Cow's milk allergy guidelines: a quality appraisal with the AGREE II instrument.

BACKGROUND: The appropriate diagnosis and management of cow's milk allergy (CMA) is challenging. OBJECTIVE: To systematically review the quality of the existing guidelines on CMA. METHODS: The Cochrane Library, MEDLINE, and EMBASE databases were searched from 2010 to November 2015. The methodological rigour, quality, and transparency of relevant guidelines were assessed with the use of the Appraisal of Guidelines for Research and Evaluation (AGREE II) tool. RESULTS: Of the 15 included guidelines, two, both developed by recognized scientific organizations, achieved the highest score (100%). Eight others were considered to be of high quality (i.e., overall quality scores >60%). The quality scores for each domain varied. Of all the domains, clarity and presentation had the highest mean score, and applicability had the lowest mean score. The scores (mean ± SD) for individual domains were as follows: domain 1 (score and purpose) 62 ± 36%; domain 2 (stakeholder involvement) 56 ± 33%; domain 3 (rigor of development) 55 ± 38%; domain 4 (clarity of presentation) 71 ± 29%; domain 5 (applicability) 44 ± 33%; and domain 6 (editorial independence) 60 ± 36%. One guideline had the maximum possible score of 100% for all AGREE II domains. CONCLUSION AND CLINICAL RELEVANCE: A number of guidelines on CMA are available; however, their quality varies. Overall, the guidelines developed by recognized professional/scientific organizations were of the highest quality. These guidelines should be recommended for use. Still, the methodological quality of CMA guidelines may be improved.

Meta-analysis: Lactobacillus GG for treating acute gastroenteritis in children--updated analysis of randomised controlled trials.

BACKGROUND: The efficacy of each probiotic should be evaluated separately. Previously, we have shown that Lactobacillus GG (LGG) is effective in treating acute gastroenteritis (AGE) in children. AIM: To update our 2007 meta-analysis on the effectiveness of LGG in treating AGE in children. METHODS: The Cochrane Library, MEDLINE and EMBASE databases were searched from August 2006 (end date of last search) to May 2013, with no language restrictions, for randomised controlled trials (RCTs) and meta-analyses. RESULTS: Fifteen RCTs (2963 participants) met the inclusion criteria in this updated meta-analysis. Combined data from 11 RCTs (n = 2444) showed that LGG significantly reduced the duration of diarrhoea compared with placebo or no treatment (mean difference, MD -1.05 days, 95% CI -1.7 to -0.4). LGG was more effective when used at a daily dose ≥10¹° CFU (eight RCTs, n = 1488, MD -1.11 days, 95% CI -1.91 to -0.31) than when used at a daily dose <10¹° CFU (three RCTs, n = 956, MD -0.9 day, 95% CI -2.5 to 0.69). LGG was effective in children treated in Europe (five RCTs, n = 744, MD -1.27 days, 95% CI -2.04 to -0.49); in the non-European setting, the difference between the LGG group and the control group was of a borderline statistical significance (six RCTs, n = 1700, MD -0.87, 95% CI -1.81 to 0.08). CONCLUSIONS: Lactobacillus GG reduces the duration of diarrhoea. A subset of patients that is more likely to benefit includes subjects treated with a high daily dose of LGG (≥10¹° CFU/day) who are either in-patients or out-patients from geographical Europe. Given the methodological limitations of many of the included trials, the evidence should be viewed with caution.

Clinical trial: effectiveness of Lactobacillus rhamnosus (strains E/N, Oxy and Pen) in the prevention of antibiotic-associated diarrhoea in children.

BACKGROUND: Convincing evidence that probiotic administration can lower the risk of antibiotic-associated diarrhoea is limited to certain micro-organisms. AIM: To determine the efficacy of administration of Lactobacillus rhamnosus (strains E/N, Oxy and Pen) for the prevention of antibiotic-associated diarrhoea in children. METHODS: Children (aged 3 months to 14 years) with common infections were enrolled in a double-blind, randomized, placebo-controlled trial in which they received standard antibiotic treatment plus 2 x 10(10) colony forming units of a probiotic (n = 120) or a placebo (n = 120), administered orally twice daily throughout antibiotic treatment. Analyses were by intention to treat. RESULTS: Any diarrhoea (>or=3 loose or watery stools/day for >or=48 h occurring during or up to 2 weeks after the antibiotic therapy) occurred in nine (7.5%) patients in the probiotic group and in 20 (17%) patients in the placebo group (relative risk, RR 0.45, 95% confidence interval, CI 0.2-0.9). Three (2.5%) children in the probiotic group developed AAD (diarrhoea caused by Clostridium difficile or otherwise unexplained diarrhoea) compared to nine (7.5%) in the placebo group (RR 0.33, 95% CI 0.1-1.06). No adverse events were observed. CONCLUSION: Administration of L. rhamnosus (strains E/N, Oxy and Pen) to children receiving antibiotics reduced the risk of any diarrhoea, as defined in this study.

Systematic review: racecadotril in the treatment of acute diarrhoea in children.

BACKGROUND: Racecadotril (acetorphan) is an antisecretory drug that exerts its antidiarrhoeal effects by inhibiting intestinal enkephalinase. AIM: To summarize studies testing the efficacy and safety of racecadotril for treating children with acute gastroenteritis. METHODS: Reports were gathered by searching electronic databases MEDLINE, EMBASE, the Cochrane Library (all up to April 2007), relevant journals, and bibliographies of reviewed articles. Only randomized-controlled trials were included. RESULTS: Three randomized-controlled trials (471 participants) met the inclusion criteria. Two trials reported stool output, and data suggested less stool output in the racecadotril group than in the control group. The duration of diarrhoea was significantly reduced in the three trials reporting this outcome. Achievement of a cure by day 5 was similar in both groups. Adverse effects were similar in both groups. CONCLUSIONS: The small number of included trials provided some evidence in favour of the use of racecadotril over placebo or no intervention, to reduce the stool output and duration of diarrhoea in children with acute gastroenteritis. However, more data in out-patients are needed. The safety as well as the cost-effectiveness of the therapy should be explored, before routine therapy with racecadotril is recommended.

Meta-analysis: Lactobacillus GG for treating acute diarrhoea in children.

AIM: To review evidence for the effectiveness of Lactobacillus GG (LGG) in treating acute infectious diarrhoea in children. METHODS: The following electronic databases were searched through August 2006 for studies relevant to acute infectious diarrhoea and LGG: MEDLINE, EMBASE, CINAHL and The Cochrane Library; additional references were obtained from reviewed articles. Only randomized-controlled trials (RCTs) were included. RESULTS: Eight RCTs (988 participants) met the inclusion criteria. Compared with controls, LGG had no effect on the total stool volume (two RCTs, n = 303). However, LGG was associated with a significant reduction in diarrhoea duration (seven RCTs, 876 infants, weighted mean difference, WMD -1.1 days (95% confidence interval, CI -1.9 to -0.3), particularly of rotavirus etiology (WMD -2.1 days, 95% CI -3.6 to -0.6), risk of diarrhoea >7 days (one RCT, n = 287, relative risk 0.25, 95% CI 0.09-0.75) and duration of hospitalization (three RCTs, n = 535, WMD -0.58, 95% CI -0.8 to -0.4; significance was lost in the random effect model). There was no reduction in the number of stools at any time interval. CONCLUSIONS: The use of LGG is associated with moderate clinical benefits in the treatment of acute diarrhoea in children. These findings should be interpreted with caution due to the important methodological limitations and heterogeneity of most of the studies.