European Review for Medical and Pharmacological Sciences 2021; 25: 3097-3104 Effect of reuteri LRE02- LR04 combination and gastrointestinal functional disorders in an Emergency Department pediatric population

G. MARGIOTTA1, S. FERRETTI1, B. GRAGLIA1, A. GATTO2, L. CAPOSSELA1, G. BERSANI2, A. CURATOLA1, A. CHIARETTI1

1Institute of Pediatrics, Fondazione Policlinico A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy 2Institute of Pediatrics, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy

Abstract. – OBJECTIVE: are living Key Words: that, when administered per os Children, Emergency Department, Gastrointestinal in adequate amounts, may confer a health bene- functional disorders, Probiotics. fit on the by the regularization of an unbal- anced gastroenteric . The objective of this study was to evaluate treatment effec- tiveness, safety, and palatability of a ’s Introduction combination (Lactobacillus reuteri LRE02-DSM 23878 and Lactobacillus rhamnosus LR04-DSM Probiotics are living microorganisms that, 16605) in a pediatric Emergency Department setting with functional gastrointestinal disor- when administered per os in adequate amounts, ders. may confer a health benefit on the host by PATIENTS AND METHODS: Three groups the regularization of an unbalanced gastro- were enrolled: children with functional abdom- enteric microbiota1. There are many different inal pain; children with ; children ways in which probiotics can help in resolve with gas colic. Self-reporting sheets were de- GI symptoms, such as the competitive exclu- livered to each patient/parent after probiotics sion of pathogenic microorganisms, inhibition treatment. The primary outcome was to eval- of adhesion, production of anti-micro- uate the evolution of clinical conditions in en- bial substances, and modulation of the immune rolled children. 2-5 RESULTS: The outcomes showed a statisti- system . As shown in numerous studies, gas- cal difference among children treated with pro- trointestinal symptoms are common to all the biotics and those who did not. In the function- children of the world. Pediatric gastrointestinal al abdominal pain group, 58.2% of patients had functional disorders (FGID) are disorders of the a moderate symptoms improvement and 33.5% brain-intestine axis. They are the most common had a complete disappearance of symptoms, cause of chronic-recurrent abdominal pain in while in the gas colic group, 68.2% of the in- fants had a moderate improvement and 23.2% the pediatric population. had a complete resolution. In the gastroenteritis Epidemiological studies have shown that ap- group, stool consistency and number of evacu- proximately 14-25% of infants, young children, ations improved in children who took probiotic and adolescents suffer from at least one gastroin- administration as well. testinal function disorder6. Functional abdominal CONCLUSIONS: Probiotics therapy, at the pain, defined as a pain that appears at least four recommended dosage of five drops per day for times per month and includes episodic or contin- 15 days, is associated with symptoms improve- uous abdominal pain that does not occur solely ment. Moreover, the use of probiotics led to a stool consistency’s normalization in a shorter during physiologic events and which cannot be time, evaluated with BSS. A randomized trial is fully explained by another medical condition. needed to confirm these results. Acute Gastroenteritis (AGE) is a very common

Corresponding Author: Antonio Gatto, MD; e-mail: [email protected] 3097 G. Margiotta, S. Ferretti, B. Graglia, A. Gatto, L. Capossela, G. Bersani, A. Curatola, A. Chiaretti disease in children. It accounts for millions of Patients and Methods visits to primary care practices and to the Emer- gency Department. ESPGHAN has defined AGE Study Design as a decrease in consistency of stools and/or This is a monocentric survey on a cohort of an increase in the frequency of evacuations, at children recruited from patients admitted to the least three in 24 hours, with or without fever or PED of the “A. Gemelli” Hospital in Rome be- vomiting7. Infantile colic is a common problem tween January 2019 and December 2019. Children affecting 10% to 30% of healthy, thriving infants. aged between 1 month and 18 years with a diag- According to the Rome IV criteria, infantile colic nosis of functional abdominal pain, according to may be diagnosed in an infant who is less than Rome IV criteria (Table I), (Group A), gastro- 5 months of age who present with recurrent and enteritis (Group B), and gas colic (Group C) were prolonged periods of crying, fussing or irritability recruited. Functional patients were subclassified that occur without an evident cause, and in whom among the various classes of disorders. Besides, there is no evidence of failure to thrive, fever or Group A patients who had met the inclusion cri- illness8. Probiotics seem to play an important role teria and who in the second phase of the study in the control of gastrointestinal symptoms in did not maintain adherence to these criteria, but pediatric age. for whom the requirements for abdominal pain Therefore, the aim of this study is to evaluate not otherwise specified (FAP-nos) are met have treatment effectiveness, safety, and palatability of been included as such, while patients who had a probiotic’s combination (Lactobacillus reuteri met the inclusion criteria but who in the second LRE02- DSM 23878 and Lactobacillus rhamno- phase of the study did not maintain adherence to sus LR04-DSM 16605) in a Pediatric Emergency these criteria and for which the requirements for Department (PED) setting with gastrointestinal FAP-nos were not met were excluded from the symptoms. functional sample.

