Functional Gastrointestinal Disorders in Infancy

No. 46 | June 2020

Functional gastrointestinal disorders in infancy

Functional gastrointestinal disorders in infants: relevance in daily practice Yvan Vandenplas The role of microbiota on infantile colic Rodrigo Vázquez Frias Management of infants with gastroesophageal reflux and constipation Carlos Lifschitz Quality of life of infants with functional gastrointestinal disorder Camille Jung

History & full Alarm ∞ Reassurance & Guidance No Functional gastrointestinal physical exam ! signs ∞ Nutritional Management disorders in infants:

Refer to specialty Yes Infant relevance in daily practice consultation Symptom- free & happy

Yvan Vandenplas Parents Less clinic KidZ Health Castle, Universitair Ziekenhuis Brussel, consultations settled and and healthcare Vrije Universiteit Brussel, Brussels, Belgium confident costs [email protected] Figure 1: Infant with (one or more) FGID(s)

Historically, functional gastrointestinal separate manifestations, more than years later.6 An infant presenting with There is quiet References Key messages: disorders (FGIDs) got limited attention 75% of the infants present with more frequent regurgitation early in life has 1. Hegar B, Dewanti NR, Kadim M, Alatas S, from health care providers because than one FGID; 15% even present with a 2 to 5 times higher risk to have Firmansyah A, Vandenplas Y.Natural evolution some evidence of regurgitation in healthy infants. Acta • Functional gastrointestinal i) symptoms were considered to three.3 Conclusion: i) FGIDs in infancy gastroesophageal reflux (GER) that FGIDs do Paediatr. 2009 Jul;98(7):1189–93. improve and finally disappear over are frequent, worldwide; ii) the majority symptoms when 9 years old. Also the 2. Vandenplas Y, Salvatore S, Ribes-Koninckx C, disorders (FGIDs) in infancy are Carvajal E, Szajewska H, Huysentruyt K. The frequent, worldwide. time, ii) there was no disease, and of infants present with a combination opposite has been shown: children have a long-term Cow Milk Symptom Score (CoMiSSTM) in presumed healthy infants. PLoS One. 2018 Jul iii) families had other health care of FGIDs. with abdominal pain-related FGIDs at • The majority of infants present 18;13(7):e0200603. priorities such as infant mortality and 7.9 years of age had higher prevalence impact on the 3. Bellaiche M, Oozeer R, Gerardi-Temporel G, with a combination of FGIDs. Faure C, Vandenplas Y. Multiple functional morbidity which was much higher The next question that needs to be of GI distress during the first three quality of life of gastrointestinal disorders are frequent in • The management of FGIDs in formula-fed infants and decrease their quality than today. Typically, the impact of addressed is: So what? Does it matter? months of life. Ex-colicky children of life. Acta Paediatr. 2018;107:1276–1282. infants consists of parental FGIDs in health care goes hand in FGIDs in infants are traditionally displayed more negative emotions the infant and 4. Horward CR, Lanphear N, Lanphear BP, Eberly reassurance and guidance and S, Lawrence RA. Parental responses to infant hand with the living standard. However, considered to disappear spontaneously according to the temperament scale. crying and colic: the effect on breastfeeding nutritional intervention. the family this does not mean that the incidence over time. However, that statement is Four year old children with a history duration. Breastfeed Med 2006;1:146–55. 5. Vik T, Grote V, Escribano J, Socha J, Verduci E, • Nutritional interventions are of FGIDs in infants in developing not valid for constipation as 25% of of infantile colic still present more Fritsch M, Carlier C, von Kries R, Koletzko B; effective and safe. countries differs from that in the children with functional constipation negative moods during meals, and of probiotics in the management of European Childhood Obesity Trial Study Group. et al. Acta Paediatr 2009;98:1344–8. 6 FGIDs. Different probiotics, prebiotics, western world. The incidence of continue to experience symptoms at report more stomach-ache. Although 6. Canivet C, Jakobsson I, Hagander B. Infantile troublesome regurgitation in Indonesia adult age. Infantile colic improves after relationships regarding crying and synbiotics and postbiotics have colic. Follow-up at 4 years of age: still more “emotional”. Acta Paediatr. 2000 ;89:13–7. is exactly the same as reported in the the age of 3–4 months; regurgitation mother-infant interaction remain resulted in the effective prevention literature, but Indonesian mothers decreases at 6 months, and certainly extremely complex, the findings point and management of constipation, seek less frequently medical help.1 The between 12 and 15 months. However, toward a possible temperamental distress and regurgitation in infants. same applies for crying: presumably, there is evidence that FGIDs do have a contribution to the pathogenesis healthy Polish infants cry significantly long-term impact on the quality of life of infantile colic. Conclusion: more than infants in Belgium and of the infant and the family. FGIDs are The cornerstone of the management 2 Spain. The most frequent FGIDs are a cause of feeding difficulties causing The development of the gastro- of FGIDs in infants consist of parental 4 troublesome regurgitation (~25%), also discontinuation of breastfeeding. intestinal microbiome is recognized as reassurance and guidance. Nutritional infantile colic (~20%) and constipation FGIDs are a well-known cause of important in promoting health in treatment, focusing on the (~10%). parental stress, depression and infants. An altered gut microbiome, development and preservation of a 5 insecurity. FGIDs are also a cause of referred to as dysbiosis, has an healthy balanced gastrointestinal Worldwide, at least 25% of infants behavioral disorders of the infant. etiologic role in the development of microbiome, has been shown to be suffer from at least one FGID. While Quality of life of a family with an infant FGIDs, such as distress and alterations effective and safe. most guidelines discuss FGIDs as with a FGID is still challenged three is stool composition. Randomized controlled trials reported efficacy

