Original Article

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AJMB, Official Journal of Faculty of Medicine, Universiti Sultan Zainal Abidin, Malaysia. Muhammad et al.

Parental experience and use of probiotics among children aged twelve months and above

Muhammad Kashif Munir*¹, Samina Khaliq², Sana Rehman¹, Hajra Azhar³, Iqra Riaz³, Atif Amin Baig⁴

1PHRC TB Research Centre, King Edward Medical University Lahore,

2Government Comprehensive High School Lahore,

3Applied Research Centre, King Edward Medical University

4Faculty of Medicine, Universiti Sultan Zainal Abidin

*Corresponding author: [email protected]

Abstract

Probiotics are the food products containing live microorganisms which when up-taken in sufficient quantities, converse health benefits to consumers. This study was aimed to find parental awareness, level of utilization, assessment of their experiences and sentiments about probiotics among their children. This descriptive study was undertaken in King Edward Medical University Lahore during July 2017 to January 2018. A total of 127 questionnaires were successfully completed comprising 45 (35.5%) from health care staff, 52 (40.9%) from parents visiting pediatric outpatients and 30 (23.6%) from school teachers. Maternal parent remained predominant in this study as there were 109 (85.8%) female and 18(14.2%) male respondents. Only 20(15.7%) were familiar with the term probiotics, 49 (38.6%) were somewhat familiar while 58 (45.6%) had no idea about term. On pursuing about preferences regarding probiotics use majority 106/127 (83.5%) of parents like to available in liquid as it is easy to consume for children. Use of probiotics among children is not very much common however it is been prescribed for number of gastrointestinal problems. Only a limited class of people is familiar with health benefits probiotics. Around 20% users do not know about the organism present in specific probiotic is also of astonishing. Due to different social set up health care providers and family physicians must discuss about the dietary supplements in terms of potential risks and benefits.

Keywords: Children; Food Supplement; Health Care Food; Probiotics, Parental.

Cite as: Muhammad Kashif Munir, Samina Khaliq, Sana Rehmanet.al. (2019).Parental experience and use of probiotics among children aged twelve months and above. Asian Journal of Medicine & Biomedicine. Vol 3 (1): 9-14

Date received: February 5^th , 2019 Date accepted: April 3^rd , 2019

Asian Journal of Medicine and Biomedicine, Vol 3:1. Open Access

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Introduction

World Health Organization and Food & Agriculture Organization of United Nations defined probiotics as

“Live microorganisms which when up-taken in sufficient quantities, converse health benefits to consumers”^[1].

Considering present domain of complementary and alternative medicine, such microbial remedies are proposed to be efficient in handling a broad range of gastrointestinal problems which ultimately help to maintain a healthy equilibrium of intestinal biota. In United Nations and other developed countries, probiotics are controlled and regulated alike food supplements and readily available users. On the other hand marketing to prescribe probiotics as medicines and its promotion are taken as lighter note and around fifty percent of websites do not indicate draw backs linked with products containing probiotics. Although sufficient probiotics are consumed in Pakistan in few natural foods especially yogurt even than the general population is not aware of its health benefits.

Probiotics are considered useful and many health conditions most of which are related to gastrointestinal tract include antibiotic associated infectious diarrhea, irritable bowel syndrome, bowel inflammation, acute pancreatitis, helicobacter pylori infection, upper respiratory tract infection and liver cirrhosis etc.

However exact mode of action for usefulness of probiotics is still hypothetical, though generally they are considered to suppress the pathogens and promote growth of normal flora which is beneficial for health.

Medical science is facing serious issues regarding high burden of drug resistant microorganisms ^[2]. Furthermore many undesirable side effects are associated with administration of various antibiotics which create uncertainty among clinicians to prescribe suitable regimen ^[3]. In this scenario, probiotics may have considered to replace antibiotics potentially to overcome such hindrances.

Much of the research is directed to understand the probiotic‟s mechanism of action in developed world and they lack information regarding influence and

expectations of people to consume probiotics ^[4]. Few key aspects can impact the efficacy of probiotics include diversity of each bacterial strain which are marketed as probiotics cannot exert same effects and evidences are present about differ strains within same species of microorganism differ in their characteristics ^[5]. At recent probiotic sales are very high around the globe and strongest growth has been observed in USA, clearly indicates consumers‟ interest ^[5].

Increasing demand and significance of probiotics forced the food industry show their keen interest in benefits of health promoting microorganisms around the globe.

Trends also claimed their influence in Pakistan but impact is limited to a typical class yet. Lack of knowledge and limited resources of public are major constrains whilst no any data about household expenditure on probiotics available as evidenced by a report in 2014 which showed US$0 expenses upon probiotics in Pakistan ^[6]. On the other hand it has been observed that probiotics are extensively used in some situation mostly considering them medicines as they are prescribed by doctors. Probiotics are also extensively used in milk powders, cereals, yogurt & dairy products and frozen desserts ^[7]. Aim of present study was to find parental awareness, level of utilization, assessment of their experiences and sentiments about probiotics.

