Articles on adoption, foster care, & pediatrics

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Probiotics and Prebiotics

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Getting Friendly with Your Gut Bacteria ...


Probiotics, or the use of beneficial bacteria, are an exciting concept in the prevention and treatment of various childhood conditions. Definitive evidence on efficacy and safety is somewhat lacking, but there have been several good studies looking at probiotics like lactobacillus and active-culture yogurts in the prevention and treatment of diarrhea. The weight of the current evidence supports the use of probiotics in acute-onset childhood diarrhea, and their use with antibiotics to prevent antibiotic-associated diarrhea. In addition, the use of probiotic formulas (available in Europe for awhile, and now in the US) may reduce the number of diarrheal illnesses for children in day-care settings. Some small studies suggest that probiotics may also help prevent colds, colic, thrush, yeasty diaper rashes, non-specific tummy aches, and urinary tract infections.

What's especially interesting is the idea that establishing a healthy gut bacterial ecosystem early in infancy may steer the development of the immune system away from hyper-reactive "atopic" conditions like eczema, asthma, and seasonal allergies; this could be very useful in families where there's a family history of these conditions. The research here is early and somewhat conflicting, but this is an area to watch.

The bacteria that colonize your intestines set up shop early on, and the bacteria found in hospital environments don't seem to be the healthiest to be colonized with. It may prove to be wise for pregnant women to consume active-culture yogurt, kefir, or probiotics, and to supplement babies with these healthy bacteria. It should be emphasized that the research on this topic is in its infancy, and that definitive safety and efficacy information is not available.  Furthermore, research has not defined what strains of probiotics work best (or at all!) for various conditions. But so far, we have not seen serious side effects except in significantly immuno-suppressed children.

As far as yogurts are concerned, not all are created equal. In kids from 8mo-2yo and in malnourished adoptees, full fat is the way to go. And check the label for sugar content - some of those brands are sugar bombs. For promotion and maintenance of healthy gut bacteria, serving yogurt daily is a safe, time-tested, granny-approved, and easy-to-find way to go. But for treatment purposes or early in infancy, you might consider probiotic supplements, which can deliver many more of these healthy bacteria than a container of yogurt.

Like any unregulated "nutriceutical", it can be hard to find reliable, standardized products, and even harder to get them covered by your insurance. Probiotics, in particular, do not always contain healthy, viable strains of bacteria. 

Culturelle supplements use Lactobacillus GG, one of the most studied strains, and are easy to find over-the-counter in most drugstores. Lactinex packets are available by prescription in some pharmacies. Nature's Way is another easy-to-find brand that sells a blend of probiotic strains, included lactobacillus reuteri, which was used in the recent infant colic study. The Biogaia drops used in that study are now available in many drugstores as well. Another excellent brand of probiotic supplements that's available locally in Seattle is the Pharmax HLC line. 

You'll also want to think about prebiotics - foods and supplements that help these healthy bacteria thrive. These can be found naturally in breast milk, honey (not for use <1yo), garlic, onions, leeks, wheat, bananas, asparagus, artichokes, and chicory root. Supplements of fructo-oligosaccharides (FOS) are also available, and Pharmax includes them in many of their probiotic formulations.

What's fun about this topic from the adoption medicine perspective is that the Eastern European docs love probiotics. "Dysbacteriosis" is a frequently seen diagnosis, often treated with "ferments and enzymes", and while you'll still want to rule out parasites like giardia and other malabsoptive causes of funny poops, I am convinced that children raised in hospitals and institutions have less healthy gut bacteria. In Russia, you can even get yogurt fortified with the power of Cosmonaut intestinal bacteria! Cosmonauts being the pinnacle of Russian health and fortitude, I suppose. Best not to think about how they collect said bacteria ...

Updated 2/13

Giardia and Other Stool Parasites

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Giardia is the most common parasitic infection in international adoptees, and is also frequently implicated in day-care center diarrhea outbreaks. Studies have shown that it is found in up to 20% of international adoptees, particularly older adoptees from Eastern Europe; in our experience it seems to come in clusters, averaging around 10-20% of our adoptees, and we do see it from China as well.

It's a microscopic flagellated protozoan parasite that is quite infectious (it can take as few as 10 cysts to cause infection), and it is typically spread by drinking contaminated water or fecal-oral transmission. So ... wash hands scrupulously after diaper changes, toilette, and before meals/food prep until giardia is ruled out, and don't have new arrivals share baths with other children at first.