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The role of microbiota Pain detection Crying on infantile colic Gut brain axis

Gut motility Intestinal Rodrigo Vázquez Frias permeability

Paediatric gastroenterologist and nutritionist at Hospital Infantil Gas production Gut low grade Figure 1: Possible de México Federico Gómez, Mexico City, Mexico. & gut distention inﬂammation mechanisms through which dysbiosis can [email protected] contribute excessive crying/colic. Adapted from Zeevenhooven J et al, 2018

The amount and pattern of infant reported an association between pro-inflammatory cytokines such Several studies References Key messages: crying are age-dependent and change IC and characteristics in intestinal as tumour necrosis factor-α 1. Zeevenhooven J, Brownie PD, L’Hoir MP, de during the first months of life. There is microbiota such as lower bacterial (TNF– ) and interleukin-1 (IL-1 ). Weerth C, Benninga MA. Infant colic: α β β among infants mechanisms and management. Nat Rev • Growing scientific evidence an increased duration of crying in the diversity, higher abundance of Also, it modulates the composition have reported an Gastroenterol Hepatol 2018;15:479–96. first weeks of life, reaching a maximum Proteobacteria and lower abundance of intestinal immune cells in neonatal 2. Benninga MA, Nurko S, Faure Ch, Hyman PE, St suggests a link between James–Roberts I, Schechter NL. Childhood the alterations in microbiota between 6 and 8 weeks of age and of Bifidobacterium and Lactobacillus.4 gut, including dendritic cells and association between Functional Gastrointestinal Disorders: Neonate/ Toddler. Gastroenterology 2016;150:1443–55. 5 and infant colic. then declining to more stable levels The clinical management of infant regulatory T cells. According to a 3. Lucas A, St James–Roberts I. Crying, fussing around 12 weeks of age.1 The Rome IV colic includes: parental education, meta-analysis, using data from 4 infant colic and and colic behaviour in breast- and bottle-fed • Limosilactobacillus (L) reuteri infants. Early Human Development criteria has drastically reviewed the reassurance and empathy provided double-blind trials, including 345 (previously known as Lactobacillus characteristics 1998;53(1),9–18. clinical definition of infant colic (IC). by the physician; modification of infant infants with colic, L. reuteri 4. Dubois NE, Gregory KE. Characterizing the reuteri*) DSM17938 is the probiotic in intestinal Intestinal Microbiome in Infantile Colic: strain with the highest evidence of According to it, infant colic occurs if care and environmental routines. DSM 17938 is effective and can be Findings Based on an Integrative Review of the 1) an infant is less than 5 months of The treatment with pharmacological recommended for treatment Literature. Biol Res Nurs 2016;18(3):307–15. efficacy and can be recommended microbiota doi:10.1177/1099800415620840 6 for breastfed infants with infant age when the symptoms start and agents, like simethicone or lactase, of breastfed infants with colic. 