Tt Luận Án Hiệu Quả Của Lactobacillus Casei Shirota Lên Tình Trạng Dinh Dưỡng, Tiêu Hóa Và Nhiễm Khuẩn Hô Hấp Cấp Ở Trẻ 3-5 Tuổi Tại 4 Xã Tỉnh Thanh Hóa.pdf

MINISTRY OF EDUCATION AND TRAINING

MINISTRY OF

HEALTH

NATIONAL INSTITUTE OF NUTRITION

------------------

PHAM THI THU

THE EFFECTS OF LACTOBACILLUS CASEI SHIROTA ON
THE NUTRITIONAL STATUS, DIGESTIVE AND ACUTE
RESPIRATORY INFECTIONS IN CHILDREN 3-5 YEARS OF
AGE IN 4 COMMUNES, THANH HOA PROVINCE

Major: Nutrition
Code: 9720401

THE ABSTRACT OF THESIS

HA NOI – 2022



THE WORK HAS BEEN COMPLETED AT NATIONAL
INSTITUTE OF NUTRITION

Supervisors:
1. Assoc.Prof. Dr. Nguyen Ngoc Sang

2. Assoc.Prof. Dr. Truong Tuyet Mai

Reviewer 1:
Reviewer 2:
Reviewer 3:

The dissertation is presented at the National Institute of Nutrition -level
Dissertation Assessment Council
Time: ....... date .......month .........year 2022.

The dissertation can be found at:
-

The library of National

-

The library of National institute of Nutrition


LIST OF THE WORKS OF THE AUTHOR
1. Pham Thi Thu, Truong Tuyet Mai, Nguyen Ngoc Sang, Hoang
Thi Hang (2021). Evaluating the effectiveness of supplementing
Lactobacillus casei Shirota (LcS) on children 3-5 years of age with
functional constipation in 4 communes, Thanh Hoa province.
Journal of Vietnamese Medicine, 509(2): 170-175.
2. Pham Thi Thu, Truong Tuyet Mai, Nguyen Ngoc Sang, Tran
Thi Thu Trang (2022). Nutritional status and some related factors
in children 3-5 years of age in 4 communes, Thanh Hoa province
in 2017. Vietnam Medical Journal, 514(2): 230-234.

3. Truong Tuyet Mai, Pham Thi Thu, Hoang Thi Hang, Tran Thi
Thu Trang, Shintaro Yui, Akira Shigehisa, Vu Thuy Tien, Truong
Viet Dung, Phan Bich Nga, Nguyen Trong Hung, Le Danh Tuyen
(2020). Efficacy of probiotics on digestive disorders and acute
respiratory infections: a controlled clinical trial in young
Vietnamese children. European Journal of Clinical Nutrition
/>

1
INTRODUCTION
The malnutrition is a serious public health problem globally,
mainly occurring in Africa and Asia. Malnutrition in children under 5
years old not only slows physical and intellectual development, but also
increases the risk of acute respiratory infections, diarrhea or
constipation for a long time, forming a pathological spiral, affecting the
children's growth and development, even leading to death.
One of the methods to support the treatment of constipation,
diarrhea, strengthen the body's resistance and bring lasting effects is the
use of probiotics. Lactobacillus casei Shirota (LcS) is a strain of
beneficial bacteria that has been studied and used in Japan since 1935.
LcS has been studied for its effects in relation to immunity and
digestion. In Vietnam, there are currently no studies evaluating the
effectiveness of Lactobacillus casei Shirota on nutritional status,
digestive health and ARI in children 3-5 years of age. Therefore, we
conducted a research with 3 objectives:
1. To describe the nutrition situation, digestion and acute
respiratory infection in children 3-5 years of age in 4 communes of
Thanh Hoa province, 2017.
2. To evaluate of the effectiveness of Lactobacillus casei Shirota
supplementation on the incidence of constipation, diarrhea and acute

respiratory infections in children 3-5 years of age in 4 communes of
Thanh Hoa province.
3. To evaluate of the effectiveness of Lactobacillus casei Shirota
supplementation on improving constipation and nutritional status in
children 3-5 years of age with functional constipation in 4 communes of
Thanh Hoa province.