Methodology

This descriptive study was undertaken in King Edward Medical University Lahore during July 2017 to January 2018. After taking the verbal and written consent one of the parents (maternal or paternal) of age 18 years and above, who bear at least one baby of age 12 months and above were recruited from various areas of the city including hospital staff, school teachers and parents visiting paediatric outpatients for check-up of their children. Parents having educational level <high school were not included in study due difficulty in understanding and perceiving the questions to be asked.

A pre-designed questionnaire was used to collect the information.

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The questionnaire was divided in various sections that include demographic data of respondents, awareness about the term of “probiotics” and their experience, perception about the use of probiotics for treatment, endorsing source of probiotics and future preferences about use of probiotics. Data was carefully collected by trained research staff in a face to face interview. Entirely anonymous questionnaires were filled and neither the respondent nor the child name was written to avoid unwanted individual linkages of individual responses.

Patients had the right to skip any question.

Data was entered and analyzed in SPSS 20.0. Qualitative variables were presented in frequency and percentages while quantitative variables were presented as mean ± standard deviation.

Results

A total of 127 questionnaires were successfully completed comprising 45 (35.5%) from health care staff, 52 (40.9%) from parents visiting pediatric outpatients and 30 (23.6%) from school teachers. Maternal parent remained predominant in this study as there were 109 (85.8%) female and 18(14.2%) male respondents. High school education was the most common 40 (31.5%) level among respondents followed by Graduation and above 60(47.2%) and higher school education as 27(21.3%).

Average family income was remained <1800 USD/year in 73 (57.5%), 1800-2500 USD in 33 (26.0%) and >2500 USD among 12(9.5%) families while remaining 9(7.0%) did not wished to reply this question. Mean ages of respondents and youngest children, number of children and households are shown in Table 1.

Table 1: Age, Number of Children and Households of Respondents (N=127)

Characteristics Mean Standard

Deviation Range Age of respondent

(years)

32.22 7.55 20-47

Age of youngest Child (Months)

41.65 21.91 12-94

Number of Children

≤ 12 years of age 2.09 0.90 1-4

Total number of Households

5.94 1.37 3-9

Probiotics knowledge and experience among respondents was observed and shown in Table 2. Only 20(15.7%) were familiar with the term probiotics, 49 (38.6%) were somewhat familiar while 58 (45.6%) had no idea about term. Rest of the questions was asked from 69 (54.4%) respondents who were familiar or somewhat familiar with probiotics. Of these 69 respondents 30.4% learned about the term „probiotic‟ from advertisement while 24.6% learned from doctor or pharmacist. Only 45 (65.2%) of 69 respondents used probiotics for their children and were eligible to respond further questions in this portion. Probiotic was given as food by 25/45 (55.6%) parents, most 29/45 (64.5%) gave bacteria to their children while beneficial response of probiotics was considered by 36/45 (80%) of the parents. On pursuing whether physician know about the use of probiotic for their children, majority 33/45 (73.3%) responded that probiotics were prescribed by their physician while others did not think it important to inform the physician.

Those who have used probiotics for their children were told about the definition of probiotic as “live microorganisms that produce health benefits when ingested” and asked if they use them in future and 70/82 (85.4%) showed their interest positively. Cost, efficacy and fear of side effects were the major concerns of the patients about use of probiotics.

On pursuing about preferences regarding probiotics use majority 106/127 (83.5%) of parents like to available in liquid as it is easy to consume for children. Response about its availability was favoring pharmacy and health food stores 77/127 (60.6%), while 23/127 (18.1%) think that probiotics must be readily available on grocery stores also. To learn more about probiotics the most of study participants 67/127 (52.7%) favored internet due to easy availability, followed by doctor/pharmacist 40/127 (31.5%) while remaining show no interest in learning about probiotics.

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Table 2: Knowledge and experience of Participants about probiotics. (N=69)

Question Response n %

Source of Learning the Term

„Probiotic‟

Advertisement 21 30.4

Doctor/Pharmacist 17 24.6

Book 13 18.8

Internet 10 14.5

Other 8 11.6

Ever Used Probiotics

Yes 45 65.2

No 24 34.8

Further questions were asked only respondents who used Probiotics. (N=45)

Probiotic Used as

Food 25 55.6

Supplement 13 28.8

Both 7 15.6

Type of Probiotic

Bacteria – Lactobacilli 17 37.7 Bacteria – Bacillus 12 26.7 Yeast - Saccharomyces 7 15.6

Do Not know 9 20.0

Inspiration to use probiotics

Physician/Pharmacist 15 33.4

Advertisement 13 28.8

Health-food store

keeper 11 24.4

Self 6 13.4

Medical Condition That provoke the use of Probiotics

Antibiotic associated

Diarrhea 17 37.7

Chronic Diarrhea 15 33.4

Constipation 5 11.1

Maintain Good Health 8 17.8 Beneficial

response of probiotics

Yes 36 80.0

No 7 15.6

Not Sure 2 4.4

Discussion

Balance in micro-biota is an essential feature for maintenance of gastrointestinal homeostasis while probiotics are the choice to control diarrheal disease ^[8]. Renewal of interest in probiotics use has been flowed in developed countries from last decade or more.

