World Journal of Pediatrics (2019) 15:255–261

https://doi.org/10.1007/s12519-019-00248-0

ORIGINAL ARTICLE

Alterations of intestinal flora and the effects of probiotics in children

with recurrent respiratory tract infection
Ke‑Liang Li1,2 · Ben‑Zhen Wang1 · Zi‑Pu Li1 · Yi‑Lei Li3 · Jing‑Jing Liang2

Received: 8 October 2018 / Accepted: 20 March 2019 / Published online: 24 April 2019
© The Author(s) 2019

Abstract
Background Recurrent respiratory tract infection (RRTI) is a disease occurred frequently in preschool children.
Methods A total of 120 RRTI children were randomly divided into active group, remission group, intervention group and
control group, meanwhile 30 healthy children were selected as the healthy group. Children in the intervention group were
given oral Bifidobaeterium tetravaccine tablets (Live) for 2 months, while the control group received routine treatment. Stool
sample were detected to analyze the bacterial strains. The occurrence of respiratory tract infection (RTI) was compared
between different groups during 1 year follow-up.
Results Compared with the healthy group, the number of Bifidobacteria and Lactobacilli in the active group, remission group,
intervention group and control group was significantly decreased (P < 0.05). The number of Bifidobacteria and Lactobacilli
in the intervention group was significantly higher compared to other RRTI groups (P < 0.05). During the follow-up period,
the average annual frequency of different acute RTI and use of antibiotics were significantly reduced (P < 0.05), the average
duration of cough, fever and use of antibiotics at each episode were also significantly shortened (P < 0.05) in the intervention
group compared to the control group.
Conclusions Children with RRTI are susceptible to intestinal flora imbalance. Oral probiotics can effectively improve the
RRTI intestinal microecological balance in children and reduce the frequency of RTI.

Keywords Children · Intestinal flora · Probiotics · Respiratory tract infections

Introduction of immunodeficiency or immature immune function, and

specific or non-specific immune dysfunction in children with
Recurrent respiratory tract infection (RRTI) is one of the RRTI were major causes of RRTI [3]. Notably, the applica-
most common reasons for the pediatric visits and hospitali- tion of immunomodulatory agents is expected to improve
zation. According to an epidemiological survey, the inci- the long-term prognosis of RRTI children.
dence rate of RRTI is about 20% in China, with an increas- Intestinal flora have a powerful regulatory effect on the
ing tendency [1]. As previously reported, RRTI in children human immune system. Human immune system could be
could increase the incidence of chronic respiratory disease regulated directly or indirectly by intestinal bacteria through
in adulthood, and thereby cause permanent lung lesions [2]. increasing the number of extra-intestinal T cells, producing
Current findings have suggested that the different degrees short-chain fatty acids, enhancing oral tolerance, or control-
ling inflammation [4]. Multiple studies have demonstrated
* Zi‑Pu Li that long-term use of probiotics could significantly reduce
[email protected] the risk of respiratory infections, and meanwhile could ben-
1
efit for the fever, cough and administration duration of anti-
Heart Center, Women’s and Children’s Hospital Affiliated
to Qingdao University, Qingdao Women’s and Children’s
bacterial agents in children [5–9]. Among these probiotics,
Hospital, 6 Tongfu Road, Qingdao 266034, Shandong, China Lactobacillus or Bifidobacterium is the most commonly used
2
Department of Pediatrics, Rizhao People’s Hospital, 126 [10]. As known, the clinical effectiveness of various probiot-
Taian Road, Rizhao 276800, Shandong, China ics was different due to their regulatory effects on the human
3
Clinical Laboratory, Rizhao People’s Hospital, 126 Taian immune function [11]. Bifidobaeterium tetravaccine tablets
Road, Rizhao 276800, Shandong, China (Live) is a probiotic preparation containing four kinds of