2
New contributions of doctoral thesis:

This is the first work in the country that has identified the
nutritional status, digestion and acute respiratory infections in children
3-5 years of age in 4 communes of Thanh Hoa province in 2017 with
the percentage of underweight, stunting and waisting is 11.2%, 15.7%
and 2.0%. The study demonstrated the effectiveness of Lactobacillus
casei Shirota on the incidence of constipation in children 3-5 years of
age after 12 weeks of intervention, in the intervention group the
incidence of constipation was significantly lower than the control group
(1.3% vs 10.4%). The results of the study also showed the effectiveness
of Lactobacillus casei Shirota in improving constipation in children 3-5
years of age with functional constipation.
The dissertation structure:
The dissertation has 120 pages with the structure as follows: the
introduction and objectives: 3 pages; overview (literature review): 32
pages; methods: 21 pages; results: 30 pages; discussion: 31 pages;
conclusions and recommendations: 3 pages. The dissertation has 37
tables, 9 figures, and 181 references.
Chapter I: OVERVIEW
1.1. The nutritional status, digestive and acute respiratory

infections
Malnutrition remains a major public health concern for children
under 5 years old in many low- and middle-income countries as it
remains the leading cause of death among children in many countries.
The according to the WHO report 2020, about 144 million children
under 5 years old are stunted, 47 million children are wasting and 14.3
million children are severely malnourished. Malnutrition remains a
significant public health problem in Vietnam. According to the survey


3
results on the nutritional status of children, the rate of underweight
malnutrition in Vietnam has decreased but is still high. The direct cause
of malnutrition is believed to be children's lack of food, improper
eating, and disease of infections (diarrhea and ARI), prolonged
constipation can all lead to malnutrition and vice versa. Malnutrition
makes children susceptible to infections and this vicious cycle
continues without appropriate intervention or management.
Diarrhea and ARI are among the top 10 causes of hospitalization
and death in children under 5 years old, while constipation is a common
and challenging problem in children, with serious implications affect
children's emotions, psychology and quality of life, accounting for
nearly 1-4% of school-age children.
1.2. The role of probiotics in gastrointestinal and immune health
Probiotics help supplement beneficial bacteria to create a balance
of bacteria in the digestive system, helping digestion better. Probitotic
competes with harmful bacteria in the colon, creating a membrane that
prevents bacteria, fungi and viruses from penetrating, protecting the
body's digestive system against pathogenic bacteria.
The presence of a healthy and diverse gut microbiota is critical to

achieving or maintaining a normal bowel function, which can
significantly reduce intestinal transit time and increase bowel frequency
and improve stool consistency. Therefore, probiotics can be considered
as natural and safe agents for the relief of functional constipation in
adults and children.
Probiotics are considered safe for the prevention and treatment of
antibiotic-associated diarrhea and infectious diarrhea. The mechanism
of action is a combination of direct competition with pathogenic
bacteria in the intestine and stimulation of local immunity. Daily


4
supplementation of LcS-containing beverages may play a role in the
prevention of acute diarrhea and may reduce acute respiratory
infections and disease severity in preschool-aged children.
1.3. The intervention studies on the effect of Lactobacillus casei
Shirota supplementation on nutritional status, gastrointestinal and
acute respiratory infections.
The numerous studies have shown that supplementation with
Lactobacillus casei Shirota significantly reduces the length of stool
retention in the intestines, increases the frequency of bowel movements,
and improves stool consistency. Therefore, probiotics can be
considered as natural and safe agents for the relief of functional
constipation in adults and children.
Probiotics have been extensively studied in recent years for the
prevention and treatment of diarrhea, especially in children. Effect of
intervention with Lactobacillus casei Shirota on the incidence of
diarrhea depends on the subject and duration of the intervention.
The studies have shown that certain strains of probiotic bacteria
can improve immune function by increasing IgA counts, increasing or

improving phagocytosis, and increasing the proportion of T
lymphocytes and natural killer cells. Several studies indicate that
Lactobacillus casei Shirota (LcS) is beneficial for immune status.
However, several studies have also shown that daily intake of
fermented milk containing LcS has no statistically or clinically
significant effect on protection against respiratory symptoms.
The research results show that the impact of probiotics on the
growth of weight and height of children is not still consistent.


