A RANDOMIZED CONTROLL TRIAL TO COMPARE THE EFFICACY OF SACCHAROMYCES BOULARDII , BACILLUS CLAUSII, AND LACTOBACILLUS RHAMNOSUS GG PREPARATION IN THE TREATMENT OF ACUTE DIARRHEA IN CHILDREN

Objective: Probiotics have been recommended as an adjunct to standard treatment of acute diarrhea but the choice of probiotics is unclear. The aim of study is to compare the efficacy of Saccharomyces boulardii , Bacillus clausii versus Lactobacillus rhamnosus in children with acute diarrhea and to expand the tolerability of S. boulardii , B. clausii versus L. rhamnosus GG in acute diarrhea. Methods: Hospital based Randomized Controlled Clinical trial (chit in box) carried out at the Department of Pediatrics, Mahatma Gandhi Hospital, Jaipur Rajasthan from January 2020 to June 2021. 120 Children were enrolled in the study and randomized to either Group A or Group B or Group C. Group A received S. boulardii , Group B received B. clausii and Group C received


INTRODUCTION
Diarrhea is interpreted as a change in bowel motions for an individual subject identify by arise in the water content, volume, and frequency of stools [1]. This disease is observed over 1400 young kids lose their lives per day, or about 525,000 kids annually, despite the readily availability of an easy and accessible therapeutic solution [2]. In spite of the fact that it is a curable disease, acute diarrhea leavings a major cause of morbidity and mortality in kids worldwide (525,000 deaths in a year among 5 years). Majority of the mortalities took place in developing countries [3].
As per the World Health Organization (WHO) and UNICEF, about to be diarrheal disease cases across the globe every year and 1.9 M kids younger than 5 years die from diarrhea each year, mainly in developing countries. This contributes to 18% of all the deaths of kids <5 years and >5000 kids are dying every day. For such demises, majority as 78% take place in African and Southeast Asian regions [1,2].
Diarrhea is generally a symptom of a contamination in the intestinal tract, due to variety of viral, bacterial and parasitic organisms, spread through contaminated drinking water/food/from person-to-person as an outcome of deficient hygiene. Another common identifiable viral cause of diarrhea is Rotavirus in all kids that belong to Reoviridae family, sometimes leads to critical dehydration in infants and children [1]. Probiotics are living micro-organisms that, upon ingestion in definite numbers, deploy health advantages a far inherent general nutrition [4]. It has been propose that probiotics regulate the immune response, build antimicrobial agents and participate in nutrient uptake and adhesion sites with pathogens [5][6][7]. The WHO suggested and recommended the treatment of acute kid diarrhea with oral rehydration salts and carrying on feeding for the prevention and treatment of dehydration, including zinc supplementation to reduce the duration and severity of the diarrheal episode, with a good safety profile [1]. Probiotics have been recommended as an adjunct to standard treatment, but the choice of probiotics is unclear. Therefore, we have conducted this study with the aim to compare and evaluate the efficacy of Saccharomyces boulardii, Bacillus clausii versus Lactobacillus rhamnosus in kids with acute diarrhea and to expand the tolerability of S. boulardii, B. clausii versus L. rhamnosus GG in decreasing the episodes/ day and time frame of acute diarrhea.

