, natural sources (see ‘fermented foods,’ below) and supplements with a lot of variety will both be more physiologic than supplements with a single strain. The microbiome can be disrupted by outside forces. The following factors have been associated with microbiome changes:
Probiotics are an ‘umbrella’ term. If you were asked “are animals good?” you might want some more specificity to the question. Which animals? Tigers or puppies? Good in what way? Probiotics can be thought of similarly. There are hundreds of different strains of probiotics, and very few of those strains are thoroughly understood. Certain health conditions will respond better to specific strains. Fermented foods have some of the best natural probiotics. Most people think about “probiotics” as something you buy in the form of a supplement. Those can be pricey. In fact, the best sources of probiotics are the natural ones from fermented foods
Many things on this list can be pretty salty, so read labels and make adjustments when possible. Maybe try making your own pickles! Some common questions In looking at how far-reaching the data around the gut microbiome is, we found ourselves reading studies from all over the spectrum of human health. These are some of the most common questions people ask us. What do strain amounts mean? Probiotics are measured in colony-forming units (CFU) The CFU shows how many viable bacteria there are in each dose. We are usually talking about millions or billions! Should pregnant people automatically take probiotics? There’s evidence that some bacteria travels up the birthing canal to seed the future microbiome. To this end, some birthing parents have started to use “prenatal probiotics.” In a small number of studies, the use of some strains, including Lactobacillus and Bifidobacterium species, have indeed been shown to decrease inflammation in mom. This can decrease the risk of preeclampsia and other disorders like gestational hypertension. The data isn’t conclusive enough to support that this is something that everybody has to do. In other words, don’t let this cause stress if you opt out. It’s entirely possible that these studies were confounded by other variables. For example, parents that take prenatal probiotics might be more likely to engage in gut-healthy behaviors. Anecdotally, Dr. Ted has noticed that babies born to mothers who took prenatal probiotics appear to have lower rates of colic and diaper rash, which may indicate a healthy microbiome. Bottom line. This appears to be a safe intervention, benign and maybe useful. If you didn’t do this and your child has these problems, let me stop you before you start feeling guilt (baseline reaction for many parents). You can’t manage the past. Know that there are likely millions of children with perfect guts that still have these problems, and there are options for infants. Tell me about the probiotics marketed towards infants It is possible that babies are missing some important strains of good bacteria. Think about this gut imbalance almost like a vitamin D deficiency. If a breastfeeding mom is low (and this is more common than you might think) her breast milk won’t have adequate amounts of this essential vitamin. If this is the case, the breastfed babies will benefit from a Vitamin D supplement. Even though many moms have reasonable vitamin D levels, the AAP suggests that all breastfed babies get vitamin D drops just in case. To follow up with this analogy, a birth mother might be lacking in certain strains of bacteria that can be useful for babies. This could be due to generations of antibiotic use and/or dietary changes. Other interventions, such as C-sections, may further interfere with the normal transmission of flora during vaginal birth. To fill in this deficit, researchers have created a probiotic for just this strain. The primary one that has been studied is Bifidobacterium Infantis (B.Infantis). Some of these probiotics, such as Evivo (a brand of B. infantis) are expensive although you don’t need to take them long term. Unlike vitamin D, there is not a universal recommendation quite yet. Anecdotally, we have noticed that many babies taking B. infantis poop less, get less diaper rash, and gain weight well. Taking it is quite safe, and in babies with diaper rash, excessive poops (>10 per day), or colic it may be beneficial. Most infants take it easily but there are some babies who don’t seem to like it. One quirk about Bifidobacterium infantis: it’s been shown to specifically break down and metabolize human milk oligosaccharides (HMOs). The studies that have shown that it decreases stool output, diaper rash and colic were done on parents that were exclusively or mostly breastfed. There are some formulas that market themselves as having HMOs, but rigorous studies on if Bifidobacterium infantis makes use of those HMOs are lacking. Can probiotics help with their colic/rash/fussiness/loose, frequent poop/constipation issues? There are ongoing studies about this. Some strains with ample data are Lactobacillus reuteri and Lactobacillus rhamnosus, both of which are marketed to infants 0-12 months of age (and older). These strains have been studied more extensively than B. Infantis, and the American Academy of Pediatrics even recommends a short trial of Lactobacillus