13
Vol.:(0123456789)
256 World Journal of Pediatrics (2019) 15:255–261

strains (Bifidobacterium infantis, Lactobacillus acidophilus, tract infection disappear for more than 4 days. They were
Enterococcus faecalis and Bacillus cereus). Among them, given oral Bifidobaeterium tetravaccine tablets (Live) for
the first three bacteria are the main intestinal probiotics. 2 months after this episode; (4) Control group included 30
Besides, the Bacillus cereus can colonize in the intestine children who had fever, cough, stuffy nose, runny nose and
and consume oxygen to create an anaerobic environment for other symptoms of respiratory tract infection. They were
Bifidobacteria, thus promoting the growth and reproduction given conventional symptomatic treatment.
of anaerobic bacteria such as Bifidobacteria. Stool specimens in the four groups were collected to ana-
Based on the above reported studies, we aimed to inves- lyze the intestinal flora at the corresponding time points. For
tigate the clinical effects of Bifidobaeterium tetravaccine the active group and the remission group, stool specimens
tablets (Live) on RRTI, and expected to provide a highly were collected within 1–2 days after enrollment, while for
effective way for the prevention and treatment of RRTI. the intervention group and the control group, were collected
within 1 week after oral administration of Bifidobaeterium
tetravaccine tablets (Live) or conventional symptomatic
Methods treatment, respectively.

Ethical statement Healthy control

Ethical approval for the study has been obtained from the Totally 30 children underwent a physical examination in the
Ethics Committee of Rizhao People’s Hospital (code num- Department of Children Healthcare, People’s Hospital of
ber: rzrmyy2015llpj002). In addition, written informed Rizhao were enrolled as the healthy control (15 boys and
consent was obtained from parents or legal guardians of all 15 girls). Inclusion criteria were as follows: (1) children
children prior to any study-related procedure in the study. younger than 11 years old; (2) healthy subjects with no his-
tory of genetic disease, heart, liver, kidney and blood dis-
RRTI patients eases; (3) subjects who had no history of upper RTI, acute
and chronic gastrointestinal disease more than 1 week before
A total of 120 RRTI children admitted to the People’s Hos- specimens collection; (4) subjects who had no history of
pital of Rizhao between July 2015 and December 2015 were using antibiotics and probiotics, and had normal stool indi-
recruited into this study. Patients were eligible for enroll- cators by routine examination.
ment in the RRTI group if they were 11 years of age or
younger and had a clinical diagnosis of RRTI. The diagnosis Development of RRTI questionnaire
of RRTI was performed according to the criteria issued by
the Pediatric Society, Chinese Medical Association in 2007 Questionnaires were distributed to the control and interven-
[12]. Additionally, the children with RRTI were eligible for tion groups. The questionnaire was compiled by a trained
enrollment if they had no history of other diseases and no and full-time doctor (reviewed the patient’s previous medical
history of using antibiotics and probiotics. Exclusion criteria records and treatment) and the guardians of children. The
were as follows: (1) patients who were diagnosed with RRTI items mainly included: incidence, etiology, incentives, fre-
caused by organic or congenital lesions, or primary immu- quency of hospitalizations, frequency and timing of admin-
nodeficiency; (2) patients with mental illness; (3) during the istration of antibiotics and shortest interval of acute upper
follow-up, patients who were not received Bifidobaeterium RTI, acute bronchitis or pneumonia within 12 months from
tetravaccine tablets (Live) in accordance with the prescribed the time of survey, as well as the presence or absence of
method for a period greater than 20% of the follow-up dura- underlying diseases, etc.
tion or were given other immunosuppressive drugs or with-
drew from the study. Stool specimens collection
All children with RRTI included in this study were
equally assigned by a random number table into 4 groups: Two samples (≈ 3 cm3) were collected into two collection
(1) remission group included 30 children without history of tubes containing colony stabilizer, respectively. The child
respiratory infection for more than 1 week; (2) Active group defecated on an opened aseptic paper-plastic bag (prepared
included 30 children who had fever, cough, stuffy nose, by the People’s Hospital of Rizhao), then an appropriate
runny nose and other symptoms of RTI or those who had amount of stool was transferred into the tube using a dis-
these symptoms disappear within 3 days; (3) Intervention posable sterile tongue depressor. Next, the tube was imme-
group included 30 children with RRTI who had fever, cough, diately placed in an ice bucket and stored at − 80 °C within
stuffy nose, runny nose and other symptoms of respiratory 6 hours.