METHODS
This study was hospital-based Randomized Controlled Clinical trial (chit in box) conducted at the Department of Pediatrics Mahatma Gandhi Hospital, Jaipur Rajasthan from Jan 2020 to June2021. The study groups included children of 1 month-18 years who were admitted in pediatric ward with complaints of acute diarrhea (duration <14 days) and parents were ready to give written consent. Exclusion criteria were children suffering from dysentery, having evidence of severe malnutrition, signs of any existing illnesses of acute onset (meningitis, sepsis, and pneumonia), immunodeficiency, underlying severe chronic diseases, food allergy or other chronic gastrointestinal diseases, use of probiotics in the last 3 weeks, use of antibiotics or any antimotility medication in the past 3 weeks and during the study, poor compliance (administration of <3 doses of the study medication), and parents were not willing to give written informed consent. After written informed consent were obtained from the parents, detailed medical history taken from children and parents, clinical examination, and laboratory investigations. Subjects who will fulfill the inclusion and exclusion criteria were enrolled in the study and randomized to either As shown in Primer. The Categorical significant data were presented as numbers (percent) and comparison made among groups using Chi-square test. The quantitative data were presented as mean and standard deviation and were compared using by Analysis of variance test. Probability p<0.05 was considered statistically significant. Table 1 showed the age distribution of the cases among the group. Most of the cases (49.17%) were observed in age group 5 to 10 followed by <5 years of age (Chi-square=6.844 with degree of freedom; p=0.335). The table also showed the sex distribution of the cases among the group. Most of the cases (53.33%) were observed males. Groups were comparable according to sex (Chi-square=0.469 with 2° of freedom; p=0.791). No significant difference was observed among the groups according to weight (p=0.834). No significant difference was observed among the groups according assessment of dehydration. Out of total 120 children, 45% cases were observed no dehydration followed by 34.17% were some dehydration and 20.83% were with severe dehydration (Chi-square=3.893 with 4° of freedom; p=0.421). Groups were comparable according to age, sex, weight, and dehydration assessment. Table 2 showed according to consistency of stools, initially all cases were observed with liquid stool, then on day 2 and day 3 there was statistically significant improvement in consistency was observed in Group C as compared to Group A and Group B (p<0.001). Table 3 showed that there was a statistically significant reduction in the frequency of diarrhea within all the groups. There was no significant difference observed among the groups. Table 4 showed that significant difference was observed among the groups according to improvement/persistence of stool (p=0.045). Significant higher cases (87.5%) were improved in Group C compare to Group B followed by Group A (67.5% and 65%, respectively). Table 5 showed that all patients were observed well tolerated and well accepted no symptoms were observed of any side effects such as the vomiting, nausea, and abdominal pain during the study period.