Table I. Rome IV diagnostic criteria for functional abdominal pain disorders9. Rome IV diagnostic criteria for functional abdominal pain disorders (AP-FGIDs)

Irritable bowel syndrome The criteria must be fulfilled for at least 2 months and include all of the following. • Abdominal pain at least 4 days per month associated with defecation and/or a change in the frequency of stool and/or a change in the appearance of stool • Abdominal pain does not resolve with resolution of (children in whom the pain resolves have functional constipation, not ) • After appropriate evaluation, the symptoms cannot be fully explained by another medical condition Functional dyspepsia The criteria must be fulfilled for at least 2 months before diagnosis and must include one or more of the following bothersome symptoms at least 4 days per month. • Postprandial fullness. • Early satiation. • Epigastric pain or burning not associated with defecation. • After appropriate evaluation, the symptoms cannot be fully explained by another medical condition. Abdominal migraine The criteria must be fulfilled for at least 6 months before diagnosis and include all of the following occurring at least twice. • Paroxysmal episodes of intense, acute periumbilical, midline or diffuse abdominal pain lasting 1 hour or more (should be the most severe and distressing symptom). • Episodes are separated by weeks to months; the pain is incapacitating and interferes with normal activities; stereotypical pattern and symptoms in the individual patient. • The pain is associated with two or more of the following: anorexia, nausea, vomiting, headache, photophobia or pallor. • After appropriate evaluation, the symptoms cannot be fully explained by another medical condition. Functional abdominal pain not otherwise specified. The criteria must be fulfilled for at least 2 months before diagnosis and at least four times per month and include all of the following. • Episodic or continuous abdominal pain that does not occur solely during physiological events (for example, eating and menses). • Insufficient criteria for irritable bowel syndrome, functional dyspepsia or abdominal migraine. • After appropriate evaluation, the abdominal pain cannot be fully explained by another medical condition.

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All patients included in the study were ran- (BSS)12; (2) evaluation of the prevalence of AEs domized by an electronic system to receive or between the groups. not a probiotic combination [Lactobacillus reu- Written informed consent was obtained from teri LRE02 (DSM 23878, 2×108 CFU daily) and the parents of children enrolled in the study, Lactobacillus rhamnosus LR04 (DSM 16605) according to the principles outlined in the Decla- 1×10 9 CFU daily] for 15 days. This treatment was ration of Helsinki. added to prescriptions, frequently represented by , deemed necessary by the physician. 5 days after the end of the treatment, parents of the Statistical Analysis enrolled patients were contacted to be subjected We performed statistical analysis with Graph- to a telephone interview. Pad Prism version 8.01 for Windows (Graph- Based on this interview, Medical Doctors Pad Software®, San Diego, USA, www.graphpad. (MDs) evaluated both the treatment effective- com). The tests used to control distributions ness in determining remission of the symptoms, normality (or non-normality) were: Shapiro-Wilk both safety and palatability of the drug, and the normality test, D’Agostino and Pearson omni- possible occurrence of adverse effects (AEs). bus normality test, Kolmogorov-Smirnov nor- To evaluate outcomes in children with acute mality test. We applied the Mann-Whitney test gastroenteritis (Group B), a validated scale (the for non-parametric distribution. Differently, we Modified Vesikari Scale, Table II) was used9-11, performed the standard Student’s t-test. To match while in Group A and C a clinical outcome re- the prevalence between the groups we applied ported by parents as “no improvement”, “moder- the Chi-squared test. We considered statistically ate improvement” or “complete disappearance of significant a p-value <0.05. symptoms” was used. For Group A and B, mod- ifications of and stool consistency were also evaluated using (BBS). Results The primary outcome of this study was to evaluate the evolution of clinical conditions in We enrolled 457 patients from 1 month to enrolled children. 18 years old, with a mean age (±SD) of 28±21 Secondary outcomes were: (1) assessment months. Group A, (children with functional ab- of stool solidity using the Bristol Stool Scale dominal pain), included 176 patients (38.51%),

Table II. Modified Vesikari Scale*.