5. Hoang TK, Freeborn J, Wang T, Mai T, He B, Park S, et al. Human Breast Milk Promotes the colic. stop; 2) recurrent and prolonged is not supported by clinical evidence; In addition to that, a recent study, Immunomodulatory Function of Probiotic periods of infant crying, fussing, or while the use of certain probiotic not included in the meta-analysis, There is evidence suggesting that Lactobacillus reuteri DSM 17938 in the Neonatal • Partially hydrolyzed formula may Rat Intestine. J Probiotics Health 2019;7(1). irritability reported by caregivers that strains may be helpful.1 has shown that infants with colic partially hydrolyzed formula (pHF) pii: 210. offer some useful alternative to occur without obvious cause and treated with L. reuteri DSM 17938 use in non-exclusively breastfed 6. Sung V, D’Amico F, Cabana MD, Chau K, Koren intact protein in the dietary G, Savino F, et al. Lactobacillus reuteri Treat cannot be prevented or resolved by Amongst the few probiotic strains for 30 days not only significantly infants maybe associated with Infant Colic: A Meta-analysis. Pediatrics management of infant colic, but 2018;141(1):e20171811. doi:10.1542/ caregivers; and 3) has no evidence used in the treatment of infant colic, decreased crying time, but also decreased colic incidence compared more randomized controlled trials peds.2017–1811 of failure to thrive, fever, or illness.2 Limosilactobacillus (L) reuteri had confirmed reduction in faecal with infants, fed intact protein infant 7. Savino F, Garro M, Montanari P, Galliano I, are needed to support its efficacy. Bergallo M. Crying Time and ROR /FOXP3 1,8 γ All of the above should be present to (previously known as Lactobacillus calprotectin and RORg/FOXP3 ratio, formula. pHF may offer some useful Expression in Lactobacillus reuteri DSM17938- diagnose infant colic. IC occurs in reuteri*) DSM 17938 has been the most supporting the hypothesis of probiotic alternative to intact protein in the Treated Infants with Colic: A Randomized Trial. J Pediatr 2018;192:171–7 both breast-fed and formula-fed studied. It inhibits pathogen growth induced local and systemic reduction dietary management of common 8. Vandenplas Y, Latiff AHA, Fleischer DM, infants.3 The etiology of IC is in inflammation.7 More studies are FGIDs, although well-designed, Gutiérrez-Castrellon P, Miqdady MIS, Smith P, and affects the immune system in et al. Partially hydrolyzed formula in suggested to be multifactorial such different ways: through a modulatory needed for better understanding of randomized trials are needed to allow non-exclusively breastfed infants: A systematic review and expert consensus. Nutrition as gastrointestinal, psychosocial, and effect of the pro-inflammatory the efficacy mechanism of probiotics to recommend the use of pHF for 2019;57:268–74. doi:10.1016/j.nut.2018.05.018 neurodevelopmental, with increasing signalling via Toll-like receptor 4 in infant colic. treatment in infants with FGIDs.9 9. Vandenplas Y, Cruchet S, Faure C, Lee H, Di Lorenzo C, Staiano A, et al. Acta Paediatr importance of the role of intestinal (TLR4) and nuclear factor-B (NF-B), 2014;103:689–95. doi: 10.1111/apa.12637 microbiome. Several studies have resulting in decreased mucosal *Due to reclassification of Lactobacillus genus into groups of closely related species, Lactobacillus reuteri is renamed to Limosilactobacillus reuteri (see infographics at page 9)

