In Europe, besides appropriate rehydration and patient education, probiotics are also advised in the management of acute diarrhea in childhood.3
Probiotics are live microorganisms that survive in the gastrointestinal tract and have a health benefit on the host. S. boulardii
is a non-pathogenic probiotic yeast, which is naturally resistant to gastric acidity and antibiotics. Extensive research has shown a significant reduction of the duration of acute watery diarrhea of infectious origin.5
Also bloody diarrhea due to amebiasis in children is shortened in comparison to placebo when S. boulardii
is added to metronidazole.12
Yogurt is a coagulated fermented milk product that is the result of fermentation with L. bulgaricus
and S. thermophilus
and its fluid shelters these probiotic microorganisms.5
The therapeutic dose of yogurt has been reported to be around 106
CFU of Lactobacilli
The yogurt fluid used in this study was extracted from a commercially available yogurt (Pinar®
, Pınar JSC, Eskisehir, Turkey) containing 107
colony forming unit (CFU) per 100 gram. L. bulgaricus
and S. thermophilus
that are used to ferment milk to yogurt, are considered to be probiotics and yogurt fluid shelters these probiotics6
(information provided by the manufacturer). Mixtures of L. bulgaris
and S. thermophilus
and formulas supplemented with S. thermophilus
have been shown to be beneficial in the treatment by decreasing the duration and frequency of non-bloody diarrhea in children and in the prevention of diarrheal episodes.15–17
Boudraa et al.18
compared the same formula, not-fermented and fermented with L. bulgaricus
and S. thermophilus,
in children with acute watery diarrhea. The yogurt feeding was associated with a 31% decrease in the median duration of diarrhea and a decrease in stool frequency in favor of the yogurt group.18
In a randomized controlled trial performed in 80 children, the authors reported an average mean duration of hospitalization of 2.7 days in the yogurt group, which was significantly (0.4 day) shorter than the control group, in whom only routine hospital treatment of diarrhea was applied.17
A meta-analysis performed by Van Niel et al.19
demonstrated a reduction in diarrhea duration of about 0.7 days with yogurt compared with placebo, with different protocols, and also showed reduction of stool frequency on second day of yogurt.
According to a meta-analysis, S. boulardii
reduces the duration of diarrhea by approximately 1 day and leads to complete healing at day 3.5,20–23
In another Turkish study, Kurugol and Koturoğlu22
compared the effect of S. boulardii
in 200 children and showed that duration of diarrhea shortened from 5.5 to 4.7 days, while the mean duration of hospitalization was shortened from 3.9 days to 2.9 days in S. boulardii
treated patients. We also observed that diarrhea lasted approximately 4.5 day with S. boulardii
treatment. In our study, compared with YF, S. boulardii
did not shorten the duration of hospitalization.
This clinical trial is unique in terms of comparing YF with S. boulardii. We preferred YF because most of the ill children prefer to drink rather than to eat during an episode of acute diarrhea. It is easier for children to drink 30–60 mL fluid instead of eating 100–200 gr yogurt.
Previously, Gaon et al.24
evaluated the efficacy of cow milk with S. boulardii.
They randomized 89 children with persistent diarrhea to receive pasteurized cow milk alone, or supplemented with Lactobacillus casei
and L. acidophilus
or S. boulardii
) CFU. Both mix probiotic groups and S. boulardii
reduced the duration of diarrhea compared with cow milk alone in patients infected with Shigella, E. coli
, and Salmonella. There was no difference in the subgroup infected by rotavirus. We also could not find a difference in rotavirus infected patients. Although the duration of diarrhea shortened by approximately 2 days and the hospital stay duration was reduced about 1 day in the YF group compared with the S. boulardii
group, these findings were not significant. In terms of vomiting, this study demonstrated an equal effect between S. boulardii
In regard to the duration of diarrhea (4.5 versus 4.8 days) and hospitalization days (4.7 versus 4.7 days), the 2 were comparable. However, regarding the number of children with resolution of diarrhea on day 3, efficacy tended to be greater in the S. boulardii group for the per protocol analysis. However, the intention to treat analysis showed a statistically significant difference favoring S. boulardii over YF for the number of patients with normal stools in day 3 (16 patients (48.5%) versus 8 patients (25.5%); P = 0.033).
Compared with S. boulardii,
YF can be easily made at home and needs no prescription. But YF is much more difficult to administer in hospitalized patients. In our hospital settings, yogurt was freshly prepared and directly delivered from the manufacturer to the hospital and YF was prepared daily. But one must realize that an ideal probiotic culture should contain 106
CFU viable cells per milliliter and that most of this fermentative bacteria's have a poor viability.25
We could not perform a daily bacterial count from YF. But the manufacturer provided that 100 mL YF fluid contains 107
microorganism at the end of their shelf life. But still because of the lack of data on viability of the bacteria in YF in different environmental conditions, the results of this trial cannot be extrapolated to the normal daily situation, because it cannot be excluded that the YF of not day-fresh yogurt may contain fewer viable probiotic microorganisms.
In conclusion, the effect of daily freshly prepared YF was comparable to S. boulardii in the treatment of acute non-bloody diarrhea in children. Although the overall duration of diarrhea in both groups was not different, normalization of stool composition and frequency was more rapid in the S. boulardii group. On day 3, significantly more patients were cured in the S. boulardii group than in the YF group. These results should be confirmed with a large scale placebo controlled clinical trial evaluating the efficacy of commercialized yogurt.