Synbiotics for Inflammatory Bowel Disease: Useful in Adults but Problematic in Paediatrics

Introduction An altered colonic microbiota contributes to inflammatory bowel disease (IBD) pathogenesis. Adult studies suggest modification of the microbiota by synbiotics (probiotics+prebiotics) can improve ulcerative colitis (UC)1 and Crohn9s disease (CD)2. Aim To assess the feasibility of using a synbiotic in children with IBD. Methods Patients with IBD aged 6 to 16 years were approached. Children were excluded if they used any prebiotic/probiotic agent in the preceding 14 days, were using antibiotics or had a severe IBD exacerbation. Patients were withdrawn if they started antibiotics or another prebiotic/probiotic or they wished to discontinue. Participation involved taking the probiotic ( Bifidobacterium longum in a capsule) and prebiotic (3.5 g Synergy 1 inulin oligofructose) twice daily for 12 weeks. A pre-study questionnaire and physician9s global assessment (PGA) were completed. Questionnaires were provided for return at 1, 4, 8 and 12 weeks. Trial completion involved finishing the synbiotic course and returning all questionnaires. Results 23 children were recruited. 11 (48%) were male. Median age was 13.4 years (7.8–16.6 years). 11 had CD, 6 UC and 4 IBD-unspecified. Initial PGA was ‘inactive’ in 19, ‘mild’ in 3, ‘moderate’ in 1 and ‘severe’ in 1. Only 3 of the first 17 patients completed the study. Feedback indicated the prebiotic was poorly tolerated, therefore the last six participants undertook a tapered probiotic course: none in week 1, once daily in week 2, then twice daily from week 3. Only two of six completed the modified study. Completion overall was 5/23 (22%). Reasons for withdrawal were: six diarrhoea/IBD flare, six stopped returning questionnaires, four required antibiotics, one advised by GP because of rash, one unwell on prebiotic but completed probiotic and one parent stopped after noticing ‘no difference. Conclusion Although synbiotics have shown promise in adult IBD this feasibility study in fairly well paediatric IBD patients has shown poor tolerability. We suspect the drop-out rate was due to the prebiotic agent, but further studies are necessary to assess the tolerance of different prebiotics/probiotics in paediatric IBD before larger efficacy trials.