Journal Pre-proof
Evidence of Lactobacillus reuteri to reduce colic in
breastfed babies: Systematic review and metaanalysis
Angela Pierina dos Reis Buzzo Zermiani, Ana
Luiza Pelissari Peçanha de Paula Soares, Bárbara
Leticia da Silva Guedes de Moura, Edson Roberto
Arpini Miguel, Luciana Dias Ghiraldi Lopes,
Natália de Carvalho Scharf Santana, Thais da Silva
Santos, Izabel Galhardo Demarchi, Jorge Juarez
Teixeira
PII:
S0965-2299(21)00122-9
DOI:
https://doi.org/10.1016/j.ctim.2021.102781
Reference:
YCTIM102781
To appear in: Complementary Therapies in Medicine
Received date: 3 September 2020
Revised date: 30 August 2021
Accepted date: 5 October 2021
Please cite this article as: Angela Pierina dos Reis Buzzo Zermiani, Ana Luiza
Pelissari Peçanha de Paula Soares, Bárbara Leticia da Silva Guedes de Moura,
Edson Roberto Arpini Miguel, Luciana Dias Ghiraldi Lopes, Natália de Carvalho
Scharf Santana, Thais da Silva Santos, Izabel Galhardo Demarchi and Jorge
Juarez Teixeira, Evidence of Lactobacillus reuteri to reduce colic in breastfed
babies: Systematic review and meta-analysis, Complementary Therapies in
Medicine, (2020) doi:https://doi.org/10.1016/j.ctim.2021.102781
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Evidence of Lactobacillus reuteri to reduce colic in breastfed
babies: Systematic review and meta-analysis
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Angela Pierina dos Reis Buzzo Zermiani1, Ana Luiza Pelissari Peçanha de Paula Soares1,
Bárbara Leticia da Silva Guedes de Moura1, Edson Roberto Arpini Miguel2, Luciana Dias
Ghiraldi Lopes3, Natália de Carvalho Scharf Santana4, Thais da Silva Santos1, Izabel
Galhardo Demarchi5, Jorge Juarez Teixeira6*
1
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M.Sc in Biosciences and Physiopathology. Postgraduate Program in Biosciences and
Physiopathology. Department of Clinical Analysis and Biomedicine. State University of
Maringá, Maringá, PR.
2
Ph.D. in Clinical Medicine. Department of Medicine, Regional University Hospital of
Maringá, PR.
3
Ph.D. in Health Science. Department of Clinical Analysis and Biomedicine. State
University of Maringá, Maringá, PR.
4
Ph.D. in Biosciences and Physiopathology. Postgraduate Program in Biosciences and
Physiopathology. Department of Clinical Analysis and Biomedicine. State University of
Maringá, Maringá.
5
Ph.D. in in Health Science. Department of Clinical Analysis. Federal University of Santa
Catarina, Florianópolis, SC.
6
Ph.D. in Public Health. Postgraduate Program in Biosciences and Physiopathology.
Department of Clinical Analysis and Biomedicine. State University of Maringá, Maringá,
PR.
Corresponding author*:
Jorge Juarez Teixeira. Postgraduate Program in Biosciences and Physiopathology,
Department of Clinical Analyses and Biomedicine, State University Maringa, 5790
Colombo Avenue, - 87020-900 - Maringa, Brazil. E-mail: jjvteixeira@gmail.com
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ABSTRACT
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Objective: To investigate evidence for the treatment of childhood colic by supplementing
Lactobacillus reuteri in infants breastfed with breast milk.
Methods: The study was conducted according to the PRISMA protocol. The databases used
for acquiring data were PubMed and Web of Science, applying MeSH terms and free terms.
Meta-analysis was conducted using Stata TM 12.0. The risk of bias was evaluated by the
Review Manager (RevMan) 5.3 tool, and the strength of evidence was assessed by the
Grading of Recommendations Assessment, Development and Evaluation (GRADE).