Score on the Vesikari Scale

Scale component 0 Points 1 Point 2 Points 3 Points

Duration of diarrhea (hr) 0 1-96 97-120 ≥ 121 Maximum no. of watery stools per 24 hr 0 1-3 4-5 ≥ 6 Duration of vomiting (hr) 0 1-24 25-48 ≥ 49 Maximum no. of vomiting episodes per 24 hr 0 1 2-4 ≥ 5 Maximum recorded rectal temperature (°C)† < 37.0 37.1-38.4 38.5-38.9 ≥ 39.0 Unscheduled health care visit None NA Primary care Emergency department Treatment None Rehydration Hospitalization NA with intravenous fluids

*In the modified Vesikari scale score, one variable (percent dehydration) in the original score was replaced with the variable of unscheduled health care visits to better measure the effect of acute gastroenteritis in outpatients, given that the ability to perform frequent in-person assessments in an outpatient cohort of children can be challenging. Scores range from 0 to 20, with higher scores indicating more severe disease. Children with a score of 9 or more were considered to have moderate-to-severe gastroenteritis. NA denotes not applicable. †Temperatures were adjusted for the location of measurement: 1.1°C was added to axillary temperatures and 0.6°C was added to oral temperatures. Modified from: Schnadower D, Tarr PI, Casper TC, Gorelick MH, Dean JM, O’Connell KJ, Mahajan P, Levine AC, Bhatt SR, Roskind CG, Powell EC, Rogers AJ, Vance C, Sapien RE, Olsen CS, Metheney M, Dickey VP, Hall-Moore C, Freedman SB. Lactobacillus rhamnosus GG versus placebo for acute gastroenteritis in children. N Engl J Med 2018; 379: 2002-2014.

3099 G. Margiotta, S. Ferretti, B. Graglia, A. Gatto, L. Capossela, G. Bersani, A. Curatola, A. Chiaretti

Table III. Overall distribution of the infections among the Children with functional abdominal pain were enrolled patients. included in the study. As shown in Figure 2, the Infections Prevalence main age was between 7 and 15 years; 56.4% of the patient were female. Upper Respiratory Tract Infections (URTI) 57 (59.3%) Of these 176 patients, 35 were hospitalized, Lower Respiratory Tract Infections (LRTI) 21 (21.8%) 107 were referred to outpatient facilities and the Urinary Tract Infections (UTI) 8 (8.4%) Otitis (OT) 6 (6.3%) remaining 34 were sent home. The main diagno- Other 4 (4.2%) ses in this group were functional dyspepsia (38 cases, 21.6%), IBS (21 cases, 11.9%), abdominal migraine (15 cases, 8.5%), and FAP (27 cases, 15.3%) (Figure 3). group B (children with gastroenteritis), 249 pa- Clinical characteristics and psychosocial fac- tients (54.49%), and group C (children with gas tors associated with functional abdominal pain colic) 32 patients (7.0%). 96 children (21%) also are reported in Figure 4. had other infections that required ther- In this group stool consistency was evaluated apy (Table III). at the beginning of the treatment (T0) and after 15 days (T1). The results, reported in Table III, Group A (Functional Abdominal Pain) show statistical differences between T0 and T1. As for group A, during the study, 1130 children The telephone interview performed at the end with abdominal pain were admitted to the PER: of the treatment showed that 58.2% of patients 493 had organic pain, 461 were doubtful cases, with functional abdominal pain had a moderate and 176 had functional abdominal pain, as shown symptoms improvement, 33.5% had a complete in Figure 1. disappearance of symptoms, and the remaining 8.3% showed no improvement at the end of the therapy.