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Management of infants 50 with gastroesophageal 40 30 reflux and constipation 20

% of children spitting up children % of Natural History of 10 regurgitation in infants and Carlos Lifschitz children constructed from data obtained from Associate Physician, Hospital Italiano de Buenos Aires, Argentina 0 1 2 3 4 5 6 7 8 9 10 11 ... 18 reference 2. Age in months [email protected]

We will discuss here two of the pump inhibitors in infants with Constipation Because of their References 3 three more frequent functional regurgitation. Discontinuation of 1. Hegar B, Dewanti NR, Kadim M, et al. Natural Key messages: Diagnosis of constipation in infants breastfeeding is not recommended safety profile, evolution of regurgitation in healthy infants. gastrointestinal disorders (FGIDs) is relatively simple; it must include Acta Paediatr 2009; 98:1189–1193 • Although we all know that in infants. but alginates can be used to thicken 2. James Martin A. Natural History and Familial 1 month of at least 2 of the following: probiotics may Relationships of Infant Spilling to 9 Years of functional gastrointestinal breastmilk in the stomach. Early 1) two or fewer defecations per week Age. Pediatrics. 2002; 109:1061 disorders (FGIDs) in infants are administration of Limosilactobacillus 3. Orenstein SR, Hassall E, Furmaga-Jablonska W, 2) history of excessive stool retention, be an attractive transient problems, parents Gastroesophageal reflux (L) reuteri (previously known as et al. Multicenter, double-blind, randomized, painful or hard bowel movements, placebo controlled trial assessing the efficacy sometimes want more than Although regurgitation can occur at Lactobacillus reuteri*) DSM17938 has option in the and safety of proton pump inhibitor 3) large-diameter stools and/or lansoprazole in infants with symptoms of just words. any age, it peaks around 4 months been shown to control regurgitation gastroesophageal reflux disease. J Pediatr presence of a large fecal mass in the treatment of of age, tapering from 6 months and episodes in full-term breastfed 2009; 154:514–520 e4. • Breastfeeding should never rectum.7 This is the only infantile FGID 4. Garofoli F, Civardi E, Indrio F, et al. The early 4 declining in frequency until 12–15 infants. Thickened feedings and functional administration of Lactobacillus reuteri DSM be discontinued as a form of for which treatment recommendations months1 (Figure 1).2 When correctly antiregurgitation formulas can 17938 controls regurgitation episodes in treatment of a FGID. include medications: lactulose constipation full-term breastfed infants. Int J Food Sci Nutr. identified, unnecessary doctor visits decrease regurgitation in healthy 201465:646–8 • Dietary management if necessary, 1–2 g/kg, once or twice/day or 5. Indrio F, Riezzo G, Giordano P, et al. Effect of a and investigations and therapy will formula fed infants and are part of is the recommended treatment of polyethylenglycol 3350 0.2–0.8 partially hydrolysed whey infant formula be avoided. Treatment goals are to the treatment guidelines, as well as supplemented with starch and Lactobacillus regurgitation while medications g/kg/day. reuteri DSM 17938 on regurgitation and gastric provide symptom relief, prevent an empirical trial of an extensively motility. Nutrients 2017. 9; 1181 can be used for treatment of 8 complications and effective hydrolyzed protein formula. A study constipation in formula fed infants. 6. Vandenplas Y , Cruchet S, C Faure, et al. When constipation. However, parents usually don’t In addition, in a 2010 study,9 the should we use partially hydrolysed formulae for reassurance. In order to improve with a partially hydrolyzed whey frequent gastrointestinal symptoms and allergy like their infants to be on long term prevention? Acta Paediatr. 2014;103, 689–95 the caregiver-child interaction formula (PHWF) supplemented with authors concluded that the medication despite their lack of side administration of L reuteri (DSM 7. Benninga MA, Nurko S, Faure C, et al. relieving the caregiver’s fears about starch and L. reuteri DSM 17938 Childhood Functional Gastrointestinal effects, generally good results, 17938), a probiotic (live beneficial Disorders: Neonate/Toddler. Gastroenterology the condition may lead to reduction significantly reduced regurgitation 2016;150:1443–1455 palatability, ease of administration bacteria), administered to infants with of parents’ anxiety and consequently compared to controls.5 Overall, PHWF 8. ESPGHAN Committee on Nutrition: Braegger C, and cost. In the first year of life, dietary Chmielewska A, Decsi T, et al. Supplementation demand for medications, as may offer a useful alternative to intact chronic constipation had a positive manipulation is almost impossible of Infant Formula with Probiotics and/or management guidelines do not protein in the dietary management of effect on bowel frequency, even when Prebiotics: A systematic review and comment except for changing the formula type by the ESPGHAN Committee on Nutrition. recommend their use. Multiple trials common functional gastrointestinal there was no improvement in stool J Ped Gastroenterol Nutr 2011;52: 238–250 in non-breastfed infants. Prebiotics, showed a lack of benefit of proton symptoms.6 consistency. Because of their safety 9. Coccorullo P, Strisciuglio C, Martinelli M, et al. small non digestible and Lactobacillus reuteri (DSM 17938) in infants with profile, probiotics may be an attractive functional chronic constipation: a double- nonabsorbable carbohydrates, have option in the treatment of functional blind, randomized, placebo-controlled study. J Pediatr. 2010;157:598–602 been shown to prevent or relief constipation. *Due to reclassification of Lactobacillus genus into groups of closely related species, Lactobacillus reuteri is renamed to Limosilactobacillus reuteri (see infographics at page 9)

