Probiotics for Preterm Infants—Update 2024

Necrotising enterocolitis (NEC) continues to be associated with high mortality and morbidity in preterm neonates despite recent advances in neonatal care. Current evidence from randomised controlled trials (RCTs), non-RCTs, and systematic reviews provides substantial data showing probiotics significantly reduce the risk of NEC ≥ Stage II, late-onset sepsis, all-cause mortality, and feeding intolerance in preterm neonates. This review provides an update on the current status of probiotic supplementation in preterm neonates to guide research and clinical practice.

Prophylactic probiotic supplementation has been adopted as a standard practice in many neonatal intensive care units around the world. Conditional recommendations for using probiotics for preterm neonates have been provided by various expert bodies. However, concerns including the lack of data supporting benefits in extremely preterm neonates, heterogeneity of probiotic strains used in RCTs, unavailability of high-quality probiotic products, and the fear of probiotic sepsis continue to be the barrier against its widespread acceptance. A recent warning from the US Food and Drug Administration (FDA) authorities regarding probiotic supplementation following the death of an extremely preterm neonate subsequent to probiotic sepsis has further increased the uncertainty about the safety of probiotics, especially in extremely preterm neonates.

An overwhelming body of evidence suggests that the benefits of probiotics outweigh the rare risk of sepsis due to the administered strains in preterm infants. Further research is required to optimise the benefits and safety of probiotics for preterm infants, including those who are born < 28 weeks of gestation.