Giardia can be asymptomatic, but symptoms often include loose, watery stools, with a certain foul-smelling greasy, floaty, frothy je ne sais quoi. Flatulence, cramps, bloating, and malaise can also be present. Chronic giardia may be associated with significant weight loss and failure-to-thrive. It also can cause secondary lactase deficiency - interfering with the intestine's ability to digest lactose. Even after successful treatment, loose stools can persist for a month or two. Cutting back on lactose, and supplementation with probiotics (unproven but likely to be safe) may help during this time period.

To diagnose giardia and other intestinal parasites, we recommend submitting 3 stool samples collected 2-3 days apart (preserved promptly after passage in a polyvinyl alcohol kit) for ova and parasite (O&P) examination, and one fresh (<1hr old) sample for Giardia antigen. Some refugee centers treat empirically with albendazole on arrival; we don't, because we prefer to know what we're treating, and because albendazole is ineffective against some of the common parasitic infections in adoptees. If the initial stool tests (remember, collect them 2-3 days apart to increase the chances of finding something) are negative but symptoms consistent with intestinal parasites persist, consider rescreening the stool; initial stool examinations miss infections in some children.

It's also important to do a "test-of-cure" giardia antigen test 1-2 months after treatment to confirm treatment success. If an adoptee tests positive for giardia, we treat, regardless of symptoms. You may not realize until later that the giardia was in fact causing symptoms, including malaise and poor growth; we also do this for the "public health" of the adoptive family.

Folks who don't see a lot of giardia often prescribe flagyl (metronidazole); in our experience this has an unacceptable failure rate. A better choice is Tinidazole, which was recently FDA approved for this indication, but has been in off-label use for some time, even in children <3yo. A convenient one-time 50mg/kg dose (max 2g) is what we use. It's mighty bitter, so mix with espresso syrup or other intensely sweet/flavorful option. See our medication tricks and tips for other ideas. Clark's Pharmacy in Bellevue, WA (425-881-0222) has it available in convenient dosing, is giardia savvy, and does mail order. Alinia is another recently approved medication for giardia that seems to be a reasonable alternative.

We don't automatically test or treat family members if giardia is promptly diagnosed in a new arrival, but if the child has been home awhile, if there are other young children around, or if anyone else is symptomatic then they should get checked as well.

Other stool parasites like Ascaris lumbricoides, Blastocystis hominis, Dientamoeba fragilis, Entamoeba histolytica, Trichuris trichiura, hookworms, and pinworms are also commonly identified in international adoptees. O&P results will often include non-pathogens, or commensals, which are not felt to cause illness and do not require treatment. However, they can be a sign that other parasites are present, and you should make sure that all 3 stool samples are evaluated. Links with good information about these and other, less familiar parasites are listed below.

Other Stool Parasite Resources:

Constipation

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It's a sad day when poop just isn't funny anymore ... at least for someone like me who does enjoy poop humor and things scatological (it's an occupational hazard). That sad day is a lot more likely to happen when travelling to adopt a child. In fact, constipation is so common a concern for travelling adoptive parents that I've taken to inventing medical terminology with a reassuring cachet such as "transitional slowed bowels", just to take the edge off of the hour-and-minute countdown since last passed stool. It's also a problem for many other children in my practice ... our modern processed diet may be to blame, as a diet low in fiber, low in fluids, and high in sugars predisposes kids to constipation.

In general, constipation is defined more by what your child is passing rather than how often. Normal stool frequency in infants varies from several times a day to 1-2 times per week. But if your child is passing painful, hard "rocks", "golf balls", or "boulders" (egad), especially if there is intermittent leakage of more liquid stool (encopresis), then indeed we've got a problem. If your child is vomiting, or has a full, tight, and tender belly, then we've really got a problem needing urgent medical attention.

In the recently adopted child, constipation is often blamed on iron, when in fact it's more likely to be from the stress of travel and transition, dietary changes, and perhaps dehydration. The association between iron and constipation is overrated, and since most adoptees are iron-deficient, it's not wise to try and limit their iron intake.

Soy formula can cause harder stools, so you may not want to switch your child to this if constipation is an issue. Luckily, cow milk intolerance is another overrated issue - most infants and young toddlers tolerate cow milk products just fine (rarely, cow milk protein allergy can be associated with intractable constipation).

To assist you in your quest for smooth bowel movements, or SmoovementsTM, if you will ... I will now share with you ancient secrets of "FPBM - For Proper Bowel Movements". Let's start with F - FLUIDS, FRUITS, and FIBER are your Friends when it comes to constipation.