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Mean change in score from inclusion to D15 (mean ± SD) by type of FGIDa Table 2: Mean change Quality of life of Constipation Diarrhea Regurgitation Constant Regurgitation Regurgitation in QUALIN scores (N=122) (N=24) (N=443) crying and diarrhea and constipation between Inclusion and (N=35) (N=57) (N=134) Day 15 according to the type of FGID3 QUALIN Score +11.46±30.17 +6.77±16.44 +11.02±53.84 +10.60±18.48 +7.21±22.01 +9.99±31.37 infants with functional (p<0.0001) (p=0.0438) (p<0.0001) (p=0.0007) (p=0.0136) (p=0.0002) gastrointestinal disorders aFGID: functional gastrointestinal disorder; SD: standard deviation. Variable Change in QoLb Reference p-value Odds ratio 95%CI

Age < 1 month vs >3 months Increase Stability 0.0470 1.71 1.01 2.89 Camille Jung Age [1;2] months vs >3 months Increase Stability <0.0001 2.42 1.63 3.61 Table 3: Multivariate Age [2;3] months vs >3 months Increase Stability 0.0299 1.56 1.04 2.34 Centre Hospitalier Intercommunal de Creteil, France analysis of factors Partial breastfeeding Yes vs. No Increase Stability 0.0241 1.43 1.05 1.94 associated with an [email protected] increase in quality Dietary advice Yes vs. No Increase Stability 0.0016 1.63 1.20 2.19 of life3 bQoL: quality of life (assessed using the QUALIN questionnaire).