13
World Journal of Pediatrics (2019) 15:255–261 257

Genome DNA extraction and quantitative PCR Clinical evaluation

Genome DNA was extracted from the stool samples using According to the previous report, clinical efficacy was
stool DNA rapid extraction Kit (Aidlab Biotechnologies divided into four categories including [2]: (1) Cure: patients
Co., Ltd. Beijing, China) according to the manufacturer’s did not have recurrence of respiratory tract infection or occa-
protocol. Primers were designed according to 16SrRNA sional upper respiratory tract infection that was cured with-
sequences of Bifidobacteria, Lactobacillus, Escherichia out any treatment within 1 year; (2) Marked effect: within
coli, respectively; and then were verified in BLAST data- 1 year, patients had < 3 times of episodes of respiratory tract
base. The upstream and downstream primer sequences infection, with effectively improved conditions that only
were as follows: Bifidobacteria 5′-CTC CTG GAA required oral drugs; (3) Effectiveness: within 1 year, patients
ACG GGT GG-3′, 5′-CTC CTG GAA ACG GGT GG-3′ had < 5 times episodes of respiratory tract infection, with
(550 bp); Lactobacillus 5′-CTG ATG TGA AAG CCC alleviated symptoms; (4) Ineffectiveness: within 1 year, the
TCG-3′, 5′-GAG CCT CAG CGT CAG TTG-3′ (166 bp); frequency of episodes of respiratory tract infection did not
Escherichia coli 5′-CTG ATG TGA AAG CCC TCG-3′, change or were increased.
5′-CGG GTA ACG TCA ATG AGC AAA-3′(95 bp). Prim-
ers were synthesized by Shanghai Sangon Biotech Co., Statistical analysis
Ltd.
The PCR reaction was amplified using a Stratagene Statistical analyses were performed using SPSS19.0 soft-
M × 3000P PCR machine (Agilent Technologies, Inc.). ware (IBM, New York, USA). Mean ± standard devia-
The stool DNA samples were subjected to conventional tion (SD) was used to represent the continuous variables.
PCR using each of the bacterial primers, and the ampli- Qualitative data were described by number or percentage.
fied products were subjected to PAGE electrophoresis, fol- Quantitative PCR data were performed using logarithm
lowed by comparing with the standard molecular weight process (1og copies/g) and were expressed as mean ± SD.
mark to verify them. The fluorescent quantified PCR was For multiple sets of data, one-way analysis of variance was
performed to obtain the three bacteria number of all the performed, multiple comparisons of strains among different
DNA samples. Consequently, the solubility curves of groups were conducted using t test, and percentage data were
fluorescence quantitative PCR of the three bacteria were compared using χ2 test. All statistical tests were two-sided
developed to verify the PCR amplification products. The tests, and P < 0.05 was considered statistically significant.
standard strains and colonies of the tree bacteria were seri-
ally diluted ­(102–1010 cfu/mL), followed by fluorescence
quantitative PCR to detect the sensitivity of the fluorescent Results
quantitative PCR.
Initial patient characteristics

Treatment The baseline characteristics of patients in the five groups

were analyzed. The gender (male/female), age (month), body
Bifidobaeterium tetravaccine tablets (Live) was administered weight (kg) and body surface area ­(m2) of children in five
orally for 2 months. For children < 1 year, 2 tablets were groups were, respectively, as follows: 16/14, 43.17 ± 25.51,
given each time (twice daily), while for those ≥ 1 year, 3 15.6 ± 4.8, 0.65 ± 0.05 in the remission group; 17/13,
tablets were used each time (twice daily). During follow- 47.70 ± 29.38, 16.4 ± 5.4, 0.68 ± 0.10 in the active group;
up, children with RTI were given conventional treatment, 14/16, 46.60 ± 30.20, 16.2 ± 5.5, 0.67 ± 0.05 in the inter-
and based on this, anti-infective treatment were rationally vention group; 14/16, 44.80 ± 24.09, 16.0 ± 4.5, 0.66 ± 0.28
selected according to the disease condition and the age of in the control group; and 15/15, 50.80 ± 27.19, 17.0 ± 4.9,
children. Meanwhile, no other immunomodulatory agents 0.69 ± 0.02 in the healthy group. No significant difference in
and probiotic preparations were allowed during the follow- patients’ characteristics (age, gender, body weight, and body
up. Rational use of antimicrobial methods, such as strict surface area) was found among the five groups (P > 0.05).
application criteria, reasonable choice of the timing given
(antibiotics and Bifidobaeterium tetravaccine tablets (Live) Validation, standard curves and solubility
interval of more than 2 hours), and shorten the course of curves of PCR products‑amplified fragments
treatment, were given to both of the intervention group and of Bifidobacteria, Lactobacilli and Escherichia coli
control group. Besides, there was no difference in the choice,
time, type and course of antibiotic application between the PAGE electrophoresis of amplified fragments of Bifidobacte-
two groups. ria, Lactobacilli and Escherichia coli revealed that the PCR

