A pilot study to test the safety of use of lactulose in preterm infants and to preliminary assess the hypothesis that lactulose would support the early growth of Lactobacilli in the stools of premature infants and possibly would also improve nutritional status and decrease NEC and late-onset sepsis.

Prospective, double-blind, placebo-controlled single center pilot study in 23-34 weeks gestation premature infants. Study group will receive 1% lactulose, while control group will receive 1% dextrose placebo in all their feeds (human milk or preterm formula). Clinical parameters will be followed. Stool samples will be sent for culture.

• Necrotizing Enterocolitis
• Sepsis

• Drug: Lactulose
• Dietary Supplement: Dextrose

• Experimental: Study group will receive 1% lactulose in all their feeds (human milk or preterm formula)
• Placebo Comparator: Control group will receive 1% dextrose placebo in all their feeds (human milk or preterm formula).

• Rotimi VO, Duerden BI. The development of the bacterial flora in normal neonates. J Med Microbiol. 1981 Feb;14(1):51-62.
• Orrhage K, Nord CE. Factors controlling the bacterial colonization of the intestine in breastfed infants. Acta Paediatr Suppl. 1999 Aug;88(430):47-57. Review.
• Benno Y, Sawada K, Mitsuoka T. The intestinal microflora of infants: composition of fecal flora in breast-fed and bottle-fed infants. Microbiol Immunol. 1984;28(9):975-86.
• Guarner F, Malagelada JR. Gut flora in health and disease. Lancet. 2003 Feb 8;361(9356):512-9. Review.
• Vanderhoof JA, Young RJ. Probiotics in pediatrics. Pediatrics. 2002 May;109(5):956-8. Review. No abstract available.
• Bennet R, Eriksson M, Nord CE, Zetterström R. Fecal bacterial microflora of newborn infants during intensive care management and treatment with five antibiotic regimens. Pediatr Infect Dis. 1986 Sep-Oct;5(5):533-9.
• Hall MA, Cole CB, Smith SL, Fuller R, Rolles CJ. Factors influencing the presence of faecal lactobacilli in early infancy. Arch Dis Child. 1990 Feb;65(2):185-8.
• Sakata H, Yoshioka H, Fujita K. Development of the intestinal flora in very low birth weight infants compared to normal full-term newborns. Eur J Pediatr. 1985 Jul;144(2):186-90.
• Caicedo RA, Schanler RJ, Li N, Neu J. The developing intestinal ecosystem: implications for the neonate. Pediatr Res. 2005 Oct;58(4):625-8. Review.
• Gewolb IH, Schwalbe RS, Taciak VL, Harrison TS, Panigrahi P. Stool microflora in extremely low birthweight infants. Arch Dis Child Fetal Neonatal Ed. 1999 May;80(3):F167-73.
• Gaynes RP, Edwards JR, Jarvis WR, Culver DH, Tolson JS, Martone WJ. Nosocomial infections among neonates in high-risk nurseries in the United States. National Nosocomial Infections Surveillance System. Pediatrics. 1996 Sep;98(3 Pt 1):357-61.
• Millar M, Wilks M, Costeloe K. Probiotics for preterm infants? Arch Dis Child Fetal Neonatal Ed. 2003 Sep;88(5):F354-8. Review.
• Neu J, Caicedo R. Probiotics: protecting the intestinal ecosystem? J Pediatr. 2005 Aug;147(2):143-6. No abstract available.
• Dani C, Biadaioli R, Bertini G, Martelli E, Rubaltelli FF. Probiotics feeding in prevention of urinary tract infection, bacterial sepsis and necrotizing enterocolitis in preterm infants. A prospective double-blind study. Biol Neonate. 2002 Aug;82(2):103-8.
• Millar MR, Bacon C, Smith SL, Walker V, Hall MA. Enteral feeding of premature infants with Lactobacillus GG. Arch Dis Child. 1993 Nov;69(5 Spec No):483-7.
• Agarwal R, Sharma N, Chaudhry R, Deorari A, Paul VK, Gewolb IH, Panigrahi P. Effects of oral Lactobacillus GG on enteric microflora in low-birth-weight neonates. J Pediatr Gastroenterol Nutr. 2003 Mar;36(3):397-402.
• Kitajima H, Sumida Y, Tanaka R, Yuki N, Takayama H, Fujimura M. Early administration of Bifidobacterium breve to preterm infants: randomised controlled trial. Arch Dis Child Fetal Neonatal Ed. 1997 Mar;76(2):F101-7.
• Caplan MS, Jilling T. Neonatal necrotizing enterocolitis: possible role of probiotic supplementation. J Pediatr Gastroenterol Nutr. 2000;30 Suppl 2:S18-22. Review. No abstract available.
• Costalos C, Skouteri V, Gounaris A, Sevastiadou S, Triandafilidou A, Ekonomidou C, Kontaxaki F, Petrochilou V. Enteral feeding of premature infants with Saccharomyces boulardii. Early Hum Dev. 2003 Nov;74(2):89-96.
• Hoyos AB. Reduced incidence of necrotizing enterocolitis associated with enteral administration of Lactobacillus acidophilus and Bifidobacterium infantis to neonates in an intensive care unit. Int J Infect Dis. 1999 Summer;3(4):197-202.