5
CHAPTER 2: METHODS
2.1. Study subjects, setting and study period
- Criteria for selecting study subjects for objective 1,2: Children aged 35 years of age, attending preschool, parents or main caregivers of
children who agree to participate in the study and do not have mental
illness, the child did not give up one of the study stages . Criteria for
selecting study subjects for objective 3: children selected from
objective 2, diagnosed as functional constipation. Exclusion criteria for
objective 2;3: Children with severe malnutrition, severe diseases (acute
respiratory infections, acute diarrhea...), children using probiotics out of
the program, children with birth defects, chronic liver and kidney
diseases , digest.
- Study setting: The cross-sectional study and intervention study in 4
communes: Yen Thai commune, Dinh Thanh commune, Yen Dinh
district (intervention group) and Van Thang commune, Cong Chinh
commune, Nong Cong district (control group), Thanh Hoa province.
- Study period: Cross-sectional study from June 2017 to Augusst 2017;
interventional study from November 2017 to January 2018, data entry
and analyses, and complete the dissertation from February 2018 to
December 2021.

2.2. Study design: The study was divided into two phases
- Phase 1: A cross-sectional descriptive study
- Phase 2: A controlled community intervention study. This study was
conducted on two groups. The control group is a group of children who
eat normally at home and kindergarten, without using the supplement
Lactobacillus casei Shirota for 12 weeks. The intervention group is a
group of children who eat normally at home and kindergarten, but was


6
allowed to use 1 box of products containing 6.5 billion Lactobacillus
casei Shirota per day (65ml/box) x 7 days per week x 12 weeks.
2.3. Sample size
- For objective 1: Cross-sectional descriptive study, the minimum
sample size is 225 children/commune x 4 communes=1020 children.
Actually studied 1136 children.
- For objective 2: A controlled community intervention study, the
minimum sample size is 506 children/group x 2 groups = 1012
children. In fact, 1036 children were studied.
- For objective 3: A controlled community intervention study, the
minimum sample size is 90 children/group. In fact, 216 children were
studied.
2.4. Sampling method
The purposely selected 2 communes Yen Thai, Dinh Thanh, Yen
Dinh district as the intervention group and 2 communes Van Thang and
Cong Chinh in Nong Cong district as the control group.


7

Screening investigation
1136 children 3-5 years old in 4 communes in 2
districts of Yen Dinh and Nong Cong, Thanh Hoa
province
Initial investigation (T0)
1036 children 3–5 years old
(216 children with constipation)
General information, diseases, anthropometrics

Disease, anthropometry,
food consumption
frequency

Control group
(Nong Cong district)
518 children
(108 children with
constipation)

Investigation (T8)
Disease, anthropometry,
food consumption
frequency

8
drop
out

25 drop
out

Investigation (T12)
Disease, anthropometry
The end of the
intervention,
continue tracking

510 children in the
intervention group meet
the analysis criteria
(108 children with
constipation)

Investigation (T16)

Disease, anthropometry,
food consumption
frequency

Monitor the disease situation daily

Investigation (T4)

(Yen Dinh district)
518 children
(108 children with
constipation)

suplementing LCS
Monitor the disease situation daily

Intervention group

493 children in the
intervention group meet
the analysis criteria
(108 children with
constipation)

Flow chart summary of the study
2.5. The methods of data collection and assessment
- General information and information on digestive status, acute
respiratory infections, eating and drinking status of children at the time


8
of the survey were collected by interviewing parents or main caregivers
with pre-designed interview questions.
- The current health status of children at the time of the survey was
collected through medical examination by the pediatrician.
- Digestive status, acute respiratory infections, children's eating and
drinking status every day during the 12 weeks of intervention and after
4 weeks of stopping the intervention were directly monitored, collected
and synthesized by supervisors from teacher's dalily logbook of the
child's illness and eating status and mother's dalily logbook of the
child's illness and eating status.
- Collecting anthropometric data of children at different times through
weighing and measuring children's height.
- Assess the characteristics of the child's stool based on the Bristol
Stool Scale tool.

- Evaluate children with functional constipation according to ROME III
criteria.
- Evaluation of diarrhea and acute respiratory infections according to
IMCI
- Cumulative incidence = Number of children infected in a certain
period of time/total number of children without disease at the beginning
of the study.
- Frequency of illness: the symptoms of constipation, diarrhea, and
acute respiratory infections disappear within 2 consecutive days, then it
is considered the end of an episode. If the child has a relapse, it is
considered a child with a new episode. The frequency of children's
disease is the number of episodes the child has during the intervention
period.