Group B (Children with Gastroenteritis) In Group B, 249 patients were enrolled. 203 (81.5%) of them had viral gastroenteritis, 42 (16.9%) bacterial gastroenteritis, and 4 (1.6%) parasitic gastroenteritis. As for population char- acteristics, 66.7% were female and the most af- fected age group was between 9 and 35 months of age. Of these 249 patients, 75 were hospitalized, 120 were referred to outpatient facilities, and the remaining 54 were sent home. Stool consistency results after the treatment are reported in Figure 5. At T0, the mean value of the BSS (Bristol Figure 1. Distribution of Group A population. Stool Scale) score was 4.5±1.5 (median 4, IQR

Figure 2. A-B, Gender and age distribution in Group A.

3100 Probiotics in pediatric gastroenteric disorders

Figure 3. Types of functional disorders in Group A.

3-5), while fifteen days after the treatment (T1), the mean value of BBS was 3.7±1.2 (median 4, Figure 5. Bristol Stool Scale (BSS) score for evaluation of IQR 3-4), (median 4, IQR 3-5) (p<0.0001). No stool consistency in group B patients at the beginning (T0) moderate or severe BBS score are reported by the and 15 days after the treatment (T1). (***p-value: < 0.001). parents of treated children. In this group, diarrhea improved after 1.7 days from the beginning of the treatment and the num- of these infants were hospitalized but all were ber of evacuations per day was 3.5±1.8 without no subsequently referred to outpatient facilities. The report of significant weight loss. telephone interview performed at the end of the treatment reported that 68.2% of the infants had Group C (Infants with Gas Colic) a moderate improvement, 23.2% had a complete In this group, 32 patients were enrolled. The disappearance of symptoms and the remaining characteristics of this group were: 72.6% of the 8.6% showed no improvement at the end of the patients were male and the most affected age therapy. No side effects were reported during and group was between 3 and 5 months of age. None after the treatment with probiotics.

Discussion

The word probiotic (from the latin pro and the Greek βιοσ literally meaning “for life”) was in- troduced by the German scientist Werner Kollath in 1953 to designate “active substances that are essential for a healthy development of life13. Since then, the scientific world has started to in- crease knowledge about probiotics and their health applications, both for intestinal and extra-intestinal disorders14, especially in children15-18. A recent recommendation of Working Group Figure 4. Characteristics and psychosocial factors. on Probiotics and Prebiotics of the European

Table IV. Comparison of stool consistency (Bristol Stool Scale) in patients with functional abdominal pain at the beginning of the treatment (T0) and 15 days after (T1). Time T0 T1 p-value

Bristol Stool Scale T0 6.3 ± 0.5 6.3 ± 0.5 > 0.05 T1 3.7 ± 1.3 4.4 ± 1.4 < 0.001 p-value < 0.001 < 0.001