Therapeutic uses of probiotics includes as immunity modulators, decreasing blood cholesterol level, preventing cancers, treating rheumatoid arthritis, diarrhea, constipation, candidiasis and urinary tract infection ^[9].

Consumer knowledge in developed countries has been claimed to higher with the passage of time reported consistency of 65% awareness among respondents in two different studies during 2011 and 2014 ^[4,10]. Comparable results regarding awareness among 54.4% respondents are shown in present study. On the other hand in current survey parental education level below matriculation was excluded from survey therefore results cannot be

generalized and it is assumed that there is sufficient awareness among educated community while economic survey of Pakistan 2016-17 revealed the literacy rate of country as 58% further increase the awareness gap.

About 35.4% of the respondents of parents who participated in current survey brought probiotics used for their children is again high as compared to the similar sort of studies in other countries that reported 29.9% in USA and 25% in New Zealand ^[4,11]. There are again two major reasons for this high rate than other countries in present survey that are exclusion criteria for lower education level and participation of around 35%

healthcare staff who are already aware of the benefits of probiotics to at least some extent. This pertinent phenomenon has been endorsed by former study which identified people with younger age, female gender and higher education levels are more prone to use probiotics as compared to others¹¹. Inconsistent results are found in present study as compared to data indicating the users desire their doctor/pharmacist knowledgeable being top choices ^[12] as the third most top choice revealed presently by 28.8% users is advertisement on TV or radio.

Almost all the respondents in this survey who provide probiotics to their children for treating medical conditions are related to gastrointestinal tract health.

Although other studies also reported the major perception of probiotic users is to maintain good gastrointestinal health but they were also aware of its potential benefits to support immune system, prevent vaginal infections and allergic skin conditions⁴. Lee et.al. reported that most of the 59.2% probiotic consumers did not inform their physician because they did not think it important is unlikely in present study as 73.3% consumers used probiotics on prescription of their family physicians which also suggests the trend of prescribing a probiotic is to lift off. In present study more than 60% parents desired availability of probiotics at pharmacy or health food stores while around 18% prefer to buy from grocery stores.

Fear of side effects was higher among non-users as compared to users further most of the parents wanted to buy probiotics from pharmacy or health care store must

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not be considered to limit to “take a pill” but also get some knowledge about the foods they buy. Foods like yogurt, fermented milk products and kefir are more probably thought as functional food components in developed world ^[13-16]. Misguided views about probiotics may also common as in Netherland and Brazil people supposed coconut water, fruits, soft drink and cheese comprise probiotics ^[15,17]. More than 50% of the respondents in this study are supposed to take probiotic information from internet and around 31% want to take it from healthcare professionals is also unlike other studies^4,11. However it is fact that web based sources of information are not always accurate ^[17] while health care professionals may not be able to give much of their time due to busy schedule.

Although a good response was obtained from parents in present survey even then the results could not be generalized to countrywide population as in this pilot work the respondents were only from Lahore which includes in big cities of country and bears much more facilities compared to other parts of the country.

In conclusion, study showed that use of probiotics among children is not very much common however it is been prescribed for number of gastrointestinal problems. Only a limited class of people is familiar with health benefits probiotics. Around 20% users do not know about the organism present in specific probiotic is also of astonishing. Due to different social set up health care providers and family physicians must discuss about the dietary supplements in terms of potential risks and benefits.

References

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ftp://ftp.fao.org/es/esn/food/wgreport2.pdf.

Accessed in February, 2018.

2. Saleem T, Khalid U, Habib N. Probiotics in clinical practice: panacea or predicament? J Pak Med Assoc. 2010 ;60(11):981.

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[https://propakistani.pk/2017/05/26/literacy- rate-pakistan-drops-2-2016-17/]

12. Schultz M, Baranchi A, Thurston L, Yu YC, Wang L, Chen J, Sapsford M, Chung J, Binsadiq M, Craig L, Wilkins B. Consumer demographics and expectations of probiotic therapy in New Zealand: results of a large telephone survey. N Z Med J.

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13. Babajimopoulos M, Fotiadou E, Alexandridou E, Nikolaidou A. Consumer‟s knowledge on probiotics and consumption of these products in the city of Thessaloniki, Greece; Poster presented at: Proceedings of the 9th Karlsruhe Nutrition Congress; October 10–12, 2004;

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14. Landström E, Hursti UK, Becker W, Magnusson M. Use of functional foods among Swedish consumers is related to health- consciousness and perceived effect. Br J Nutr. 2007;98(5):1058-69.

15. Rijkers GT, Bimmel D, Grevers D, den Haan N, Hristova Y. Consumer perception of beneficial effects of probiotics for human health. Benef Microbes. 2013;4(1):117-21.

16. Mullie P, Gudlinckx I, Clarys P, Degrave E, Hulens M, Vansant G. Cultural, socioeconomic and nutritional determinants of functional food consumption patterns. Eur J Clin Nutr. 2009;63(11):1290-6.

17. Viana JV, da Cruz AG, Zoellner SS, Silva R, Batista ALD. Probiotic foods: consumer perception and attitudes. Int J Food Science Technol. 2008;43(9):1577-80.

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