13
258 World Journal of Pediatrics (2019) 15:255–261

Fig. 1  Standard curves of fluorescence quantitative PCR of Bifidobacteria, Lactobacilli and Escherichia coli

amplification products consisted of a single band and had and remission group (P < 0.05), and was slightly higher com-
a length consistent with the expected length of the DNA pared to healthy group (P > 0.05). Meanwhile, the number
fragment; these data confirmed that each primer had a good of intestinal Bifidobacteria and Lactobacilli in the active
specificity. Fluorescence quantitative PCR of the serial dilu- group was slightly smaller compared to the remission group
tions of the three bacterial strains still showed characteris- with statistically insignificant difference (P > 0.05), while
tic growth curves at 100 cfu/mL, which indicated a good the number of Escherichia coli was increased compared to
detection sensitivity (Fig. 1). The solubility curves from all the remission group, intervention group and healthy group
three bacteria had a single peak, no nonspecific amplifica- (P < 0.05).
tion, primer dimer and other interference phenomena were
observed (Fig. 2). Follow‑up results of RRTI control and intervention
groups
Comparison of fluorescence quantitative PCR results
of intestinal flora among different groups As shown in Table 2, the annual average of acute upper
RTIs, acute (branch) bronchitis, pneumonia and the total
As shown in Table 1, the number of intestinal Bifidobacteria number of antibiotics use per subject in the intervention
and Lactobacilli in the remission group, active group and group were significantly lower than those in the control
control group was significantly decreased compared with the group (P < 0.05). Besides, the average use of antibiotics,
healthy group (P < 0.05). In addition, the number of intesti- the duration of cough and the duration of fever per episode
nal Bifidobacteria and Lactobacilli in intervention group was of RTI were significantly reduced compared to the con-
significantly higher compared to control group, active group trol group (P < 0.05). Total of 16 subjects (22 times) in the

13
World Journal of Pediatrics (2019) 15:255–261 259

Fig. 2  Solubility curves of fluorescence quantitative PCR of Bifidobacteria, Lactobacilli and Escherichia coli

Table 1  Comparison of fluorescence quantitative PCR results of group (n = 27, 90%) was significant higher than that of con-
intestinal flora among different groups (mean ± SD, log copies/g) trol group (n = 10, 33.3%).
Groups Number Bifidobacteria Lactobacilli Escherichia
of cases coli Adverse reactions
Healthy 30 8.89 ± 0.49 8.52 ± 1.42 7.42 ± 1.11
Remission 30 7.99 ± 1.16* 7.76 ± 0.45* 7.56 ± 1.30
There were no cases of adverse events and drug-related
Active 30 7.87 ± 1.39* 7.51 ± 0.55* 8.11 ± 1.24*†
adverse reactions during the administration of Bifidobae-
Control 30 7.91 ± 1.23* 7.70 ± 0.54* 7.78 ± 1.39
terium tetravaccine tablets (Live) and during the follow-up
Interven- 30 8.93 ± 1.08†‡§ 8.71 ± 1.06†‡§ 7.44 ± 1.22‡
period.
tion
F value 7.1191 10.9949 1.5841
P value <0.0001 <0.0001 0.1816 Discussion
*
Compared with the healthy group P < 0.05, compared with the
remission group †P < 0.05, compared with the active group ‡P < 0.05, In the present study, we found that RRTI children suffered
compared with the control group §P < 0.05 from intestinal flora imbalance, which was manifested as a
significant reduction in the number of Bifidobacteria and
control group required hospitalization, which was signifi- Lactobacilli and an increase in the number of Escherichia
cant higher than that in the intervention group (4 subjects, 5 coli. At the same time, this study revealed that the number
times) (P < 0.05). The total effectiveness rate of intervention of Bifidobacteria and Lactobacilli in active stage of RRTI