9
- Assessment of nutritional status of children: according to the WHO
growth classification in 2006.
2.6. Research implementation
Organizing product drinking in the intervention group: Organized into
concentrated drinking points at Kindergarten when children go to
Kindergarten by supervisors and teachers who are in charge of directly
distributing products to children, Once a day, after lunch. On Saturdays
and Sundays, children don't go to school or if they are sick, supervisors
and collaborator transfer LcS supplement products in cold bottles to
take home for children to drink or supervisors, teachers guide parents/
the children's family members come to Kindergarten to bring them back
to drink, ensure that the children are used continuously, and that the
tested products are always preserved in the best conditions. Give the
child to drink once a day, after lunch

2.7. Data analysis
- Anthropometric data were calculated using the WHO Anthro and
WHO Anthro plus 2006. Analyze the data using SPSS 25.0 software.
- Applied statistical tests: Chi- square test (2 - test) or Fisher exact test;
Paired t-test, independent t-test; Test Mann Whitney U Test, Wilcoxon
test; one-way ANOVA, Survival analysis.
- To evaluate the effectiveness of the intervention, using the following
indexes: ARR (absolute risk reduction): NNT: (the number of patients
you need to treat to prevent one additional bad outcome).
2.8. Research ethics
The study was approved by the Ethical Review Board in
Biomedical Research of the National Institute of Nutrition according to
Decision No. 778/QD-VDD dated June 26, 2017.


10
Chapter III. RESEARCH RESULTS
3.1. The nutrition situation, digestion and acute respiratory
infection in children 3-5 years of age in 4 communes of Thanh Hoa
province.
Table 3.1. The Malnutrition stastus in 4 communes of Thanh Hoa
province
Yen Dinh district

Nong Cong district

Total

Yen Thai

Dinh Thanh

Van Thang

Cong Chinh

(n=260)

(n=288)

(n=297)

(n=291)

Under weight

(%)
27(10.3)

(%)
33(11.4)

(%)
26(8.8)

(%)
41 (14.1)

127(11.2)

0.219

Stunting

44(16.9)

50(17.3)

33(11.1)

51(17.5)

178(15.7)

0.095

6(2.3)

4(1.4)

4(1.3)

9(3.1)

23(2.0)

0.383

Malnutrition

Waisting

(n=1136)

p

(%)

2

(p) χ test compare rates of underweight, stunting and waisting among
research communes

Underweight accounted for the highest rate of 15.7%, followed by
stunting at 11.2% and wasting in both Yen Dinh and Nong Cong
districts accounting for the lowest rate of 2.0%.
Table 3.2. The percentage of children with constipation, diarrhea, acute
respiratory infections in 4 communes of Thanh Hoa province
Yen Dinh district
Disease

Yen Thai

Dinh Thanh

Nong Cong district
Van Thang

Cong Chinh

(n=260)
(n=288)
(n=297)
(%)
(%)
(%)
Constipation
61(23.5)
72(25.0)
76(25.6)
Diarrhea
24(9.2)
21(7.3)
26(8.8)
ARI
56(21.5)
59(20.5)
75(25.3)
(p) χ2 test compare rates of constipation, diarrhea,
among research communes

Total
(n=1136)
(%)

p

(n=291)
(%)
71(24.4)

280 (24.6) 0.947
29(10.0)
100(8.8)
0.713
50(17.2)
240(21.1)
0.119
acute respiratory infections


11
The percentage of constipation, diarrhea and ARI in 4 communes
were 24.6%, 8.8% and 21.2%.
3.2. The efficacy of Lactobacillus casei Shirota on the cumulative
incidence of constipation, diarrhea, and acute respiratory
infections during the 12 weeks of intervention and after 4 weeks of
stopping the intervention.
Table 3.3. The efficacy of Lactobacillus casei Shirota on the
cumulative incidence of constipation during the 12 weeks of
intervention and after 4 weeks of stopping the intervention.
Intervention group
Control group
(n = 510)
(n = 493 )
Time
(n)
(%)
(n)
(%)
T0-T4

61
16.3
103
28.3
T0-T8
77
20.6
133
36.5
T0-T12
81
21.7
157
43.1
T0-T16
85
22.7
188
51.6

p
0.000
0.000
0.000
0.000

(p)χ2 test compare percentages of 2 groups at the same time

The percentage of children with the cumulative incidence of
constipation in the intervention group was significantly lower than the

control group after 4.8,12 weeks of intervention and after 4 weeks of
stopping the intervention, 16.3% vs 28.3%; 20.6% vs 36.5%; 21.7% vs
43.1% and 22.7% vs 51.6%. The difference was statistically significant
with p<0.001.