Results: Ten clinical trials were included in the review. The administration of L. reuteri
(DSM 17938 or ATCC55730) was tested in infants (n = 248) versus the control/placebo
group (n = 229). Eight articles were included in the meta-analysis. There was a significant
response in reducing crying time (minutes/day) and treatment effectiveness (reduction ≥
50% in average daily crying time) in the first week (p = 0.001 and p=0.003, respectively).
These results were similar in the second, third weeks (p <0.001 for both outcomes) and
fourth weeks (p=<0.001 and p=0.002, respectively). The risk of bias was low for the
majority of the studies. Confidence in evidence was considered very low for crying time
and low for effectiveness treatment.
Conclusions: The evidence shows that the administration of Lactobacillus reuteri to babies
fed with breast milk reduces the crying time in babies diagnosed with colic. But our
confidence in the effect estimate is limited.
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Keywords: Lactobacillus reuteri, colic, crying, breastfeeding
INTRODUCTION
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The inconsolable crying of newborns is a problem faced by babies worldwide 1 and can be
classified as colic when other diagnoses of intestinal discomfort are ruled out 2. Although it
is benign 3, daily crying that lasts for hours is a significant burden for caregivers, which can
lead to the development of maternal depression 4 and early weaning 5.
The etiology of crying remains uncertain, but it is believed to be multifactorial 3,6–8. One of
the consequences of an unregulated gut microbiota is enteric inflammation caused by an
imbalance between pathogenic and non-pathogenic bacteria 9. Several studies have proven
the effectiveness of colic treatment and prevention via the use of probiotics 10–12. Studies
have demonstrated the ability of probiotics to significantly reduce the crying time of
newborn babies 4,12–16. Lactobacillus reuteri bacteria are involved in maintaining a balanced
gut microbiota to compete with pathogenic microorganisms causing local inflammatory
bowel disease 14,16. A study in which the researchers supplemented pregnant women with
probiotics showed a significant reduction in gastrointestinal symptoms in breastfed infants
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. with an increased immune regulatory capacity from the probiotic dosages received
from the prenatal period up to two years old 19.
In a recent study, probiotics were listed as one of the components of breast milk and
demonstrated the occurrence of bacterial translocation through a supposed enteromammary
pathway. The study highlights the importance of this fact, which could provide
opportunities to obtain greater control over a deregulated microbiota 11 and, therefore, the
prevention of many diseases. However, there is evidence that there are differences between
the gut microbiota of babies who are fed breast-milk to those fed milk formula 20.
Systematic reviews and meta-analyses have shown the effectiveness of L. reuteri in
reducing the crying time in colic babies 21,22; however, the findings involve breastfeeding
and the use of milk formulations. According to our understanding, this is the most updated
search systematic review and meta-analysis of studies that did not include infants who were
fed milk formula.
Faced with evidence of the use of probiotics to reduce colic in babies, we analyzed the
published clinical trials on the prevention of infant colic by supplementing with L. reuteri
in infants breastfed, with breast-milk.
METHODS
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Search strategy
The study was conducted according to the PRISMA Statement 23. In the first step, two
researchers from group one selected and the defined of the search descriptors (APRBZ,
JJT). The databases used to search for studies were PubMed and Web of Science. The
search for publications in PubMed followed MeSH (Medical Subject Headings) strategy
terms; for Web of Science, the search was performed by topics (TS).For each of the
databases, the words were organized and crossed in three blocks. In the first block, the
following terms appeared: “colic,” “gastrointestinal diseases,” “inflammatory bowel
disease,” “crying,” and “dysbiosis”; block 2 contained: “gastrointestinal microbiome” and
“Lactobacillus reuteri”; whereas the following appeared in block 3: “mammaryglands,”
“milk, human,” “breastfeeding,” “infant, newborn,” and “infant.” It used the Boolean “OR”
function to cross intra-block terms, while the Boolean “AND” function to associate the
three blocks. To increase the sensitivity of the PubMed search, we also searched for free
terms, using the following terms: “Lactobacillus reuteri,” “colic,” “gastrointestinal
diseases,” “breast-feeding,” “human milk,” “crying,” and “infant.” The applied filters were
for publications available in English, Portuguese, or Spanish until February 2019.