Table 2  Follow-up results of respiratory tract infection in RRTI control and intervention groups
Items Control group (n = 30) Intervention t value P value
group (n = 30)

Average number of acute upper respiratory tract infections (times/y) 4.03 ± 4.95 1.93 ± 2.12 2.1360 0.0185
Average number of acute bronchitis or bronchitis (times/y) 0.83 ± 0.71 0.37 ± 0.75 2.4396 0.0089
Average number of pneumonia (times/y) 1.47 ± 2.12 0.40 ± 1.41 2.3018 0.0125
Average number of use of antibiotics (times/y) 2.17 ± 3.54 0.63 ± 1.47 2.2006 0.0159
Duration of use of antibiotics for each onset (d) 6.12 ± 2.87 4.13 ± 2.54 2.8440 0.0031
Duration of fever for each onset (d) 3.57 ± 1.93 2.03 ± 1.45 3.4942 0.0005
Duration of cough for each onset (d) 6.53 ± 3.39 4.02 ± 1.85 3.5598 0.0004

13
260 World Journal of Pediatrics (2019) 15:255–261

was lower than that in remission stage, while the number of and meanwhile infection and transmission resistance
Escherichia coli was significantly increased. Further, this sug- induced by probiotics have not been reported in China [27].
gested that the imbalance in intestinal flora is more prominent Similarly, in our study, no obvious adverse reactions were
in the active stage than in the remission stage of RRTI, so we observed in all cases receiving oral Bifidobaeterium tetravac-
could speculate that the imbalance of intestinal flora is related cine tablets (Live).
to the episode of RRTI. After receiving Bifidobaeterium tetra- In summary, RRTI remains a major challenge for global
vaccine tablets (Live) treatment, the number of Bifidobacteria public healthy, causing high morbidity and mortality among
and Lactobacilli in children with RRTI was restored to the children [10]. Currently, probiotics have provided a new way
level of healthy controls, and was significantly higher com- for the prevention and treatment of children with RRTI. Nev-
pared to RRTI control group, suggesting that Bifidobaeterium ertheless, since the curative effect of probiotics is limited to
tetravaccine tablets (Live) can effectively increase the number the influence of different strains, dose and treatment course,
of Bifidobacteria and Lactobacilli in children with RRTI, and and the same strain may also have different effects on the
thereby to maintain the balance of intestinal micro-ecology. children of different ages, its actual effectiveness should be
Probiotics have been shown to have various immunomod- verified using multi-center, large-scale and prospective clini-
ulatory effects in the host [13–15]. Existing studies have cal studies.
revealed that early innate immunity of lung tissues against
foreign infections is derived from the systemic regulation
of intestinal flora via NOD-like receptors (NLRs), while the Author contributors Li KL wrote the first draft of this paper. All
authors contributed to the intellectual content and approved the final
intestinal probiotics can also regulate IgA production by reg- version. Li ZP is the guarantor.
ulating pulmonary dendritic cells [16]. Intestinal probiotics
enhance the host’s resistance to Pneumococcal pneumonia and Funding This study was supported by the Qingdao Outstanding Health
S. aureus pneumonia [17, 18], as well as promote the antiviral Professional Development Fund (Qingdao FPCSE 2017-4).
effect in the lungs. Animal experiments have demonstrated
that mice lacking probiotics have significant deficiencies in Compliance with ethical standards