12

Group

N

Control group
NhómGroup
Intervention

Chứng
Probability
of new
cumulative
constipation

0

Week

2

Figure 3.1. Kaplan–Meier chart of the cumulative incidence of
constipation in the intervention and control groups

The probability of cumulative constipation in intervention group
was lower than the control group. The mean time of children without
incidence of constipation after 12 weeks intervention in intervention
group was significantly greater than the control group (p=0.000).
Table 3.4. The effectiveness of prevention to the cumulative incidence
of constipation after 12 weeks of intervention
Intervention group
Indicators
(n = 374)
Cumulative incidence of
81 (21.7%)
constipation
No new cumulative
293 (78.3%)
incidence of constipation

Control group
(n = 364)

p

157 (43.1%)
0.000
207 (56.9%)


13
ARR% (95%CI)

0.214(0.148-0.280)

NNT

4.656 (3.564-6.714)

(ARR) Absolute risk reduction after 12 weeks intervention.
(NNT) Number needed to treat to reduce 1 case after12 week
intervention
(p) χ2 test compare percentages of 2 groups at the same time.
After 12 weeks of intervention, supplementing Lactobacillus casei
Shirota reduced 21.4% of cumulative incidence of constipation. There
was a significant difference in the cumulative incidence of constipation
between the two groups (p<0.001).
Table 3.5. The efficacy of Lactobacillus casei Shirota on the
cumulative incidence of diarrhea during the 12 weeks of intervention
and after 4 weeks of stopping the intervention.
Intervention group
Control group
(n
=
510)
(n = 493 )
Time
(n)
(%)
(n)
(%)

p

T0-T4

86

18.2

84

18.6

0.932

T0-T8

137

29.0

138

30.5

0.615

T0-T12

170

35.9

172

38.1

0.540

T0-T16

180

38.1

204

45.1

0.033

(p)χ2 test compare percentages of 2 groups at the same time

The percentage of children with the cumulative incidence of
diarrhea in the intervention group was lower than the control group
after 4,8,12 weeks of intervention (p>0.05). However, after stopping
the intervention for 4 weeks, the cumulative incidence of diarrhea in the
intervention group was significantly lower than that the control group
(p<0.05).


14

Group
Control group
Intervention Group
Probability
of new
cumulative
diarrhea

Week

Figure 3.2. Kaplan–Meier chart of the cumulative incidence of diarrhea
in the intervention and control groups
The probability of cumulative diarrhea in intervention group was
lower than the control group. The mean time of children without
incidence of diarrhea after 12 weeks intervention and after 4 weeks of


15
stopping the intervention in intervention group was greater than the
control group (p>0.05).
Table 3.6. The efficacy of Lactobacillus casei Shirota on the
cumulative incidence of acute respiratory infection during the 12 weeks
of intervention and after 4 weeks of stopping the intervention.
Intervention group
Control group
(n = 510)
(n = 493 )
Time
(n)
(%)

(n)
(%)
T0-T4
57
14.5
59
15.9
T0-T8
100
25.5
107
28.9
T0-T12
132
33.7
141
38.1
T0-T16
138
35.2
175
47.3

p
0.615
0.328
0.227
0.001

(p)χ2 test compare percentages of 2 groups at the same time

The percentage of children with the cumulative incidence of ARI
in the intervention group was lower than the control group after 4,8,12
weeks of intervention (p>0.05). However, after stopping the
intervention for 4 weeks, the cumulative incidence of ARI in the
intervention group was significantly lower than that the control group
(p<0.05).


16

Group
Control group
Intervention
Group
Nhóm

chứng

Probability
of new
cumulative
ARI

0

Week

Figure 3.3. ,0
Kaplan–Meier chart of the cumulative incidence of ARI in

the intervention and control groups
The probability cumulative of ARI in intervention group was
lower than the control group. The mean time of children without
cumulative incidence of ARI after 12 weeks intervention in intervetion
group was greater than the control group (p>0.05). However, after 4
weeks stopping the intervention, the probability cumulative of ARI in
intervention group was significantly lower than that the control group
(p<0.05).
3.3. The evaluation of the effectiveness of Lactobacillus casei
Shirota supplementation on improving constipation and nutritional
status in children 3-5 years of age with functional constipation in 4
communes of Thanh Hoa province.

N