Selection Criteria and Eligibility
For the second step, articles that met the criteria of the study (based on titles and abstracts)
were selected. For this stage, group two - composed of four researchers (APRBZ, ALPPPS,
BLSGM, and TSS) - met and decided upon the articles of interest by consensus. The
selected studies were included as they evaluated colic infants after intervention with L.
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reuteri compared to a control group. The exclusion criteria which were applied included:
clinical trials in which the babies were not fed through breast milk; studies where it was not
clear what type of feeding the baby received; studies that did not use the probiotic L. reuteri
in isolation; or studies that did not observe the outcomes related to colic/crying in infants.
Publications in the form of systematic reviews, meta-analyses, editorials, letters, errata,
comments, interviews, news, comparative studies, and patents were also excluded.
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Data extraction
The group formed by the researchers from group two met to extract and tabulate the data.
The adjustments were made by consensus and validated by an expert (JJT). The following
data were extracted: author, country, type of study, clinical trial record, follow-up day,
period evaluated, time of treatment, drug administration, family history of gastrointestinal
and atopic disease, samples, population control, adverse effects, average age of the infants,
type of feeding, sex, type of delivery, gestational age, birth weight, evaluation of crying
time, fecal evaluation, results, and conclusion. At this step, the publications were randomly
distributed to group three (BLSGM, NCSS, LDGL, and EAM)—in full format—for
evaluation and validation of the selected articles, as well as to ensure the reliability of the
data extracted in the tables.
There was a conversion to mean, and standard deviation for studies showed median and
interquartile crying time data, using an Excel® spreadsheet with the formulas developed by
Wan et al. (2014) 24.
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Study quality and Bias risk assessment
At the stage of complete readings of articles, all references were analyzed to increase the
sensitivity of the research. Review Manager (RevMan) 5.3 software was used to assess the
risk of bias 25 (Figure 04).
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Meta-analysis
The meta-analysis was performed using Stata® software version 12.0. Relative risk (RR)
and weighted mean difference (WMD) measures were used to assess the effect estimate,
with a 95% confidence interval and statistical significance of p <0.05. The efficacy of
treatment was defined as a ≥ 50% reduction in the babies’ average daily crying time and
was analyzed by RR. At the same time, the WMD for the average crying time was
expressed in minutes per day. The analysis of heterogeneity between studies was performed
via I² and X² tests, where I² above 50% would allow substantial heterogeneity, and the X²
test for heterogeneity was considered statistically significant when the p-value was
<0.05.The random-effect model was adopted in the analyses in which the heterogeneity
was over 50%. For the analysis of publication bias, we used Begg's and Egger's tests with a
significance for p <0.05 and a visual evaluation of the funnel graph.
Confidence in cumulative evidence
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Two blinded reviewers (TSS and IGD) assessed the quality of using The Grading of
Recommendations Assessment Development and Evaluation (GRADE)26. Any
disagreement was solved by consensus. A summary of the findings table was generated
using GRADEpro software (McMaster University, Hamilton, Canada)27.
RESULTS
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Of the 786 potential studies, ten randomized controlled trials were selected after employing
the inclusion and exclusion criteria 3,4,12,14,15,18,28–31 (Figure 01). Eight trials were doubleblind 3,12,14,15,18,29–31, single-blind 4, and open-label 28. The mean age variation in the L.
reuteri group was 24 ± 9.7 to 56 ± 27.4 days of life, and the control group was 23.5 ± 8.3 to
46.11 ± 20.3 days (Table 01). The population studied consisted of babies diagnosed with
colic based on the classification of the Wessel or modified Wessel protocol.
Of the 476 patients in the sample, 248 used the probiotic; 229 did not use it (the control
group). The total sample consisted of 47% boys. The type of delivery was described in
seven studies 4,12,14,15,18,28,29, 74% of which were vaginal deliveries. Between the two
groups, vaginal delivery was distributed among 70.8% in the treatment group and 77.2%
among the control group (Table 01).
In nine studies, five oral drops of L. reuteri DSM 17938 (1x108 colony forming units) oil
suspension were administered daily versus placebo 3,4,12,14,15,18,29–31. One study tested the
same dosage of L. reuteri ATCC55730 against simethicone 28. In all papers, the parents
recorded the crying time or fussiness, daily, and the duration of treatment ranged from 21 to
42 days (Table 01).
A publication identified, on the 21st day, the presence of L. reuteri in the feces of 12 of the
13 babies who received the probiotic, while no L. reuteri was found in the placebo group 14.
None of the papers reported any adverse effects on the use of probiotics. The results of the
intervention on crying time per day are highlighted in Supplementary Table S1. We also
demonstrated the number of babies who responded to treatment (treatment effectiveness) in
each period analyzed when crying time decreased by at least 50% (Supplementary Table
S2). The graphical representation of the reduction in crying time in minutes is in the
supplementary figure 3.
After 21 days of intervention, the majority 3,4,12,14,15,30,31 of the studies recorded and
compared crying time. It is noted that, of the four articles that evaluated the effectiveness of
supplementation with L. reuteri after a week of intervention 4,12,14,15, three of them found a
reduction in crying time with significant results, mostly towards the end of treatment.4,12,15.
In the second week of treatment, five articles analyzed the crying time 3,4,12,14,15, four of
which showed significant effectiveness when the treatment group was compared to the
placebo group 3,4,12,15. Six studies evaluated the crying time after 21 days of treatment
3,4,12,14,15,31
, five of which presented significance concerning the placebo group 3,4,12,14,15.
This study did not show a significant p-value on the 21st day 31 due to the small sample
size, which may have influenced the outcome. After 28 days of intervention, the four
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studies found a significant reduction in crying time in the group that received probiotics
3,4,30
(Supplementary Table S1).
One of the studies included in the systematic review found that mothers of babies treated
with L. reuteri were less likely to develop maternal depression, suggesting that this result
can be even better when breastfeeding occurs by breast milk. Some studies initially selected
discriminate the number of patients who received human milk or formula, but did not report
this information on the results; therefore, they were not included in our article 13,32,33.
Most of the items presented a low risk of bias (green color) in the analysis of the risk of
bias (Figure 04). The prevalent item showing an uncertain risk was other biases (yellow
color). There are found a percentage of high risk (red color) in some items as selection bias,
performance bias, detection bias, attrition bias, and other bias.
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Meta-analysis
For the meta-analysis, eight studies were included 3,4,12,14,15,29–31. Two articles were
excluded from the meta-analysis: Savino et al. (2007) for having used the medicine
simethicone as a control 28, and Garofoli et al. (2014), which did not show data on the
outcomes of crying time and treatment effectiveness 18.
The crying time was evaluated in seven studies 3,4,12,14,15,30,31. A meta-analysis was also
performed on subgroups according to the intervention period (zero, 7th, 14th, 21st and 28th
days) (Figure 02). Heterogeneity by subgroup was I2 = 0.0% (p = 0.836) at time zero, and
after 7th, 14th, 21st and 28th days, I2 was ≥ 70.0% (p <0.05). The results show that
supplementation with L. reuteri reduced the crying time (min/d) in infants from the 7th day
of treatment (WMD = -29.5; CI 95%: -47.6 to -11.6; p=0.001), 14th (WMD = -62.7; CI
95%: -93.9 to -31.4; p<0.001), 21st (WMD = -58.3; CI 95%: -76.5 to -40.0; p<0.001), and ≥
28thdays (WMD = -82.7; CI 95%: -105.7 to -59.7; p<0.001) (Figure 2 and Supplementary –
Table S2).
From the funnel plot (Supplementary Figure S1), it can be seen that on the 14th
(Supplementary - Figure S1-C) and 21st day (Supplementary - Figure S1-D), there was
asymmetry, indicating publication bias. On the other hand, in the Egger's test, only the 21st
day showed significance for publication bias (p=0.013) (Supplementary Table S3).
The treatment effectiveness of L. reuteri and placebo groups was compared in seven studies
3,4,12,14,15,29,30
. The subgroup analysis according to the intervention period showed
heterogeneity of I2 = 0.0% (p = 0.508) after seventh, I2 = 39.5% (p = 0.175) on the 14th day,
I2 = 28.0% (p = 0.225) in 21st, and I2 = 12.7% (p = 0.329) on the 28thday or more.
Supplementation with L. reuteri showed a significant result for the treatment effectiveness
in the seventh (RR = 2.60; CI 95%:1.40-4.90; p=0.003), 14th (RR = 2.32; CI 95%: 1.553.45; p<0.001), 21th (RR = 1.76; CI 95%: 1.34-2.31; p<0.001), and ≥28thdays (RR = 1.61;
CI 95%: 1.58-2.24; p=0.002) (Figure 3 and Supplementary – Table S3).
The funnel plot showed asymmetry in the seventh (Supplementary Figure S2-A), 14th
(Supplementary Figure S2-B), and ≥ 28thday (Supplementary Figure S2-D). However,
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Egger's test was not statistically significant for publication bias in any of the periods
evaluated (Supplementary Table S3).
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Confidence in cumulative evidence
The confidence in cumulative evidence was considered very low for crying time and low
for effectiveness treatment (Table 02). Our confidence in the effect estimate for
effectiveness treatment was limited, since the true effect may be substantially different
from the estimate of the effect. For crying time, we have very little confidence in the effect
estimate, and the true effect is likely to be substantially different from the estimate of
effect. Potential limitations are likely to lower confidence in the estimate of effect, as even
rates and low sample size; the subjectivity of the measure of crying time; did not assess
compliance; non-representative sample. Also, we observed the differing estimates of the
treatment effect; unexplained heterogeneity in subgroup analysis; minimal overlap of
confidence intervals (CI). Some results were consistent with substantial benefit and
substantial harm, suggesting the need to rate down for imprecision. We also found
publication bias.
DISCUSSION
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Evidence from our meta-analysis suggests that prevention with supplementation of L.
reuteri during all periods analyzed increased the effectiveness against colic in babies,
corroborating other research with breastfed infants 15,22. In another meta-analysis carried
out by Xu et al. (2015), there was an emphasis on increasing the effectiveness of the
intervention until the third week 34. Still, it was no longer valid after the fourth week 4,34.
The difference in the findings by Xu et al. (2015) was likely due to the non-separation of
infants who were breastfed, from those who were fed by formula 34.
L. reuteri bacteria naturally colonize the gastrointestinal tract, not only in humans but also
in several vertebrates. Thus, its specific relationship with human health has been studied
worldwide 31,35–42. A study of the link between L. reuteri and human health listed the
characteristic properties of this probiotic, as well as the strains that best adhere to
enterocytes through the production of biofilm-forming exopolysaccharides (EPS). It was
shown that the use of this probiotic promotes, for example, the reduction of the chance of
infection by pathogenic microorganisms. In addition, L. reuteri can, for example, suppress
the gene expression of proinflammatory cytokines from the conversion of dietary Lhistidine to biogenic amine histamine by some strains, which may suppress the production
of tumor necrosis factor (TNF), inflammatory cytokines, and a stimulus for the production
of various vitamins, depending on the strain—such as folate (B9) and cobalamin (B12).
There is also the production of the substance reuterine, an antimicrobial compound that
mainly acts against gram-negative bacteria and produces other metabolites that are equally
effective against bacterial infections of the gastrointestinal tract – such as lactic acid, acetic
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acid, ethanol, and reuterocyclin – with action against species such as Helicobacter pylori,
Escherichia coli, Clostridium difficile, and Salmonella 35.
In addition to the advantages of using probiotics for dysbiosis, it is essential to list the
benefits of breastfeeding. Further to nutritional properties, probiotics can promote the
balance of the infant’s intestinal microbiota 43. Human milk oligosaccharides (HMOs) are
complex soluble carbohydrates produced in the mammary glands 44,45, and act as a
protective factor against enteral dysfunction 46. Only 1% of these bioactive compounds are
absorbed by the gastrointestinal tract, which makes it possible for it to act as a prebiotic
and, thus, promotes the growth of bifidobacteria and other beneficial bacteria 47. These
oligosaccharides also adhere to pathogenic bacteria, inhibiting them from lodging in the
intestinal mucosa 44,47–49. In addition, epithelial cells use the energy of fatty acids produced
by bifidobacteria and, consequently, appear to modulate the immune response and inhibit
genes involved in inflammatory processes 44,45,49. The union between the HMOs and the
type of microbiome of breast milk may be the key to the overall development of the health
of breastfed babies 49,50.
Still thinking about the benefits of breastfed babies, we can mention that breast milk is
composed of macro and micronutrients, hormones, growth factors, cytokines,
immunoglobulins, and microorganisms others49. Researches have shown that Lactobacilli
isolated from breast milk, as commensal bacteria, can prevent the growth of pathogenic
microorganisms by expression of antimicrobial components and exclusion by
competitiveness44,51.In addition, the composition of the mother's microbiota is suggested as
the initial source for the development of the baby's microbiome49. There seems to be an
enteromammary pathway through which the bacteria present in the maternal intestine cross
the intestinal barrier and are carried to the mammary glands by the blood / lymphatic
stream. They will integrate with the milk ingested by the child and finally reach their
intestines 52.
In the present study, we observed that after the intervention with the probiotic, there was a
reduction of approximately 83 minutes in the crying time (≥ 28th days). Other metaanalyses also provided the same effect after the use of L. reuteri 21,22,34. However, in some
studies, infants who used feed formulas were not excluded 21,34.
The assumption is that the formation of the individual's microbiota is due to factors such as
the type of food, delivery, prenatal exposure to microbes, exposure to antibiotics, and
immediate contact with microorganisms after birth 53. It would be interesting to analyze the
association between the type of delivery and the improvement of colic (with the use of
probiotics). This direction would allow verifying the infants who had contact with the
mother's vaginal flora. In our study, 74% of the population – 70.8% in the L. reuteri group,
and 77.2% in the placebo group – would present a better result than those born by cesarean
section. Nevertheless, the articles that discriminate the percentage of their sample along the
lines of different types of delivery did not bring this separation in the results, making it
impossible for our comparison 4,12,14,15,18,28,29. We suggest that the new studies, in addition
to the type of food received by the baby, include other variables related to the formation
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and composition of the individual's microbiota, as the type of delivery and exposure to
antibiotics. Until the role of this probiotic and the physiopathology of colic are better
known, it is suggested that supplementation with L. reuteri should be performed with
caution and in cases of a confirmed diagnosis of infant colic.
Strength and limitations of the study
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Researchers performed numerous and relentless analyzes of publications at random and by
consensus to ensure the most significant volume of publications and data accuracy. A
strong point of our study was to select exclusively breastfed babies because the literature
reports that babies who received formula-fed did not to decreased abundance of
Lactobacillus or Bifidobacterium54, also cry less than breastfed babies55.
The Lactobacillus reuteri for the prevention of infantile colic is effective and promising.
The evidence from this systematic review and meta-analysis showed that most of the
studies that used L. reuteri in infants who were breastfed, significantly reduced crying time
in colic babies by the seventh day of treatment, without causing any adverse effects.
Some limitations of the study can be pointed out, as the study was unable to clarify the
mechanisms that lead to the appearance of colic, the exact role of microorganisms in this
process, and how breast milk contributes to preventing crying episodes. However, after
obtaining a clearer picture of the pathophysiology of functional dysfunction, there may be
other viable interventions for those children who for some reason are deprived of breast
milk, such as creating more improved milk formulas or even other means of maintaining
the health of microbiota. In addition, in a Canadian study, infants with colic remitted by
three months of age were more likely to be female56. As our sample was made up of more
girls (53%) than boys (47%), we cannot rule out the influence of this factor on reducing
crying time. Another limitation that we can point out in our study is that our population
may be more subject to mild or low-risk cases for infantile colic, as they are breastfed
babies and most were born by vaginal delivery. In the literature, some studies indicate an
association between colic and difficult delivery57 or even interruption of breastfeeding in
complicated delivery and intensive intervention 58,59. In addition, we can indicate another
limitation that was using only two databases to search for articles, despite being databases
used worldwide and robust. The effect estimate is very low and low for crying time and
effectiveness treatment, respectively, based on GRADE. Indicating that the true effect is
likely to be or maybe substantially different from the estimate of the effect. Therefore, more
studies are needed, with larger samples, for our confidence to reproduce the true effect
estimate.
ACKNOWLEDGMENTS
We would like to thank Editage (www.editage.com) for English language editing.
10
CONFLICT OF INTEREST
The authors declare that there is no conflict of interest.
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Rev. Assoc. Med. Bras. 2018. 64( 2 ): 164-169. doi: 10.1590/1806-9282.64.02.164
Figure 01. Flowchart of the articles included in the systematic review and metaanalysis
Jo
ur
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al
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f
16
Figure 02. Forest plot of weighted mean difference (WMD) by subgroups of crying
time in children who received the intervention with L. reuteri (Probiotic) and the
placebo group, with a 95% confidence interval (CI).
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Pr
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f
17
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Figure 03. Forest plot of relative risk (RR) by subgroups on the treatment
effectiveness of Lactobacillus reuteri with a reduction of ≥ 50% in the mean
crying time of children compared to the placebo group in the
follow-up periods on the 7th, 14th, 21st and ≥ 28th days, with a 95%
confidence interval (CI).
Pr
e-
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18
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Figure 4. Risk of bias in the studies included in the systematic review.
19
Table 01. Descriptive data from the ten studies included in the qualitative analysis of the systematic review.
Samp
Follo
Evaluat
DA
DT
Study
le
w-up
CY Design
ed
(drops/d (day
(year)
(LR/
(days
period
ay)
s)
P)
)
5/1
21
08/2013
02/2016
5/1
42
5/1
28
5/1
28
40
RCT(D
(20/2
NR
B)
0)
39 02/2013
RCT(S
Mi et al.
(20/1
4 CN
B)
(2015)
9) 04/2014
IT
NR
5/1
al
83 04/2004
Savino
RCT(O
(41/4
et al. IT
T)
2) 05/2005
(2007)26
5/1
54 08/2015
Savino
RCT(D
(32/2
et al. IT
B)
3
2)
09/2016
(2018a)
5/1
Jo
ur
n
50 03/2008
Savino
RCT(D
(25/2
et al. IT
B)
5) 08/2009
(2010)14
NR
LR:29.7±13.
4;
P:28.6±17.6
LR=29.8±11.
7;
21
21
P=29.6±12.9
**
LR=38.2±15.
1, 7,
9;
28
14,
STH=37.8±1
21, 28
3.8*
LR=24.8±9.7
7, 14,
21
;
21
P=23.5±8.3*
LR=47.9±25.
8;
30
30
P=46.11±20.
3
7, 14,
21, 28
Pr
29 03/2008
Roos et
RCT(D
(15/1
al.(2013 IT
B)
4) 08/2009
)27
28
oo
US RCT(D 19
A
B)
(13/7)
LR=75/25;
7, 14, LR=42.1±8.9 45.8/5
P=82.1/17.
21 ; P=41.1±9.4
0
9
21,
LR=56±27.4;
42,
P=41.7±15.6 69/43
NR
92,
*
176
f
52 02/2012
RCT(D
(24/2
B)
8) 04/2014
pr
CA
Male¥ Delivery¥¥
(LR/P) (VG/CS)
(MN/MD ±
%
%
SD) days
e-
Chau et
al.
(2015)12
Fathere
e et
al.(2017
)29
Garofol
i et al.
(2014)18
Infant age
Savino
30 10/2016
RCT(D
et al.
IT
(18/1
B)
(2018b)
2)
07/2017
28
5/1
28
28
Szajews
80 01/2010
RCT(D
ka et
PL
(40/4
B)
al.(2013
0)
12/2011
)15
5/1
21
7, 14,
21, 28
20/70
LR=80/20;
P=85/15
65/53
LR=70/30;
P=79/21
LR=60/40;
60/50 P=78.6/21.
4
LR=65.9/3
4.1;
23/21
STH:64.3/3
5.7
60/56
LR=48/52;
P=75/25
40.6/4
6.4
NR
LR=25.4±12.
44.4/3
8;
3.3
P=27.9±11.5
NR
LR=34.3±12.
LR=87.5/1
5;
65/55
2.5;
P=38.1±11.7
P=82.5/7.5
Legend: CY:Country; CA:Canada; USA:States United of America; CN:China; IT:Italy; PL:Poland; RCT:randomized
clinical trial; OT:open-label trial; DB:double-blind; SB:single-blind; NR:Not reported;LR:Lactobacillus reuteri;
P:placebo; STH: Simethicone; DA: Drug administration; DT:Duration of treatment;MN:Mean; MD:
Median;SD:Standard Deviation; VG:vaginal; CS:cesarean; *recalculated using the formula of Wan et. al. (2014);
**Median; ¥ total sum of boys was 47%; ¥¥ total sum of vaginal delivery was 74%, 70.8% in L. reuteri group, and
77.2% in control group.
20
Table 02- The Grading of Recommendations Assessment Development and Evaluation
(GRADE)
Certainty assessment
№ of
studie
s
Study
design
Risk of
bias
Inconsistency
Indirectness
Imprecision
Serious
Serious b
Not serious
Serious c
Other
considerations
Certainty
Publication
bias strongly
suspected
all plausible
residual
confounding
would suggest
spurious effect,
while no effect
was observed d
⨁◯◯◯
VERY
LOW
Crying time
7
RCT
pr
oo
f
a
Treatment effectiveness (minimum of 50% reduction of colic in babies)
7
RCT
Serious
Not serious
Not serious
Serious e
al
Pr
e-
a
Publication
bias strongly
suspected
all plausible
residual
confounding
would suggest
spurious effect,
while no effect
was observed d
⨁⨁◯◯
LOW
Jo
ur
n
RCT: randomized controlled trials. a. Potential limitations are likely to lower confidence in the estimate of
effect. The subjectivity of the measure of crying time; Did not assess compliance; Non-representative sample.
b. Widely differing estimates of the treatment effect; unexplained heterogeneity in subgroup analysis;
Minimal overlap of confidence intervals. c. Event rates and sample size are low. The results are consistent
with substantial benefit and substantial harm, suggesting the need to rate down for imprecision. d. Publication
bias; Coincidence or third variable. e. Even rates and sample size are low.
21
Highlights


Jo
ur
n
al
Pr
e-
pr
oo
f

There was a significant reduction in gastrointestinal symptoms in breastfed babies by
mothers who received probiotics supplement.
The use of L. reuteri for the treatment of infantile colic is effective and promising and does
not cause adverse effects.
•
The use of Lactobacillus reuteri in infants who are breastfed significantly reduces
the crying time in infants with colic.