DISCUSSION
The first and foremost challenge in picking up a suitable probiotic is the heterogeneity of products accessible from which to pick and the absence of advice on which products may be more successful. Probiotics are explained as live micro-organisms that, when managed in enough amounts, consult a health advantage on the host [8,9]. Nevertheless, the load of evidence for health advantage varies country to country.
In 2013, probiotics were used extensively in Europe and Asia but further use was disallowed on label due to the disparity of proof for multiple claims for health benefits [10]. At present, regulations specific to probiotics are in flux and vary badly from one to another country.
A major cause of morbidity and mortality in developing countries is pediatric acute diarrhea may be due to bacterial or viral etiologies. Latin-American instructions now endorsed some probiotics should be provided with oral rehydration therapy for care of acute pediatric diarrhea [11].
As per the study by Gopchade 2019 found that most frequently affected age group was between 1 and 3 years of age (51.67%) followed by 1 month and 1 year of age (31.67%) [14].
Protection against diarrhea in first 6 month of age group may be give out by many reasons such as maternal antibodies in opposition to enteric pathogens, breastfeeding. It is feasible that post 6 months of age, with the launch of supplementary foods and altering nutritional habits, this defense is lost [15].
In current research work, 53.33% cases were observed in male category. Groups were comparable according to sex. Mostly diarrhea was associated with males, observed by similar outcome reported by Siziya et al. (2009) [16]. Lahiri et al. 2015 considered 131cases admitted to the pediatric ward where 63.4% were males and rest was females [12]. As per Irfan et al., 2017, 51.4% were male and rest was female. Furthermore, as per Gopchade 2019, out of 120 kids, up to the age of 5 years, were 65% boys with M: F ratio of 1:0.53 [13,14]. As per Chakravarthi et al., 2019, incidence of acute diarrhea was considered in 54.6% males which were positively linked with diarrhea [17].
As per our study, no significant difference was observed among the groups as per assessment of dehydration. Out of total 120 children, 45% cases were observed no dehydration followed by 34.17% were some dehydration and 20.83% were with severe dehydration. Out of 66 patients with dehydration, 41 patients (62.12%) were diagnosed to be having some dehydration whereas 25 (38.46%) patients were found to have severe dehydration. Similar findings were observed from Gopchade 2019, where out of 120 patients 73.33% cases were treated having some dehydration and 26.67% patients were observed to have severe dehydration [14]. As per Chakravarthi et al., 2019, in 39.1% cases severe dehydration was present and some dehydration was present in 60.8% [17].
Therefore, there was a statistically significant reduction in the frequency of diarrhea with in the groups. This shows that these therapies were effective in reducing the frequency of diarrhea. On comparing symbiotic with probiotics on day 1, there was a statistically significant reduction in the frequency of diarrhea (p=0.049). This may probably be due to the effect of symbiotic in reducing the frequency of diarrhea.
According to consistency of stools, initially all cases were observed with liquid stool. On D2 semisolid were observed higher in Group C as compared to both Groups A and B. And D3 similar observation was observed that Group C was better than other two probiotics (p<0.001).
The study of Nista et al. (2004) find a more decrease in case of diarrhea in the B. clausii group differ with the placebo group after 1 (relative risk [RR] of 0.30; p=0.01) and 2 weeks (RR=0.38) of treatment, decreases the incidences of epigastric discomfort and nausea (p<0.05 for both events) [18]. Plus a meta-analysis on probiotics (Lactobacillus, Bifidobacterium, Saccharomyces, Streptococcus, Enterococcus, and/ or Bacillus) for the treatment and prevention of antibiotic associated diarrhea shown a favorable response [19]. Canani et al. (2007) found that 1 day post the 1 st probiotic administration, the daily count of stools was significantly less (p<0.001) in kids who got L. rhamnosus strain GG [20]. As per Keya Lahiri et al. (2015) found that B. clausii decreased the time, recurrence, and hospital stay of diarrhea thereby decreasing the care and social costs [12]. As per Salloju et al.
(2017) found that on initial day and stool recurrence were more than 3 times in both groups. On day 3 onward, the episodes was <3 times a day in 14 (35%) of 40 in the S. boulardii group and 1 (2.5%) of 40 in the B. clausii group (p=0.001). On day 4, S. boulardii was 2 times more likely to reduce the frequency of stools to <3/day than B. clausii group [21]. Szajewska H2014 found that L. rhamnosus GG (typically at 10 10 CFU/day for 5-7 days) and S. boulardii (typically at 250-750 mg/ day [10 9 -10 10 CFU] for 5-7 days), for which proof keep up use as adjuncts to rehydration for controlling acute infectious diarrhea in pediatric patients [25]. In our study, significant difference was observed among the groups according to improvement/persistence of diarrhea. Statistically significant (p=0.045) higher cases (87.5%) improved in Group C as compared to Group A (67.5%) and Group B (65%, respectively).
In our study, all patients were observed well tolerated and well accepted no symptoms were observed of any side effects (vomiting, nausea, and abdominal pain) during the study period. This was in correlation with the studies conducted by VanNiel (2002) observed that the effect of various probiotic species and strains on diarrhea was presently well accepted [26]. Boyle et al. (2006) where addition of synbiotics did not increase the frequency or severity of Adverse Drug Reactions [27].     included studies using L. Acidophilus LB and observed a statistically significant mean decrease in diarrhea episodes pooled from four trials was 21 h [25].

Strength of study
We compared three probiotics in the same study period in various patients. Hardly any other study could be traced comparing three probiotic in same study.

Limitation of study
Number of cases (sample size) is small in this study. Further study with larger sample size may strengthen the results.

CONCLUSION
This study was conducted with the aim to compare and evaluate the efficacy and tolerability of S. boulardii, B. clausii versus L. rhamnosus GG in the management of acute diarrhea. From the study, we concluded that 1. L. rhamnosus GG., B. clausii, and S. boulardii, all the three probiotics shorten the frequency, while L. rhamnosus GG significantly reduce the frequency, improve the consistency and color of stools in diarrhea compared to B. clausii and S. boulardii. 2. Tolerability of S. boulardii, B. clausii, and L. rhamnosus GG was good with no adverse effect. 3. However, larger studies are needed to extend the clinical application of various probiotics and appropriate dose required to obtain best results.

ACKNOWLEDGMENTS
We are thankful to the department faculty and our patients without their support this study would not have been possible.

FUNDING
No funding sources.

CONFLICT OF INTEREST
None declared.