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Meta-analyses indicate that giving probiotics to preterm neonates significantly decreases risk of necrotising enterocolitis (NEC) or death.1–⇓3 Multiple randomised controlled trials including >5000 very low birthweight (VLBW) infants have not shown any adverse effects associated with probiotic use,3 and no disadvantages to growth or neurodevelopment are apparent.4 Routine probiotic supplementation has been offered in Bradford since September 2011 and in Norwich and Newcastle since January 2013 via Probiotics in Neonates Collaboration (PINC-UK). We treat all infants born <32 weeks’ gestation and all VLBW preterm infants using Infloran, a probiotic produced to assured drug quality standards using Good Manufacturing Practices (Desma Healthcare, Switzerland). This provides a daily dose of 1 billion each of live Lactobacillus acidophilus and Bifidobacterium bifidum at a cost of ∼£1 per day. Parents either receive a written information sheet (see online supplementary S1) or discussion with nursing and medical staff, allowing them the opportunity to opt out of treatment. We aim to commence probiotics soon after birth with the first colostrum administration or when feeds are tolerated, and use a standardised feeding regime.
We are unaware of any published studies reporting parents’ views on probiotics in preterm infants. We therefore aimed to evaluate parents’ opinions on our practice. In December 2013, we posted a structured questionnaire survey proforma (see online supplementary S2) along with our probiotic information sheet (see online supplementary S1) to all 80 sets of parents of the 90 babies treated with probiotics and discharged home from one unit (Norwich) between January and November 2013. Fifty three parents replied, of whom 42/53 (79%) recalled receiving the probiotics information leaflet and found it helpful; 39/53 (74%) considered it unnecessary to inform parents prior to starting probiotics; 46/51 (90%) had not worried that their baby was being given live bacteria; 46/52 (88%) had not worried specifically about any possible unknown risks of probiotics and 45/51 (88%) reported that their anxiety in the neonatal unit had been eased by knowing that their baby was receiving probiotics.
Pertinently, the vast majority of respondents (51/53; 96%) considered that parents of high-risk premature babies born at other units that do not yet offer probiotics should have the right to be informed of the evidence of their potential benefits. Most (34/53; 64%) also felt that, given the current evidence on risk reduction for NEC or death, other parents deserved the right to be informed of the data and the option of probiotic treatment for their babies.
Given the strong evidence to date for probiotic efficacy and safety,1–5 we were also interested to see the extent of their use in the UK. In February 2014, we contacted by telephone a senior doctor (Specialty Registrar/consultant) or nurse in charge at all 58 tertiary-level UK neonatal intensive care units to ask about their unit's practice. Only 7/58 (12%) units gave probiotics to preterm/VLBW babies; 11/58 (19%) units stated they were considering whether to introduce probiotics and 22/58 (38%) units reported that they were awaiting results of the Probiotic in Preterm babies Study (https://www.npeu.ox.ac.uk/pips) before deciding.
This study confirms our collective experience that parents presented with the current evidence appear to understand and appreciate it; they enthusiastically embrace probiotic usage. Across our units <1% of parents have declined probiotic prophylaxis. We find that parents focus on the short-term outcomes of survival and avoiding NEC rather than on any theoretical longer-term effects such as on immune function or metabolism.6 While doctors debate and deliberate, parents would appear to prefer probiotic proactivity.
We warmly thank all parents, doctors and nurses who responded to our surveys. We are indebted to all our nursing, pharmacy, microbiology, dietetic, medical and surgical colleagues for their support.
Contributors PC conceived the idea and designed the surveys; RS undertook all data collection; PC and RS wrote the manuscript with input from all authors and all approved the final version.
Funding The cost of return postage for the parental survey was funded by the Norfolk and Norwich University Hospital Neonatal Unit Research Fund.
Competing interests None.
Provenance and peer review Not commissioned; internally peer reviewed.