reuteri in babies with colic, although in formal trials, only 30% of babies have been shown to benefit from this. Common brands that are popular for colic include culterelle, Gerber Soothe and Biogaia. Culterelle is covered by some insurance plans if your doc writes a prescription. Again, it’s worth remembering that the data here are extremely new, and every baby reacts differently to probiotics. Baby probiotics aren’t a classic medicine where we can predict the impact. If you’re that parent with an endlessly crying baby, probiotics are certainly another tool to try. Should probiotics be a daily supplement for my young child? After infancy, the microbiome is a little more fixed. Just like with iron or other vitamins, a healthy lifestyle and a little attention to the right foods can be sufficient, but if we find evidence of a deficiency we would supplement (think kids with anemia or rickets from low vitamin d). Probiotics may fall into this category. Probiotic supplements are likely not necessary for everyone, but if someone is experiencing any signs of gut imbalance, such as bloating, pain, or diarrhea that can’t be explained by the doctor or things such as food intolerance, it is safe and probably worthwhile to do a trial of probiotics. What about after my kid is sick? Will probiotics help to reset the gut flora? Anecdotally, probiotics along with a bland starchy diet are our first line of treatment for kids with a tummy bug. Finding a brand with multiple strains may be the best way to help get the gut back in balance. A couple of good multi-strain probiotic choices that I have had success with for my little patients are Jarro-dophilus and/or Florajen for kids. Will probiotics help with eczema and asthma? We were tempted to not even include this question, because the answer is so muddled. It is early in the understanding of the research. There seem to be a number of correlations between poor gut health and asthma/eczema. That said, the research doesn’t give us an answer yet about which probiotic strains you can take to decrease the odds of having asthma or eczema, so even talking about this connection doesn’t feel responsible. Then what do you do if you have a child with bad eczema? Moisturize, Moisturize, Moisturize, but as far as diet goes, we would recommend a balanced diet with a predominance of natural prebiotics: fruits, vegetables, and safe fermented foods like kefir, apple cider vinegar, and sauerkraut. Pay attention to any foods that seem like they are triggers that are making the eczema worse. Should I take probiotics with antibiotics? As of this writing, the answer is all over the place. There have been a number of studies that suggest a small benefit to taking probiotics with antibiotics, whereby the number of days with diarrhea might be shorter. But wait, along came a well-publicized study done recently that suggested that people who took probiotic supplements while taking antibiotics actually had a gut that was disrupted for longer than that of people who didn’t (but this study only analyzed poop content, it didn’t ask participants how they felt.) For a moment I shifted my advice on this front, but I am back to adding the probiotics to the mix. That is just a ‘gut check’, pardon the pun. In any event, We both absolutely recommend finding natural sources (Greek yogurt, kombucha, etc) as soon as the patient is interested in taking them. More questions without good answers. How do I choose the best probiotic? There are a lot of ways that probiotics will market themselves. Strain number, size, etc. can all make for strong claims on boxes. Be a careful label reader. Make sure that everything in the probiotic is safe and there is nothing you are allergic or sensitive to, like soy or dairy. Can too much be no good? This depends on the specific strain, and the size of the person who is taking the probiotic. Typically taking a larger amount might cause some temporary bloating but is not dangerous. Anyone who is immune compromised should check with their doctor. How much does refrigeration matter? This also depends on the product. Most medicine, probiotic or not, will stay more potent in the refrigerator. But not all strains require refrigeration to stay effective. In any case it is very important to pay attention to the expiration date. Probiotics are likely not as potent as they age. Is it better to use a brand with many strains than one strain? In general, this seems to be true, but it’s difficult to come up with specific guiding principles. Some strains, like Bifidobacterium infantis, can have a big impact without variety, but in general, variety seems to be more physiologic. Can you use 2 products at the same time? Yes, you can, but the impact and symptoms from doing that are less understood. It’s safe, but there could be unintended side effects like bloating. In conclusion... Gut health is worth your attention. Adding fiber and fermented food to the diet is beneficial. Probiotics when taken as directed may have some good health benefits and are generally considered safe. So there you have it. Lots of food for thought but much less clear direction than I was hoping to offer. Enormous thanks to Dr Ted for writing and working on this post with me. Shout out to Brittany Williams for her input as well! |