It is estimated that 20-30% of fortunately infrequent: maternal Quality of Life questionnaire (Qualin), Quality of Life is References Key messages: consultations during the first months postpartum depression, shaken baby which is a general QoL questionnaire 1. Vandenplas Y et al (2015) Prevalence and health of life are related to Functional syndrome, early cessation of validated in several languages.3 outcomes of functional gastrointestinal a marker of symptoms in infants from birth to 12 months of • Although benign and with gastrointestinal disorders (FGIDs).1 breastfeeding or behavior and sleep Medical management was mainly symptom severity age. J Pediatr Gastroenterol Nutr 61:531–537 Although FGIDs are benign and of problems, etc.2 These complications based on dietary advices: prescription 2. Zeevenhooven J, Browne PD, L’Hoir MP, de favorable outcome, functional Weerth C, Benninga MA. Infant colic: gastrointestinal disorders (FGIDs) favorable outcome, they cause are partly related to the difficulties for of an infant formula targeting the that must be mechanisms and management. Nat Rev Gastroenterol Hepatol. 2018;15:479–496 cause significant parental worry significant parental worry and anxiety. parents to manage these FGIDs. Few GI symptoms, lifestyle advice and 3. Jung et al. Quality of life of infants with and anxiety. FGIDs often occur in combination in studies have investigated the quality of reassurance. In this study, improved considered in the functional gastrointestinal disorders: a large prospective observational study. International the same infant, for example infant life (QoL) of infants and their families QoL was associated in multivariate • In FGIDs, improving quality of life management of Journal of Child Health and Nutrition. 2017; regurgitation associated with infant in cases of FGID. This is partly related analysis with younger age, lifestyle 6:62–69. is the major goal of treatment. 4. Bellaiche M, Oozeer R, Gerardi-Temporel G, colic, which could complicate the to the difficulty of having QoL scales, and dietary advices as well as symptoms Faure C, Vandenplas Y. Multiple functional • Assessment of quality of life in gastrointestinal disorders are frequent in message delivered to parents (Table 1). validated and specific to these partial breastfeeding (Table 2 and 3). formula-fed infants and decrease their quality these disorders should be a marker Physicians and more generally health disorders in infants. In a large French More recently, Bellaiche et al have of life. Acta Paediatr. 2018 Jul;107(7): 1276–1282. of effective management. difficulty of caring for these infants. caregivers may also have concerns observational study on 815 infants, performed a study on 2757 infants 5. Van Tilburg MA, Hyman PE, Walker L, et al. about complications that are QoL was assessed with the Infant under 6 months recruited by private Using the PedsQL4.0 Generic Core Prevalence of functional gastrointestinal disorders in infants and toddlers. J Pediatr 2015; French pediatricians in order to Scale to measure QoL, Van Tilburg et 166: 684-9. compare infant’s QoL with a single al showed that the mean QoL score 6. Youssef NN, Murphy TG, Langseder AL, Rosh Type of disorder No % JR. Quality of life for children with functional FGID and to those with more than one of infants suffering from FGID was abdominal pain: a comparison study of patients’ Single FGID Gas 40 1.5 and parents’ perceptions. Pediatrics 2006; 4 10 points lower on a scale of 100 than (n = 602) Constipation 55 2.0 FGIDs. The used questionnaire was 117: 54–9. that of infants without FGID (p<0.001).5 Colic 123 4.5 also the adapted-Infant Quality of Life questionnaire. In their study, multiple Another team found similar results Regurgitation 384 14.0 FGIDs were very frequent and in older children with FGID compared Two FGIDs Gas/Constipation 60 2.2 represented almost 78% of their to healthy children.6 Whereas FGIDs (n = 1739) Constipation/Colic 83 3.0 are not a life-threatening condition, Constipation/Regurgitation 130 4.7 cohort, with the combination of QoL of infants and families is greatly Gas/Regurgitation 209 7.6 gas/bloating and colic being the most Colic/Regurgitation 481 17.4 frequent (in 28% of cases). Multiple impacted by these functional Gas/Colic 776 28.1 FGIDs was associated with lower QoL disorders. QoL is a marker of symptom ≥3 FGIDs Gas/Constipation/Regurgitation 60 2.2 compared to single FGID at inclusion severity that must be considered in Table 1: Prevalence of (n = 406) Constipation/Colic/Regurgitation 81 2.9 and at follow-up visit, as well as a the management of symptoms. It must gastrointestinal (GI) Gas/Constipation/Colic 117 4.3 lower body weight and a shorter therefore be the primary target of disorders in all infants and clinical management. distribution according to Gas/Constipation/Colic/Regurgitation 148 5.4 breastfeeding duration, reflecting the the type of GI4 Total 2747 100 FGID = functional gastrointestinal disorder; n = number of infants.

