Clinical Use of Probiotics in Pediatric Allergy (cuppa): A World Allergy Organization Position Paper

Abstract

BackgroundProbiotic administration has been proposed for the prevention and treatment of specific allergic manifestations such as eczema, rhinitis, gastrointestinal allergy, food allergy, and asthma. However, published statements and scientific opinions disagree about the clinical usefulness.ObjectiveA World Allergy Organization Special Committee on Food Allergy and Nutrition review of the evidence regarding the use of probiotics for the prevention and treatment of allergy.MethodsA qualitative and narrative review of the literature on probiotic treatment of allergic disease was carried out to address the diversity and variable quality of relevant studies. This variability precluded systematization, and an expert panel group discussion method was used to evaluate the literature. In the absence of systematic reviews of treatment, meta-analyses of prevention studies were used to provide data in support of probiotic applications.ResultsDespite the plethora of literature, probiotic research is still in its infancy. There is a need for basic microbiology research on the resident human microbiota. Mechanistic studies from biology, immunology, and genetics are needed before we can claim to harness the potential of immune modulatory effects of microbiota. Meanwhile, clinicians must take a step back and try to link disease state with alterations of the microbiota through well-controlled long-term studies to identify clinical indications.ConclusionsProbiotics do not have an established role in the prevention or treatment of allergy. No single probiotic supplement or class of supplements has been demonstrated to efficiently influence the course of any allergic manifestation or long-term disease or to be sufficient to do so. Further epidemiologic, immunologic, microbiologic, genetic, and clinical studies are necessary to determine whether probiotic supplements will be useful in preventing allergy. Until then, supplementation with probiotics remains empirical in allergy medicine. In the future, basic research should focus on homoeostatic studies, and clinical research should focus on preventive medicine applications, not only in allergy. Collaborations between allergo-immunologists and microbiologists in basic research and a multidisciplinary approach in clinical research are likely to be the most fruitful.

The gut microbiota and inflammatory noncommunicable diseases: Associations and potentials for gut microbiota therapies

“…In most studies, single or several strains of lactobacilli and bifidobacteria have been used for treatment and prevention of allergic disease; the demonstrated effect of one probiotic strain cannot be extrapolated to another strain. Some probiotics exert immunomodulatory effects, mostly shown in experimental models but also in human intervention studies 8,70 . Mechanistic effects are thought to be mediated by Toll-like-receptors (TLR) to promote Th-1 cell differentiation, through enhanced production of IL-10, TGF-ß and IgA, inhibition of antigen-induced T-cell activation and suppression of TNF 8,70 .…”

“…Some probiotics exert immunomodulatory effects, mostly shown in experimental models but also in human intervention studies 8,70 . Mechanistic effects are thought to be mediated by Toll-like-receptors (TLR) to promote Th-1 cell differentiation, through enhanced production of IL-10, TGF-ß and IgA, inhibition of antigen-induced T-cell activation and suppression of TNF 8,70 . The timing of probiotics for promoting immune tolerance appears critical 8 , and a combination of pre and postnatal probiotic supplementation for allergy prevention (namely eczema) has shown the most consistent benefit, although their routine use cannot be recommended 8,30,70 .…”

“…To date, reports on later onset allergic manifestations e.g. respiratory allergic disease from initiated cohorts are limited and need to be prospectively collected and reported 8,30,70 . If prenatal microbial exposure enhances the preventive effect, as also suggested by epidemiological 71,72 and experimental studies 73 , starting supplementation in the second trimester of pregnancy, when circulating fetal T cells have developed, may be more effective 8 .…”

“…Many meta-analyses of clinical trials using probiotics have been carried out, however, there has been substantial heterogeneity in several aspects of these studies 1 . If we are to translate findings from conducted studies into recommendations in clinical practice, there is need for a more standardized approach using harmonized protocols and outcome measures in clinical trials 8,70 .…”

“LOCK”ing up allergic responses with a Polish probiotic

“…A recent World Allergy Organization systematic review 6 concurred with an earlier Cochrane Database review 7 in stating that there is not yet an established role for probiotics in preventing or treating allergies. However, the groups emphasized a need for more basic microbial research, such as that presented by Kozakova et al Evidence for protection against allergic airways disease has been shown in rodent models.…”