3101 G. Margiotta, S. Ferretti, B. Graglia, A. Gatto, L. Capossela, G. Bersani, A. Curatola, A. Chiaretti

Society of Gastroenterology, Hepatology, and Pe- for preventing AAD, as demonstrated by diatric (ESPGHAN) promotes the use a Cochrane review published in 201510, because of some probiotic strains for the prevention of it causes fewer adverse events and the NNT is antibiotic-associated diarrhea (AAD), in particu- quite low. L. reuteri has been even extensive- lar Lactobacillus rhamnosus18,19. The rationale for ly studied in several intestinal conditions, and the use of these products relies on the hypothesis its therapeutic and preventive effects have been that AAD is caused by , an imbalance documented28. Moreover, current evidence shows between intestinal microbiota and the host18,19, that the recommended product serving for daily re-established by the capability of probiotics to consumption shall contain a quantity of 109 live modulate the , induce of anti-in- cells of at least one of the strains20,29,30. flammatory and anti-oxidant responses, compete In our study, we used a combination of en- for pathogen exclusion, and produce of anti-mi- capsulated probiotics (Limosilactibacillus reuteri crobial substances. LRE02-DSM 23878, 2×108 CFU, and Lactica- The effects of probiotics are strain- and seibacillus rhamnosus LR04-DSM 16605, 1×109 dose-dependent. The production processes can CFU), reaching both the effective numbers of affect the characteristics of the probiotic, causing CFU and biological activity; microencapsulation differences in concentration and presence of any indeed increases the resistance of probiotic mi- contaminants in the various products on the mar- croorganisms during the gastro-duodenal transit. ket18,20,21. Anyway, probiotics carry out their ac- The outcomes showed a statistical difference tion with different mechanisms: maintenance of among children treated with probiotics and those the integrity of the gut barrier, modulation of the who did not. In group A (functional abdominal content of intestine microbiota through competi- pain), 58.2% of patients had a moderate symp- tive pathogen exclusion, local immune response toms improvement, 33.5% had a complete disap- by the gut-associated immune system, prevention pearance of symptoms, while in group C (infants of bacterial translocation, induction of anti-in- with gas colic), 68.2% of the infants had a mod- flammatory and antioxidant responses, as well erate improvement, 23.2% had a complete reso- as the production of anti-microbial substances22. lution. In group B, stool consistency and number Thus, probiotics positive supplementation out- of evacuations improved in children who took comes are not limited to the gut; indeed, they also probiotic administration as well; fifteen days af- play positive effects at distant sites and organs, ter the treatment (T1), the mean value of BBS was such as bones, skin, brain, and heart16,23. statistically improved (3.7±1.2, instead of 4.5±1.5 Children dysbiosis can cause long-term effects, at T0), and diarrhea improved after 1.7 days from being a risk factor for obesity24, functional gas- the beginning of the treatment. The number of trointestinal disorders25, impaired neurocognitive evacuations per day was 3.5±1.8 without any re- outcome16. Besides, dysbiosis seems to be a con- port of significant weight loss. Therefore, this is tributing factor of the pathophysiological mecha- an important outcome in order to avoid dehydra- nisms of colic and functional abdominal pain dis- tion, which is a frequent cause of hospitalization orders. Weerth et al26 revealed asserted that infants in patients with this condition. with colic had slower colonization, lower diversity Interesting data comes from Group A, which and stability of gut , and decreased was composed of children with different condi- the concentration of Lactobacillus, Bifidobacteri- tions, such as functional dyspepsia, IBS, abdomi- um and other butyrate-producing . nal migraine, and FAP: all patients, regardless of In addition, the assumption that change in the diagnosis and the source of the disorder, bene- intestinal microbiota represents a predisposing fited from probiotic treatment. Likewise, Group B factor for the development of functional abdomi- patients improved their symptoms and stool con- nal pain27 encouraged us to examine if probiotics sistency both in case of viral gastroenteritis and have some positive impacts in terms of evolution in case of bacterial or parasitic gastroenteritis. of clinical conditions and stool consistency in Moreover, no moderate or severe side effects these groups of patients. were reported during and after the treatment with Probiotics are mostly composed of Bifidobac- probiotics in any group of our analysis. We spec- terium and Lactobacillus. These ones represent ify that some children, especially in Group B, a core group of well-studied likely to were taking antibiotic therapy at the same time, impart some general benefits1. In particular, Lac- but in the evaluations, the enrolled cohort was not tobacillus rhamnosus is the preferable probiotic stratified by any eventual type of antibiotics used.