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Nestlé Nutrition THE BIG BREAKUP OF Institute Scientists re-classify one genus into Lactobacillus twenty- ve genera The Lactobacillus genus contained over 250 species. New DNA-based analytical tools enabled scientists to see that the species historically grouped under Lactobacillus were very genetically diverse and did not adhere to nomenclature conventions. Applying the most current methods, a global group of Building scientists collaborated to divide this genus into groups of closely related species—which share certain physiological and metabolic properties—under new genus names. Understanding. New names for some prominent Lactobacillus probiotic species These probiotic Current name New name Lactobacillus have not changed names: Shaping Lactobacillus casei Lacticaseibacillus casei • Lactobacillus acidophilus Lactobacillus paracasei Lacticaseibacillus paracasei • Lactobacillus delbrueckii Lactobacillus rhamnosus Lacticaseibacillus rhamnosus subsp. bulgaricus Lactobacillus plantarum Lactiplantibacillus plantarum (aka Lactobacillus Innovation. Lactobacillus brevis Levilactobacillus brevis bulgaricus) Lactobacillus salivarius Ligilactobacillus salivarius • Lactobacillus crispatus Lactobacillus fermentum Limosilactobacillus fermentum • Lactobacillus gasseri Lactobacillus reuteri Limosilactobacillus reuteri • Lactobacillus johnsonii • Lactobacillus helveticus

All new genera proposed for this group begin with the letter “L”, so the abbreviated form of genus/species – The new groupings may facilitate our such as L. rhamnosus – remain unchanged. understanding of common mechanisms that could Species names and strain designations have not changed. mediate probiotic health bene ts, because species that are more closely related (and therefore are more likely to share physiological traits) are grouped Lactobacillus timeline under the same genus. The Nestlé Nutrition We do this by sharing cutting edge 1901 Lactobacillus rst described You can nd new Lactobacillus names easily Institute was established content with our elite members here: http://lactobacillus.uantwerpen.be Lactobacillus casei Shirota – one of the 1935 in 1981 with the earliest commercial probiotics – rst sold What do the changes mean goal to advance the Offering free access to more 35 Lactobacillus species described to date for scientists? than 3000 nutrition articles and 1975 science of nutrition • New publications on Lactobacillus hundreds of video presentations strains should use the new genus 1982 DNA-based approach to taxonomy started with 16S rDNA sequencing names. You may need to provide a brief explanation of the changes to And today, we still follow a Lactobacillus rhamnosus GG isolated 1983 editors or reviewers. clear and ambitious global Making available exclusive by Goldin and Gorbach • When searching the scienti c Accredited e-learning programs literature for a speci c strain, it may be vision: which is to bring 1987 Lactobacillus reuteri species patented necessary to search under both the old nutrition science to life for genus name and the new genus name. the people who live it. 1995 67 Lactobacillus species described to date Providing valuable practical These Lactobacillus taxonomic changes are described in the following scientific paper: content to Health Care First Lactobacillus genome sequence – 2003 Zheng et al. 2020. A taxonomic note on the Professionals through our website L. plantarum WCFS1 genus Lactobacillus: Description of 23 novel genera, emended description of the genus and social media channels. Lactobacillus Beijerink 1901, and union of 2005 147 Lactobacillus species described to date Lactobacillaceae and Leuconostocaceae. IJSEM. https://doi.org/10.1099/ijsem.0.004107 Phylogenic analysis based on genomic DNA used 2015 to establish taxonomic groupings of microbes

2015 265 Lactobacillus species described to date For more information visit ISAPPscience.org Become a member today to join our growing community of over Lactobacillus genus taxonomy updated, 2020 300,000 healthcare professionals and enjoy access to all our resources at: now composed of 25 genera or follow us on Twitter @ISAPPscience Advancing science © 2020, International Scienti c Association for Probiotics and Prebiotics nestlenutrition-institute.org for better nutrition 9 10 This booklet is protected by copyright. However, it may be reproduced without the prior written permission of Nestlé Nutrition Institute but is subject to acknowledgement of the original publication.

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