clearance of K. pneumoniae from the lungs [19]. In addition,
intestinal probiotics can enhance the body’s antiviral immune Conflict of interest The author(s) declares that they have no conflict
of interest.
response by stimulating inflammasome and inducing innate
immune molecules [20], and they are involved in the regula- Ethical approval This study was approved by the Ethics Committee of
tion of pulmonary TH17-mediated antifungal immunity [21]. Rizhao People’s Hospital (code number: rzrmyy2015llpj002).
In this study, the follow-up demonstrated that the fre-
quency of respiratory tract infections, duration of cough, Open Access This article is distributed under the terms of the Crea-
duration of fever, duration and frequency of antibiotics use tive Commons Attribution 4.0 International License (http://creat​iveco​
were significantly decreased in the RRTI intervention group mmons​.org/licen​ses/by/4.0/), which permits unrestricted use, distribu-
tion, and reproduction in any medium, provided you give appropriate
compared with the control group. So far, numerous studies credit to the original author(s) and the source, provide a link to the
suggested that probiotic consumption can decrease the inci- Creative Commons license, and indicate if changes were made.
dence of respiratory tract infections in children [22–25]. A
latest systematic review including 23 RCTs and 6269 cases
has shown that the frequency of respiratory tract infec-
References
tions was significantly reduced, the duration of respiratory
tract infections was shortened in the probiotic intervention 1. Gentile A, Bardach A, Ciapponi A, Garcia-Marti S, Aruj P, Glu-
group [11]. So far, few studies have investigated changes of jovsky D, et al. Epidemiology of community-acquired pneumo-
the intestinal flora in RRTI children. Peng et al. [26] have nia in children of Latin America and the Caribbean: a system-
atic review and meta-analysis. Int J Infect Dis. 2012;16:5–15.
investigated the intestinal flora in 30 children with recurrent
2. Chen J, Xu Z, Ou X, Wang M, Yang X, Li Q. Mannose-binding
pneumonia and have found that the number of Bifidobacteria lectin polymorphisms and recurrent respiratory tract infection in
decreases and the number of Escherichia coli increases in Chinese children. Eur J Pediatr. 2009;168:1305–13.
children with recurrent pneumonia compared with healthy 3. Santos-Valente E, Reisli I, Artac H, Ott R, Sanal O, Boztug K. A
novel mutation in the complement component 3 gene in a patient
children, thus stimulating the imbalance of intestinal flora
with selective IgA deficiency. J Clin Immunol. 2013;33:127–33.
in children with recurrent pneumonia. In theory, Peng’s data 4. Samuelson DR, Welsh DA, Shellito JE. Regulation of lung immu-
suggested that probiotics should be given to promote intes- nity and host defense by the intestinal microbiota. Front Micro-
tinal flora balance during pneumonia treatment. Unfortu- biol. 2015;6:1085.
5. Wolvers D, Antoine JM, Myllyluoma E, Schrezenmeir J, Szajew-
nately, no other relevant studies have been conducted.
ska H, Rijkers GT. Guidance for substantiating the evidence for
At present, there have been no reports on serious toxici- beneficial effects of probiotics: prevention and management of
ties and side effects caused by probiotics due to its safety, infections by probiotics. J Nutr. 2010;140:698–712.