Infants:

  • several ounces of 100% fruit juice 1-2x/day, especially prune, pear, or apple juice
  • fewer white foods like bananas, rice, soy, cheese, white flour products, and ...
  • more "P" fruits and veggies like pears, peaches, prunes, plums and peas
  • substitute barley cereal for rice cereal
  • in hot climates where dehydration is a concern, a few extra ounces of water can help, but since our kids usually need the calories, I'd stick with juice or watered-down juice
  • if you've gone more than 3-4 days with no stool, and your child seems to be in pain or straining a lot, try a glycerin suppository and a warm bath; you can also gently lubricate around the anus with vaseline or diaper cream
  • if your child is straining, you might try bicycling their legs or holding them upright in squatting position (their back against your chest, holding their knees up towards their chest)

Toddlers and Older Children:

  • fruit juice, and fewer white foods/more "P" fruits and veggies as above can help ...
  • ... but in this age group, we should focus more on fiber and fluids: goal is at least their age in years plus 5-10 grams of dietary fiber per day, with lots of fluids
  • whole grain cereals (read the label - lots of fake "whole grain" stuff out there) - remember "Colon Blow Cereal" from Saturday Night Live? That's the ticket - bran cereals, whole grain cereals, muesli, mini-wheats, etc ...
  • bran muffins, cookies, crackers, and pancakes with whole grains. Metamucil makes some psyllium fiber cookie-type wafers as well ...
  • Benefiber is a nongritty, flavorless fiber supplement that dissolves more completely than Metamucil, for when you can't meet the fiber goal through diet alone
  • You can also get your 100% juice plus 10g fiber premixed in one convenient but pricey juice box (they also carry fiber cookies)
  • dried fruits (prunes, apricots, figs, raisins, etc)
  • beans, peas, and lentils
  • fresh fruits and veggies with fiber - carrots, cabbage, celery, rhubarb, prunes, pears, peaches, plums, apricots
  • the constipation chapter below has nice recipes for "Right and Regular" jam and fruit/fiber smoothies
  • you can try 1/2 tsp unprocessed bran or flax seed mixed with food 1-2x/day but only if your child is drinking adequate fluids
  • for kids 4yo and up, popcorn is a great, tasty source of fiber, as are seeds and nuts

"B"-havior: 

  • in older children with constipation, suggesting regular sitting sessions 2x/day can help - after meals is the best time
  • reward successes, lay off the failures (it's bad enough as it is)
  • regular exercise keeps you regular
  • for kids who are fearful of pooping from passing painful large-caliber stools, sitting backwards on the toilet leaning onto the tank can help
  • 3-5yo "magical thinkers" often feel that if they withhold stools after they've had a painful experience the poop will disappear. It won't. It'll just add to their "boulder collection". Reinforce that the poop needs to come out every day, and help it do so with diet, regular sitting, and Miralax.
  • counseling may be necessary (and very helpful) for older children with encopresis

Medications that start with M:

  • if diet isn't working, if symptoms are severe, if your child is withholding stool, or if there's leakage (encopresis) you need to talk to your doc
  • my hands-down favorite laxative is Miralax, a tasteless powder mixed into your choice of fluids that is very safe, well-tolerated, and effective ... and now available over-the-counter
  • if you've been dealing with long-standing constipation or encopresis, you need to continue interventions like Miralax for 2-3 months at least, to help the rectum and colon recover to a normal caliber
  • Maltsupex or Milk of Magnesia are also frequently used
  • Mineral oil is another old favorite but it's yucky (try it in ice cream) and can pose an aspiration risk in younger children
  • bowel stimulant products like senna can be used occasionally but are not for chronic use
  • DON'T enemize your child without consulting a physician, and avoid frequent rectal interventions in general (unnecessary and traumatizing)
  • DON'T give honey or karo syrup to infants - there have been cases of botulism from this. UPDATE: Karo syrup manufacturing processes are now considered safer, but karo syrup no lomnger contains some of the helpful glycoproteins, so it may be less effective.

Remember, it's all about FPBM - "For Proper, Pleasing, Painless, and Punctual Bowel Movements"

  • Fluids, Fruits, Fiber are your Friends
  • Prunes, Pears, Peaches, Plums, Peas, Psyllium, Peanuts and Popcorn
  • Bran, Beans, Benefiber, and Behavioral interventions
  • Miralax (and/or Maltsupex, Milk of Magnesia, Mineral Oil)

Other Resources: