Parents’ perspective on probiotics in preschool children: A cross-sectional survey

The human gastrointestinal (GI) tract is colonised by a complex population of microorganisms that are closely associated with the host in terms of health and disease (1). Importantly, the establishment of a stable microbial community within the GI tract early in life plays an important role in directing the development of the host’s immune, GI and nervous systems (2). Although most studies focus on microbiota composition in the first 12 months of life (2, 3), the preschool period is a very important window during which children are exposed to many disturbances on a daily basis; in addition, children in day care settings are more likely to be exposed to infections that may often require antibiotic treatment (4). The latter can significantly upset GI microbiota and lead to common side-effects such as antibiotic-associated diarrhoea (5). Dysbiosis or disturbance in the gut microbiota homeostasis occurs as a result of the loss of beneficial members, the excessive growth of potentially harmful organisms or the loss of overall microbial diversity (6). Microbiota dysbiosis has also been associated with various gastrointestinal (7) and metabolic disorders (8), autoimmune and allergic diseases (9, 10), and neuropsychiatric disorders such as autism (11). Nevertheless, there is a growing number of studies that evaluate the benefits of probiotics in preventing or treating certain health conditions in children by modulating the microbiota, such as antibiotic-related diarrhoea (12), gastrointestinal and respiratory infections (13), chronic inflammatory bowel disease (IBD) and irritable bowel syndrome (IBS) (14), atopic eczema (15), mental health (16), autism spectrum disorders (17) and obesity-related disorders (18). These clinically based health benefits were used to design the false or true claims presented to survey participants in our study. Probiotics are ‘live microorganisms that, when administered in adequate amounts, confer a health benefit on the host’. Live microorganisms refer to strains of a number of well-studied microbial species delivered at a functional dose for use as foods (fermented foods, yogurts, fermented drinks) or supplements (19). The first aim of our study was to investigate parental perspectives on probiotics use and the amount of fermented foods and/or probiotic supplements consumed by their preschool-aged children. The second aim was to find an association between variables such as knowledge, opinion, level of education, health conditions, and the consumption of probiotic foods and supplements.

Nutrition in the first years of life is one of the most important factors that affect a child’s well-being, development and health. The first years of a child’s life are also recognised as an important period in the development of healthy gut microbiota. While the composition of the gut microbiota is constantly and rapidly changing during this period, it is often exposed to stressors that can lead to dysbiosis (21, 22). While antibiotics are recognised as a key contributor to gut microbiota dysbiosis leading to various diseases, as reviewed by Vangay et al. (24), this is also the most commonly prescribed class of drugs in the child population (23, 24). Since it has been shown that consumption of probiotics can successfully reverse established microbial dysbiosis, they are commonly used as a strategy to modulate the gut microbiota (25). Probiotics are live microorganisms naturally present and/or added to food or dietary supplements. When administrated in adequate amounts, they have a favourable effect on host health (26, 27). As shown in our study, disorders associated with the digestive tract were the most frequently cited motive for the initial introduction of probiotics into children’s diets, with antibiotic treatment (25.5%) in first place. Parents also indicated that probiotic supplementation in children’s diet resulted as changed stool consistency, relief from constipation, reduction in gas and bloating, faster overcoming of colds, reduction in diarrhoea frequency, improvement in mood, and faster overcoming of allergies. Exposure to probiotics during pregnancy and early infancy could reduce the risk of developing various health problems, such as atopic dermatitis (28), necrotising enterocolitis (29) antibiotic-associated diarrhoea (30) and paediatric acute infectious diarrhoea (31, 32). As reviewed by Sestito et al., there is still a lack of evidence on the use of probiotic supplements to prevent allergic diseases. However, the World Allergy Organization (WAO), recommends probiotics during pregnancy and lactation for mothers at high risk of allergic disease in the case of atopic dermatitis (33). In our study, 8.8% of parents of children who suffered from food allergies and 6.9% of parents of children who suffered from skin allergies always used probiotics. While parents play a critical role in ensuring the well-being of their children, this cross-sectional study focused on parental perspectives regarding the use of probiotics in the preschool period. Our study results showed that parents were familiar with probiotics (all parents had heard the term before) and only 4% were unfamiliar with the benefits of probiotics consumption (Table 2). This was also evident in parents’ perspectives on, and their agreement with the statement about, the benefits of probiotics for their children. In a previous study on maternal perspective (N=413), which included children aged up to two years, most mothers believed that probiotics were beneficial (73.1%), 9.7% of mothers had a neutral opinion and 15% reported not having enough information. However, the use of probiotics in children was lower compared to their mothers (50.8% vs. 89%), suggesting that mothers are more concerned about the use of probiotics in younger children (34). In addition, Andersen et al. (35) showed that parents were willing to take probiotics on the recommendation of a physician and other healthcare professionals, or when a child might benefit from taking probiotics, but were sceptical about preventive use (35). In our study, only a small proportion (12.8%) of parents were encouraged to consume probiotics by a physician (Table 2). However, there was no significant parental reluctance regarding the use of probiotics in their children’s diet, while 88.2% of parents agreed that probiotics were beneficial for their children. Accordingly, 86.3% of parents reported that probiotics were a part of their children’s diet, while almost all parents consumed fermented foods at least once a month (88.2%) and 41.2% also/or consumed probiotic supplements (Table 2). There was also a statistically significant positive correlation between parental views regarding their children’s use of probiotics and parental educational level (rs=0.371; p<0.001), parental use of probiotic supplements (rs=0.393; p<0.001) and use by their children (rs=0.305; p=0.002), and children’s consumption of pickled turnip (rs=0.461; p=0.027). Fermented dairy products such as yoghurt, fermented milk and cheese still remain the most common vehicle for the delivery of probiotics, although many non-dairy products have also been traditionally consumed for centuries (36). Although several epidemiological studies have reported health benefits from yoghurt and other fermented foods (37), it is important to distinguish between probiotic microorganisms and fermentation-associated microbes, the latter seldom being adequately defined. Unless isolated and defined, it is impossible to assess the potential probiotic properties of the relevant strain (38). In our study, fermented food was also the most common source of probiotics in children’s diet (36.3%), followed by combined intake with probiotic supplements (28.4%) and solely by probiotic supplement (12.8%). However, the highest proportion of probiotics consumption was observed in children aged between one and two years (35.2%), followed by those between five and six (23.8%) and those aged between four and five (13.6%). The highest prevalence of consumption of probiotic supplements only (44.4%) was observed among children aged between one and two. There was a statistically significant positive correlation between the inclusion of probiotic supplements in the child’s diet and their use in the parents’ diet (rs=0.460; p<0.001), as well as the parent’s level of knowledge about the term ‘probiotics’ (rs=0.305; p=0.002). It is generally accepted that probiotic products should have a minimum concentration of 106 CFU/ mL or gram to confer health benefits to the host (39). Therefore, an adequate amount of probiotics to maintain the balance of the gut microbiota can be achieved regularly with approximately 100 g/day, which delivers about 109 viable cells into the intestinal daily probiotic food intake (40). As shown before, increased dietary variety and the increased intake of probiotic and prebiotic food can be successfully achieved by microbiota modulation-focused dietary intervention in the perinatal period (41). Although the parents in our study noted an improvement in their children’s well-being after the consumption of probiotics, no guidance or recommendations exist for this vulnerable age group. When making recommendations to parents as consumers, it is important to take into account their personal traits as well their taste predispositions (42). In our opinion, the preschool period should be considered to be an opportunity for more frequent and diverse inclusion of probiotic foods. This not only positively affects host well-being, but also introduces foods with different tastes and textures.

Further studies are needed to determine the recommended amount of probiotic foods, as well as strategies to educate parents about the benefits of including probiotic foods in children’s daily diets.