13
World Journal of Pediatrics (2019) 15:255–261 261

6. Vouloumanou EK, Makris GC, Karageorgopoulos DE, Falagas 17. Schuijt TJ, Lankelma JM, Scicluna BP, de Sousa e Melo F, Roe-
ME. Probiotics for the prevention of respiratory tract infections: lofs JJ, de Boer JD, et al. The gut microbiota plays a protective
a systematic review. Int J Antimicrob Agents. 2009;34:1–10. role in the host defence against pneumococcal pneumonia. Gut.
7. Hojsak I, Snovak N, Abdovic S, Szajewska H, Misak Z, Kolacek 2016;65:575–83.
S. Lactobacillus GG in the prevention of gastrointestinal and res- 18. Gauguet S, D’Ortona S, Ahnger-Pier K, Duan B, Surana NK,
piratory tract infections in children who attend day care centers: Lu R, et al. Intestinal microbiota of mice influences resist-
a randomized, double-blind, placebo-controlled trial. Clin Nutr. ance to Staphylococcus aureus pneumonia. Infect Immun.
2010;29:312–6. 2015;83:4003–14.
8. Leyer GJ, Li S, Mubasher ME, Reifer C, Ouwehand AC. Probiotic 19. Brown RL, Clarke TB. The regulation of host defences to infection
effects on cold and influenza-like symptom incidence and duration by the microbiota. Immunology. 2017;150:1–6.
in children. Pediatrics. 2009;124:172–9. 20. Ichinohe T, Pang IK, Kumamoto Y, Peaper DR, Ho JH, Murray
9. Guillemard E, Tondu F, Lacoin F, Schrezenmeir J. Consumption TS, et al. Microbiota regulates immune defense against respira-
of a fermented dairy product containing the probiotic Lactobacil- tory tract influenza a virus infection. Proc Natl Acad Sci USA.
lus casei DN-114001 reduces the duration of respiratory infec- 2011;108:5354–9.
tions in the elderly in a randomised controlled trial. Br J Nutr. 21. McAleer JP, Nguyen NL, Chen K, Kumar P, Ricks DM, Binnie
2010;103:58–68. M, et al. Pulmonary Th17 anti-fungal immunity is regulated by
10. Wang Y, Li X, Ge T, Xiao Y, Liao Y, Cui Y, et al. Probiotics for the gut microbiome. J Immunol. 2016;197:97.
prevention and treatment of respiratory tract infections in children: 22. Quick M. Cochrane commentary: probiotics for prevention of
a systematic review and meta-analysis of randomized controlled acute upper respiratory infection. Explore. 2015;11:418.
trials. Medicine. 2016;95:4509. 23. Garaiova I, Muchová J, Nagyová Z, Wang D, Li JV, Országhová
11. Ozen M, Kocabas SG, Dinleyici EC. Probiotics for the prevention Z, et al. Probiotics and vitamin C for the prevention of respira-
of pediatric upper respiratory tract infections: a systematic review. tory tract infections in children attending preschool: a randomised
Expert Opin Biol Therapy. 2015;15:9–20. controlled pilot study. Eur J Clin Nutr. 2015;69:373–9.
12. Diseases SGOR. Clinical concept and management of recurrent 24. Waki N, Matsumoto M, Fukui Y, Suganuma H. Effects of probi-
respiratory tract infections in children (revised). Chin J Pediatrics. otic Lactobacillus brevis KB290 on incidence of influenza infec-
2008;46:108–10. tion among schoolchildren: an open-label pilot study. Lett Appl
13. Jacobsen CN, Rosenfeldt Nielsen V, Hayford AE, Møller PL, Microbiol. 2014;59:565–71.
Michaelsen KF, Paerregaard A, et al. Screening of probi- 25. King S, Glanville J, Sanders ME, Fitzgerald A, Varley D. Effective-
otic activities of forty-seven strains of Lactobacillus spp. by ness of probiotics on the duration of illness in healthy children and
in vitro techniques and evaluation of the colonization ability adults who develop common acute respiratory infectious conditions:
of five selected strains in humans. Appl Environ Microbiol. a systematic review and meta-analysis. Br J Nutr. 2014;112:41.
1999;65:4949–56. 26. Peng S, Du TH, Zhang M. Changes in gut microbiota and serum
14. Ahrne S, Hagslatt ML. Effect of lactobacilli on paracellular per- d-lactate level and correlation analysis in children with recurrent
meability in the gut. Nutrients. 2011;3:104–17. pneumonia. Chin J Contemp Pediatr. 2016;18:113–6.
15. Morais MB, Jacob CM. The role of probiotics and prebiotics in 27. Group MBP. Evidence-based guidelines for pediatric application
pediatric practice. J Pediatr (Rio J). 2006;82(5 suppl):S189–97. of probiotics. Chin J Pract Pediatrics. 2017;32:81–90.
16. Clarke TB. Early Innate Immunity to bacterial infection in the
lung is regulated systemically by the commensal microbiota via Publisher’s Note Springer Nature remains neutral with regard to
nod-like receptor ligands. Infect Immun. 2014;82:4596–606. jurisdictional claims in published maps and institutional affiliations.

13