Role of probiotics in nutrition Dr Kibaru Elizabeth Gathoni Lecturer Egerton University Kenya paediatric nurses chapter 2015 annual scientific conference

Gut Micro flora and Role of Probiotics in Infant Nutrition

Flow of discussion Human body as a world of micro flora Breastfeeding : Bifidogenic effect Critical phase of complementary feeding Probiotics: B-lactis & B- comfortis: benefits Outline the contents of your presentation.

Human body: the world of bacteria 10 fold more bacteria than human cells Stress here also that bacteria living in the gut is called our “microflora” Our digestive tract contain 1014 bacterial cells (microflora) Human body is composed of 1013 cells Marteau M et al., World Rev Nutr Diet. 1993;74:1-21

The Intestinal Microflora 10 3 /ml content (10,000 per 1mL) 10 3 /ml content= 10,000 per 1mL 10 4/ml content=100,000 per 1mL and so on 10 12/ml content= 10,000,000,000,000 per 1mL Stress here that the number of bacteria increases as you travel down the gut. The stomach has the smallest contents and the colon has the largest content. Therefore this is the main home for the microflora, where the majority of bacterial fermentation takes place (could make a reference here to “wind” to bring a bit of humour!!) 10 12 /ml content 10 4- 10 6 /ml content

Composition and Health Effects of Predominant Human Fecal Bacteria (1) We divide the gut microflora in 3 ways, according to their overall link to health Those with solely Health Promoting Functions e.g. Bifidobacteria and Lactobacillus. These are very important in healthy gut of adults and infants. (Also known as GOOD BACTERIA) Those with BOTH Health and Pathogenic Properties e.g. E.Coli, Streptococci Those with solely pathogenic properties e.g. Clostridium, Staphylococci (Also known as BAD Bacteria)

Composition and Health Effects of Predominant Human Fecal Bacteria (2) Harmful/pathogenic effects Health promoting functions Good and bad Ps.aeruginosa Pathogens (incl. toxins) Proteus Staphylococci Clostridium Colonization resistance Veillonellae Enterococci E.coli Stimulation of immune functions Production of carcinogens Lactobacilli Streptococci Aid digestion and absorption Intestinal Putrefaction Eubacteria Bifidobacteria Synthesis of vitamins Bacteroides Roberfroid et al, 1995 11 (log bacteria/g feces)

Intestinal Ecosystem (1) There is a very close relationship between the environment we live in and the microflora living in the gut. ENVIRONMENT influences gut microflora e.g. the type of food we eat influences the microflora because the bacteria like to feed off different foods. e.g. breastmilk is high in lactose which is used as food source for Bifidobacteria. Another example is anti-biotic usage, which can often be non-specific to the type of bacteria it kills, thus can kill the good bacteria as well as the pathogens. Microflora and effect on Health The microflora which live in our gut can also have an influence on our immune response (having more good bacteria can help to support out immune protection of the body). Thus we can gain protection from infection with a good level of healthy bacteria.

Intestinal Ecosystem Diet Immune Response Microbial Flora Antibiotic Nutrition Stress Cancer Environment There is a very close relationship between the environment we live in and the microflora living in the gut. Give a couple of examples ENVIRONMENT influences gut microflora e.g. the type of food we eat influences the microflora because the bacteria like to feed off different foods. e.g. breastmilk is high in lactose which is used as food source for Bifidobacteria. Another example is anti-biotic usage, which can often be non-specific to the type of bacteria it kills, thus can kill the good bacteria as well as the pathogens. Microflora and effect on Health The microflora which live in our gut can also have an influence on our immune response (having more good bacteria can help to support out immune protection of the body). Thus we can gain protection from infection with a good level of healthy bacteria. Age Infections Exogenous Bacteria Efficacy of treatments

Early gut microflora colonization When the infant is born, the gut is sterile and the immune system is immature. Sources of early Bacterial colonization Maternal gut & vaginal flora Skin flora of mother and caregivers Birth environment Early intestinal flora is determined by Mode of birth (e.g. normal delivery vs caesarian) Household Hygiene Diet: Breastfeeding encourages growth Bifidobacteria Genetic factors When the infant is born, the gut is sterile and the immune system is immature. Because the gut is sterile at birth, many types of bacteria will want to colonise the gut! These are called “opportunist” bacteria, because they take the opportunity to find a home in the gut, and hope to colonise before others do. Therefore, at birth there can be more of the potentially pathogenic bacteria colonising, and this is influenced by different sources (as described on the slide above) i.e. mode of birth, hygiene in area where born. However, one of the main indicators for the predominant type of bacteria colonising the infants immature gut is the initial type of feeding. Breastfeeding from birth creates a very good environment for the growth of bifidobacteria, which make up about 90% of the infants gut microflora. Therefore another reason why Breast is Best!

Is Human breast milk sterile...? It is a source of diverse and active bacteria, including beneficial Bifidobacteria and Lactobacilli (Heikkilä et al. 2003, Olivares et al. 2006, Perez et al. 2007 Solis et al. 2010, Jost et al. 2011) , Bacteria It has an anti-microbial potential: Human breast milk cell - Inhibition of Staphylococcus aureus by human breast milk bacteria, including strains Lactobacilli (Heikkilä et al. 2003) - Anti-microbial potential of four Lactobacillus strains isolated from human breast milk (Olivares et al. 2006) it was assumed that breast milk is nearly sterile. This was seen as one of its particular benefits, especially in reducing the risk of diarrhea in exclusively breast-fed infants. However, with today’s advanced analytical methods in microbiology on the one hand, and the new understanding of the beneficial role that healthy intestinal microbiota play for newborns and infants on the other hand, the focus has broadened and scientific interest is now increasingly directed towards the occurrence and role of commensal bacteria in human breast milk, especially its role in the process of bacterial colonization of the infants’ gut. Subsequently, more recent studies show a multitude of diverse and active bacteria in human milk, including Bifidobacterium, Streptococcus, Lactobacillus, Enterococcus, Staphylococcus, Enterobacteriaceae, Propionibacterium and Veillonella (Martin et al. 2012, Jost et al. 2011_b, Solis et al. 2010, Martin et al. 2007).

Human breast milk is a source of beneficial Bifidobacteria and Lactobacilli (1) Several studies have demonstrated that breast milk of healthy women contains beneficial Bifidobacterium spp. ( In the range from ,102 to 104 bacterial counts/ ml.) their occurrence in Breastmilk can vary considerably from country to country and also between urban and rural areas The amount of Bifidobacteria in Breastmilk can also be influenced by the maternal allergic status. Gronlund et al. 2007 were able to show that allergic mothers have significantly (P=0.004) lower counts of Bifidobacteria in breast milk compared to non-allergic mothers

Human breast milk is a source of beneficial Bifidobacteria and Lactobacilli (2) Several studies have demonstrated that breast milk of healthy women contains beneficial Bifidobacterium spp. In the range from ,102 to 104 bacterial counts/ ml. However, their occurrence in BM can vary considerably from country to country and also between urban and rural areas The amount of Bifidobacteria in BM can also be influenced by the maternal allergic status. Gronlund et al. 2007 were able to show that allergic mothers have significantly (P=0.004) lower counts of Bifidobacteria in breast milk compared to non-allergic mothers Gueimonde et al. 2007 adapted from Sinkiewicz et al. 2006

Changes in the microflora with increased age As the baby grows and develops the actual microflora colonisation will change e.g. at the start of complementary feeding there are changes due to introduction of new foods, less protection from Breastmilk as the quantity is reduced to make way for food. This is explained more on the next slide. Point out changes in Bifidobacteria and Lactobacillus. Increase of Bacteroides and other more potentially pathogenic bacteria.

Probiotics: definition Actual definition: “probiotics are live micro-organisms, which when consumed in adequate amounts, confer a health effect on the host” FAO/WHO, 2001

PROBIOTICS: extra protection during complementary feeding This is bifidobacteria and lactobacillus Probiotics added to infant formulas can provide protection during the complementary feeding phase and for older infants.

Probiotics will aim to enhance the development of Healthy Intestinal Flora. They do this by a number of mechanisms: Stimulation of immune response, especially the production of IgA, the most important immunoglobulin (antibody) which provides protection against foreign bodies in the gut, including pathogenic bacteria Stimulate immune cells that have Phagocytic activity: i.e. those that physically eat bad bacteria e.g. macrophages Actual production of substances toxic to bad bacteria (i.e. destroys bad bacteria). These include organic acids, hydrogen peroxide and bacteriocins.

Competition with bad bacteria for nutrients Fermentation of soluble fibres will produce SCFA (short chain fatty acids propionate, butyrate and acetic acid) and fermentation of lactose will produce lactic acid, both of which (lactic acid and SCFA) will reduce the colonic PH. Creating an acidic environment favoured by good bacteria: Bifidobacteria and Lactobacillus). type of diet provided to the bacteria is very important. Competition with bad bacteria for nutrients Strengthening the tight junctions between cells and also forming a wall of protection over the gut cells, against pathogenic bacteria, to stop the pathogens sticking to the gut cells.

Probiotics: Mechanisms of action Stimulates immune system Stimulate Phagocytic cells Protection form pathogens Competition for nutrients Fermentation: Lactic acid SCFA Probiotics will aim to enhance the development of Healthy Intestinal Flora. They do this by a number of mechanisms: Stimulation of immune response, especially the production of IgA, the most important immunoglobulin (antibody) which provides protection against foreign bodies in the gut, including pathogenic bacteria (if you want to go into further detail, I suggest you use slide 18 to illustrate how the probiotic presents itself to the APC and then stimulates the IgA from the Th1 immune cells) Stimulate immune cells that have Phagocytic activity: i.e. those that physically eat bad bacteria e.g. macrophages Actual production of substances toxic to bad bacteria (i.e. destroys bad bacteria). These include organic acids, hydrogen peroxide and bacteriocins. Fermentation of soluble fibres will produce SCFA (short chain fatty acids propionate, butyrate and acetic acid) and fermentation of lactose will produce lactic acid, both of which (lactic acid and SCFA) will reduce the colonic PH. Creating an acidic environment favoured by good bacteria: Bifidobacteria and Lactobacillus). Therefore type of diet provided to the bacteria is very important. Competition with bad bacteria for nutrients (as above nutrients) Strengthening the tight junctions between cells and also forming a wall of protection over the gut cells, against pathogenic bacteria, to stop the pathogens sticking to the gut cells. Strengthen Gut wall

Protective barrier on gut cell wall This diagram clearly illustrates the way in which probiotics offer colonization resistance to the pathogenic bacteria by competing for sites for adhesion. Forming a wall of protection on the gut cell wall.

Clinically Proven Probiotics in Infant Nutrition Bifidobacterium Dominant species Lactobacillus rhamnosus Subdominant species Enhance Immune system Enhance gut barrier efficiency Gut comfort These particular Probiotics have been well researched and found to work in synergy when added to infant formula Bifidobacteria longum is dominant because it tends to survive longer in the gut and forms part of 90% of the bifidobacterium species that dominate the intestine of the BF infant. Lactobacillus rhamnosus maybe subdominant but it has quite powerful effects on gut health especially due to its property of gut wall adhesion and protection. Reduce risk of diarrhoea SYNERGY

Benefits of Probiotics in Infant Nutrition Immunity Protection Diarrhoea Allergy Constipation Antibiotics therapy Safety

B. lactis (BL): 37% reduction in prevalence and 58% reduction in episodes of community acquired, acute diarrhoea in infants and toddlers Objective. To investigate the effect of 2 different species of probiotics in preventing infections in infants attending child care centers. Methods. A double-blind, placebo-controlled, randomized trial was conducted from December 1, 2000, to September 30, 2002, at 14 child care centers in the Beer-Sheva area of Israel in healthy term infants 4 to 10 months old. Infants were assigned randomly to formula supplemented with Bifidobacterium lactis (BB-12), Lactobacillus reuteri (American Type Culture Collection 55730), or no probiotics. Duration of feeding, including follow-up, for each participant was 12 weeks. All infants were fed only the assigned formula and were not breastfed due to parental decision before recruitment to the study. Probiotic or prebiotic food products or supplements were not allowed. Main outcome measures were number of days and number of episodes with fever (>38°C) and number of days and number of episodes with diarrhea or respiratory illness. Results. Participants (n 201) were similar regarding gestational age, birth weight, gender, and previous breastfeeding. The controls (n 60), compared with those fed B lactis (n 73) or L reuteri (n 68), had significantly more febrile episodes (mean [95% confidence interval]: 0.41 [0.28–0.54] vs 0.27 [0.17– 0.37] vs 0.11 [0.04–0.18], respectively). The controls also had more diarrhea episodes (0.31 [0.22– 0.40] vs 0.13 [0.05– 0.21] vs 0.02 [0.01– 0.05], respectively) and episodes of longer duration (0.59 [0.34–0.84] vs 0.37 [0.08–0.66] vs 0.15 [0.12– 0.18] days, respectively). The L reuteri group, compared with BB-12 or controls, had a significant decrease of number of days with fever, clinic visits, child care absences, and antibiotic prescriptions. Rate and duration of respiratory illnesses did not differ significantly between groups. Conclusions. Child care infants fed a formula supplemented with L reuteri or B lactis had fewer and shorter episodes of diarrhea, with no effect on respiratory illnesses. These effects were more prominent with L reuteri, which was also the only supplement to improve additional morbidity parameters. Weizman et al. 2005

B. lactis (BL): 78% reduction in prevalence of nosocomial, acute diarrhoea and rotavirus infections in infants and toddlers In a double-blind, placebo controlled trial, infants aged 5-24 months who were admitted to a chronic medical care hospital were randomised to receive a standard infant formula or the same formula Bifidobacterium and S Thermophilus. Patients were evaluated daily for occurrence of Diarrhoea, and fecal samples, obtained weekly, were analyzed for Rotavirus antigen by enzyme immunoassay. Fecal samples were also obtained during an episode of Diarrhoea for virological and bacteriological analyses. 55 subjects were evaluated for a total of 4447 patient – days during 17 months. 8 (31%) of the 26 patients who received the control formula and 2 (7%) of the 29 who received the supplemented formula developed diarrhoea during the course of the study [P=0.035]. 10 (39%) of the subjects who received the control formula and 3 (10%) of those who received the supplemented formula shed rotavirus at some time during the study (P= 0.025). The authors concluded that supplementation of IF with Bifidobacterium and S. Thermophilus can reduce the incidence of acute diarrhoea and rotavirus shedding in infants admitted to hospital Saavedra et al. 1994

summary Human body contain bacteria(microflora) Some good others bad others with mixed effect Clinically proven good ones are bifidobacteria and lactobacteria Breast milk contain bifidobacteria and lactobacteria Probiotics are live micro-organisms containing good bacreria Probiotics have a role in preventing allergies,diarrhea management and in boosting immunity

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