LGG for Acute Diarrhoea in Children: What ESPGHAN Says

ESPGHAN, the European Society for Paediatric Gastroenterology, Hepatology and Nutrition, states that Lactobacillus rhamnosus GG may be considered for children with acute gastroenteritis alongside oral rehydration. Since 2020 this has been a weak recommendation based on low-certainty evidence, a downgrade from earlier, stronger advice.

Understanding why the recommendation changed shows how probiotic evidence is weighed, and what parents can reasonably expect from LGG during a bout of diarrhoea.

What did the earlier evidence show?

Through the 2000s and early 2010s, dozens of randomised controlled trials tested LGG in children with acute diarrhoea. Many were small, conducted in hospital settings, and measured how long diarrhoea lasted. Pooled together in meta-analyses, these trials suggested that LGG shortened diarrhoea by roughly a day on average.

On that basis, ESPGHAN's 2014 guidance gave LGG a strong recommendation as an adjunct to rehydration. The World Gastroenterology Organisation's probiotic guidelines also listed it among strains with supportive evidence.

The weaknesses of those early trials were recognised at the time. Many had small sample sizes, inconsistent definitions of when diarrhoea ended, and varying risk of bias. Small trials with positive results are also more likely to be published than small trials with negative ones.

What changed in 2018?

Two large, carefully designed trials published in the New England Journal of Medicine in 2018 changed the picture.

The first, conducted in emergency departments across the United States, randomised children aged three months to four years with acute gastroenteritis to LGG ATCC 53103 or placebo for five days. Children given LGG did not recover faster than those given placebo, on either the severity score or diarrhoea duration.

A Canadian trial of similar design tested a combination of a different L. rhamnosus strain with Lactobacillus helveticus. It also found no benefit. Because it used a different strain, it does not directly evaluate LGG, but it reinforced doubts about the general approach in this setting.

Both trials enrolled children who were well enough to be managed after an emergency visit. Their size and rigour gave them considerable weight when guidelines were revised.

What does ESPGHAN recommend now?

ESPGHAN's working group on probiotics updated its position in 2020. It concluded that LGG may be considered for children with acute gastroenteritis, but downgraded the strength of the recommendation to weak and rated the certainty of evidence as low. Saccharomyces boulardii and Lactobacillus reuteri DSM 17938 received similar weak recommendations.

A Cochrane review published the same year, pooling more than 80 trials across many probiotics, judged it uncertain whether probiotics reduce diarrhoea lasting 48 hours or longer, mainly because of inconsistency between trials.

The guideline also recommended against several strains for which evidence was absent or negative. A weak recommendation therefore still carries meaning. It identifies LGG as one of the few strains a clinician can reasonably offer, while signalling that benefit is uncertain.

How do paediatricians apply this in practice?

Paediatricians generally treat LGG as an optional addition rather than standard treatment. The core of management remains unchanged:

• oral rehydration solution to replace lost fluid and salts
• continued breastfeeding or normal feeding
• zinc for children in countries such as India, following WHO guidance
• prompt review for signs of dehydration or danger symptoms

A paediatrician may suggest LGG when parents wish to try it, when the child is early in the illness, or when there is a hospital-acquired or antibiotic-related component. Rhambac® GG Drops from ELMED Life Sciences provide LGG ATCC 53103 at 1 billion CFU per 6 drops, and any dose for acute diarrhoea should come from the prescriber. Earlier trials often used higher daily amounts, so the paediatrician considers this when advising.

Which children need urgent care instead?

A child with acute diarrhoea needs urgent medical care for signs of dehydration, such as few wet nappies, no tears, sunken eyes or lethargy, and for blood in the stool, persistent high fever, green or repeated vomiting, or severe abdominal pain. Infants under six months and children with chronic illness dehydrate faster and should be seen early. Probiotics should never delay that assessment. The broader evidence for LGG in children is covered in the guide to LGG probiotic drops for infants and children.