• Lin HC, Su BH, Chen AC, Lin TW, Tsai CH, Yeh TF, Oh W. Oral probiotics reduce the incidence and severity of necrotizing enterocolitis in very low birth weight infants. Pediatrics. 2005 Jan;115(1):1-4.
• Bin-Nun A, Bromiker R, Wilschanski M, Kaplan M, Rudensky B, Caplan M, Hammerman C. Oral probiotics prevent necrotizing enterocolitis in very low birth weight neonates. J Pediatr. 2005 Aug;147(2):192-6.
• Deshpande G, Rao S, Patole S. Probiotics for prevention of necrotising enterocolitis in preterm neonates with very low birthweight: a systematic review of randomised controlled trials. Lancet. 2007 May 12;369(9573):1614-20. Review.
• Salminen S, von Wright A, Morelli L, Marteau P, Brassart D, de Vos WM, Fondén R, Saxelin M, Collins K, Mogensen G, Birkeland SE, Mattila-Sandholm T. Demonstration of safety of probiotics -- a review. Int J Food Microbiol. 1998 Oct 20;44(1-2):93-106. Review.
• Agostoni C, Axelsson I, Goulet O, Koletzko B, Michaelsen KF, Puntis JW, Rigo J, Shamir R, Szajewska H, Turck D; ESPGHAN Committee on Nutrition. Prebiotic oligosaccharides in dietetic products for infants: a commentary by the ESPGHAN Committee on Nutrition. J Pediatr Gastroenterol Nutr. 2004 Nov;39(5):465-73.
• Gibson GR, Roberfroid MB. Dietary modulation of the human colonic microbiota: introducing the concept of prebiotics. J Nutr. 1995 Jun;125(6):1401-12. Review.
• Macfarlane S, Macfarlane GT, Cummings JH. Review article: prebiotics in the gastrointestinal tract. Aliment Pharmacol Ther. 2006 Sep 1;24(5):701-14. Review.
• Moro G, Minoli I, Mosca M, Fanaro S, Jelinek J, Stahl B, Boehm G. Dosage-related bifidogenic effects of galacto- and fructooligosaccharides in formula-fed term infants. J Pediatr Gastroenterol Nutr. 2002 Mar;34(3):291-5.
• Boehm G, Lidestri M, Casetta P, Jelinek J, Negretti F, Stahl B, Marini A. Supplementation of a bovine milk formula with an oligosaccharide mixture increases counts of faecal bifidobacteria in preterm infants. Arch Dis Child Fetal Neonatal Ed. 2002 May;86(3):F178-81.
• Lidestri M, Agosti M, Marini A, Boehm G. Oligosaccharides might stimulate calcium absorption in formula-fed preterm infants. Acta Paediatr Suppl. 2003 Sep;91(441):91-2.
• Knol J, Scholtens P, Kafka C, Steenbakkers J, Gro S, Helm K, Klarczyk M, Schöpfer H, Böckler HM, Wells J. Colon microflora in infants fed formula with galacto- and fructo-oligosaccharides: more like breast-fed infants. J Pediatr Gastroenterol Nutr. 2005 Jan;40(1):36-42.
• Mihatsch WA, Hoegel J, Pohlandt F. Prebiotic oligosaccharides reduce stool viscosity and accelerate gastrointestinal transport in preterm infants. Acta Paediatr. 2006 Jul;95(7):843-8.
• Knol J, Boehm G, Lidestri M, Negretti F, Jelinek J, Agosti M, Stahl B, Marini A, Mosca F. Increase of faecal bifidobacteria due to dietary oligosaccharides induces a reduction of clinically relevant pathogen germs in the faeces of formula-fed preterm infants. Acta Paediatr Suppl. 2005 Oct;94(449):31-3.
• Moro G, Arslanoglu S, Stahl B, Jelinek J, Wahn U, Boehm G. A mixture of prebiotic oligosaccharides reduces the incidence of atopic dermatitis during the first six months of age. Arch Dis Child. 2006 Oct;91(10):814-9. Epub 2006 Jul 27.
• Szilagyi A. Redefining lactose as a conditional prebiotic. Can J Gastroenterol. 2004 Mar;18(3):163-7. Review.
• Schumann C. Medical, nutritional and technological properties of lactulose. An update. Eur J Nutr. 2002 Nov;41 Suppl 1:I17-25. Review.
• PETUELY F. [Lactobacillus bifidus flora produced in artificially-fed infants by bifidogenic substances (bifidus factor).] Z Kinderheilkd. 1957;79(2):174-9. German. No abstract available.
• Uhlemann M, Heine W, Mohr C, Plath C, Pap S. [Effects of oral administration of bifidobacteria on intestinal microflora in premature and newborn infants] Z Geburtshilfe Neonatol. 1999 Sep-Oct;203(5):213-7. German.
• MACGILLIVRAY PC, FINLAY HV, BINNS TB. Use of lactulose to create a preponderance of Lactobacilli in the intestine of bottle-fed infants. Scott Med J. 1959 Apr;4(4):182-9. No abstract available.

Inclusion Criteria:

Premature infants were recruited based on the following criteria:

• 23-34 weeks' gestation (as determined by a combination of maternal dates, early prenatal ultrasonography and postnatal gestational age estimation based on physical and neuromuscular signs (New Ballard Score), as long as there will be gestational age agreement between the 3 methods < 2 weeks);
• Absence of major congenital malformations; and
• Informed consent obtained from parents.

Exclusion Criteria:

• Major congenital malformations and parental refusal.