3102 Probiotics in pediatric gastroenteric disorders

Examining our data, we can support the use 5) Sarkar A, Mandal S. Bifidobacteria-insight into of probiotics association to reduce symptoms and clinical outcomes and mechanisms of its probiot- stool consistency. Even though symptoms have ic action. Microbiol Res 2016; 192: 159-171. been reported by parents, the utilization of an 6) Robin SG, Keller C, Zwiener R, Hyman PE, Nurko S, Saps M, Di Lorenzo C, Shulman RJ, Hyams JS, international scale (BSS) reduced possible biases. Palsson O, van Tilburg MAL. Prevalence of pediat- Moreover, the large number of patients included ric functional gastrointestinal disorders utilizing the strengthens the achieved results. Rome IV criteria. J Pediatr 2018; 195: 134-139. 7) Gutierrez Castrellon P, Lopez Velazquez G, Diaz Garcia L, Jimenez Gutierrez C, Mancilla Ramirez Conclusions J, Estevez Jimenez J, Parra M. Diarrhea in pre- school children and Lactobacillus reuteri: a ran- domized controlled trial. Pediatrics 2014; 133: The probiotic mixture of L. reuteri LRE02-L. 904-909. rhamnosus LR04, at the recommended dosage 8) Perry R, Leach V, Penfold C and Davies P. An of five drops per day for 15 days, reduce symp- overview of systematic reviews of complementa- toms and stool consistency without an increase ry and alternative therapies for infantile colic. Syst in adverse events in patients aged between 1 Rev 2019; 8: 271. month and 18 years with FGID, gastroenteritis, 9) Rome IV Online Version – The Rome Foundation, and gas colic. Improvement of symptoms and 2020; https://theromefoundation.org/rome-iv/. better stool consistency have been demonstrated 10) Goldenberg JZ, Lytvyn L, Steurich J, Parkin P, Ma- regardless of the type of diagnosis and source of hant S, Johnston BC. Probiotics for the preven- tion of pediatric antibiotic-associated diarrhea. Co- the disorder. chrane Database Syst Rev 2015; 12: CD004827. 11) Guo Q, Goldenberg JZ, Humphrey C, Dib RE, Johnston BC. Probiotics for the prevention of pe- Conflict of Interest diatric antibiotic‐associated diarrhea. Cochrane The Authors declare that they have no conflict of interests. Database Syst Rev 2019; 4: CD004827. 12) Lewis SJ, Heaton KW. Stool form scale as a use- ful guide to intestinal transit time. Scand J Gastro- ORCID enterol 1997; 32: 920-924. Antonio Gatto: 0000-0002-8778-9328. 13) Gasbarrini G, Bonvicini F, Gramenzi A. Probiotics history. J Clin Gastroenterol 2016; 50 Suppl 2. References 14) Ferrarese R, Ceresola ER, Preti A, Canducci F. Pro- biotics, prebiotics and for weight loss and 1) Hill C, Guarner F, Reid G, Gibson GR, Merenstein metabolic syndrome in the microbiome era. Eur Rev DJ, Pot B, Morelli L, Canani RB, Flint HJ, Salmi- Med Pharmacol Sci 2018; 22: 7588-7605. nen S, Calder PC, Sanders ME. Expert consen- 15) Wiström J, Norrby SR, Myhre EB, Eriksson S, sus document. The International Scientific Asso- Granström G, Lagergren L, Englund G, Nord CE, ciation for Probiotics and Prebiotics Consensus Svenungsson B. Frequency of antibiotic-associ- Statement on the scope and appropriate use of ated diarrhoea in 2462 antibiotic-treated hospital- the term probiotic. Nat Rev Gastroenterol Hepa- ized patients: a prospective study. J Antimicrob tol 2014; 11: 506-514. Chemother 2001; 47: 43-50. 2) Hungin APS, Mitchell CR, Whorwell P, Mulligan 16) Slykerman RF, Coomarasamy C, Wickens K, C, Cole O, Agréus L, Fracasso P, Lionis C, Men- Thompson JMD, Stanley TV, Barthow C, Kang J, dive J, Philippart de Foy JM, Seifert B, Wensaas Crane J, Mitchell EA. Exposure to antibiotics in KA, Winchester C, de Wit N; European Society the first 24 months of life and neurocognitive out- for Primary Care Gastroenterology. Systemat- comes at 11 years of age. Psychopharmacology ic review: probiotics in the management of low- (Berl) 2019; 236: 1573-1582. er gastrointestinal symptoms-an Updated Evi- 17) Casas IA, Dobrogosz WJ. Validation of the pro- dence-based International Consensus. Aliment biotic concept: Lactobacillus reuteri confers Pharmacol Ther 2018; 47: 1054-1070. broad-spectrum protection against disease in hu- 3) Bron PA, Kleerebezem M, Brummer RJ, Cani PD, mans and animals. Microb Ecol Health Dis 2000; Mercenier A, MacDonald TT, Garcia-Ródenas 12: 247-285. CL, Wells JM. Can probiotics modulate human 18) Drago L, Meroni G, Chiaretti A, Laforgia N, Cuc- disease by impacting intestinal barrier function? chiara S, Baldassarre ME, on Behalf of The Sur- Br J Nutr 2017; 117: 93-107. veyflor Group. Effect of Limosilactobacillus reuteri 4) Bermudez-Brito M, Plaza-Diaz J, Munoz-Queza- LRE02-Lacticaseibacillus rhamnosus LR04 com- da S, Gomez-Llorente C and Gil A. Probiotic bination on antibiotic-associated diarrhea in a pe- mechanisms of action. Ann Nutr Metab 2012; 61: diatric population: a national survey. J Clin Med 160-174. 2020; 9: 3080.

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