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Probiotics, which are live microorganisms that provide health benefits to the host when consumed in adequate amounts, have gained significant attention in recent years (Araya M et al 2002). They can restore balance to disrupted gut microbiomes, regulate gastrointestinal issues, enhance immunity, relieve stress, optimize metabolism, and contribute to other effects (Suez J et al 2019). This has led to their widespread consumption as a dietary supplement worldwide, successfully growing into a multi-billion-dollar industry (Clarke TC et al 2015). The probiotic dietary supplements market was valued at nearly $6,395.5 million in 2022, with a compound annual growth rate (CAGR) of 7.7% since 2017, with the Asia-Pacific region, especially in China and Korea, is expected to be the fastest-growing market for dietary supplements, with a CAGR of 9.3% from 2021 to 2028 [Industry Analytics Research consulting (ARC I) 2023]. Gradually, probiotic-enhanced products are moving further into the mainstream in China. The market size of probiotic supplements in China scaled to around 56.8 billion yuan in 2021. The market is expected to grow further and reach 74 billion yuan by 2025 (Ou X 2024). The South Korea probiotic supplement market was valued at US$165.187 million in 2022 and is expected to grow at a CAGR of 11.78% during 2024 to 2029 (ARC I 2023).

Currently, numerous studies were conducted to propose probiotic supplementation as a therapy for various health issues in children, including acute gastroenteritis, antibiotic associated diarrhea, necrotizing enterocolitis (NEC), constipation, allergic disease, colic a respiratory infection (Vandenplas Y et al 2013, Irwin N et al 2020). Clinical studies indicate that probiotics can help prevent or treat a range of acute and chronic health problems while maintaining an excellent safety profile (Chen YC et al 2012, Wang Y et al 2016). Early childhood is a critical period for the development of gut health and immune function, making it essential to explore the use of probiotic supplements in this vulnerable population (Dogra SK et al 2021). Studies have shown that early-life probiotic supplementation reduced the risk of neuropsychiatric disorders developing later in childhood, possibly through mechanisms involving gut microbiota composition (Partty A et al 2015). Probiotic supplements were found to reduced antibiotic-associated diarrhea risk in children in Korea, as shown in a meta-analysis including Korean studies (Ambarsari A et al 2022). A prophylactic probiotic intervention with a carefully chosen strain combination could be a valuable tool for alleviating the health of the pediatric population, which can enhance biochemical parameters and serum concentration, as well as boost nutritional absorption capacity, which can, in turn, strengthen overall health and immunity if given for at least five weeks or more (Ballini A et al 2019). The report titled “Probiotic Supplements for Kids Market Forecast (2021—2026)” by Industry ARC I, indicates that probiotic supplements for kids market size is estimated at $1.8 billion in 2020, projected to grow at a CAGR of 7.3% during the forecast period 2021—2026 (ARC I 2024).

Despite the growing body of research on the probiotics in children, there is limited literature reporting on the prevalence of probiotic supplementation in healthy children (Irwin N et al 2020). A scoping review revealed the prevalence of probiotic supplement usage ranged from 4% to 51% across various countries (Irwin N et al 2020). Kim HS et al (2013) found that 25.6% of Korean mothers of preschoolers reported the use of probiotic supplements for their children. On the contrary, studies in China have primarily focused on intervention trials assessing the impact of probiotic supplements on digestibility and immunity in infants (Xiao L et al 2017), or have targeted infants aged 18 months (Chen YC et al 2012), clinical pediatric population (An Y & Cheng Q 2013), cancer patients (Yao D et al 2023) or young adults (Ma T et al 2021). Limited information exists regarding the status of probiotic supplementation focusing on preschool-aged children in China.

Parents play a crucial role in the decision to use probiotic supplements for their children, the probiotic supplements use in a child’s diet was positively correlated with parents’ consumption and level of knowledge about the term probiotic (Bezek K et al 2023). Andersen SS et al (2018) demonstrated that parents were receptive to probiotics based on healthcare professionals’ recommendations or potential child benefits, yet they exhibited skepticism toward preventive applications. In the Australian Capital Territory, 47.4% of preschool-aged children have been exposed to probiotics, with 14.9% consuming them within the last month (Irwin N et al 2022). A quantitative study conducted in Alberta, Canada, revealed that while mothers possess a strong understanding of probiotics, more than a third expressed uncertainty regarding the health risks associated with probiotic supplement use (Bridgman SL et al 2014). Moreover, parent-related perception were most focused on clinical pediatric population (An Y & Cheng Q 2013). Therefore, the present study aims to explore the status of probiotic supplements usage of preschool-aged children in Chongqing, China, and to investigate parental perceptions of the benefits and risks associated with the probiotic supplements usage.

Table 1 presents the characteristics of the survey participants and prevalence of probiotic supplements usage. In this study, 48.75% of parents reported their 3-6-year-old children using supplements in the past year, which is lower than the prevalence of probiotic supplementation among infants (<3 years old) in Chongqing (85.43%) in 2013 (An Y & Cheng Q 2013). The usage of probiotic supplements varies significantly across studies due to differences in study populations and time of probiotic use (e.g., current, recent, or lifetime exposure) (Bezek K et al 2023). This study targeted the usage of probiotic supplements among preschool children in China, particularly in Chongqing city. Previous studies that associated probiotic supplementation behavior in China primarily focused on clinical intervention trials, such as testing probiotic effects on infants (Xiao L et al 2017), probiotic supplements usage for infants aged 18 months (Chen YC et al 2012), clinical pediatric population (An Y & Cheng Q 2013), cancer patients (Yao D et al 2023) or young adults. Differences (Ma T et al 2021) be attributed to biases across studies involving hospital clinic pediatric populations, which could influence probiotic usage for disease improvement or treatment. Additionally, differences in determining the probiotic supplement usage over an infant’s lifespan may contribute to varying prevalence rates.

Nevertheless, probiotic supplement usage among preschool children in Chongqing appears higher compared to other regions over the past year. In Slovenia, 28.4% of children consume a combination of probiotic foods and supplements, while 12.8% consume only probiotic supplements (Bezek K et al 2023). In the Australian Capital Territory, 47.4% of preschool-aged children have been exposed to probiotics, and 14.9% have taken probiotic supplements in the previous month (Irwin N et al 2022). The prevalence of probiotic supplement usage among preschoolers in three Korean cities was 25.6% (Kim HS et al 2013). A scoping review spanning from studies in the United States to Finland reported prevalence rates of probiotic supplement usage ranging from 4% to 11% for current or recent usage and 16% to 51% for lifetime exposure (Irwin N et al 2020).

The majority of respondents were mothers (82.81%), with over 60% being over 30 years old, well-educated, and residing in urban areas. More than 48% of patents reported that they were currently using probiotic supplements for children. Those using probiotics for their children had higher education level (71.27% vs. 54.75%, p<0.001), nutrition education experience (29.27% vs. 20.95%, p=0.01), and indicated higher dietary behavior scores of their children (3.82 vs. 3.47, p<0.001) compared to non-users. Additionally, there were fewer parents from rural areas and with children aged 5—6 years or having only one child in the user group (p<0.05). Differences in education level of parents, nutrition education experience of parents, and dietary behavior scores of children between probiotic supplement users and non-users might reflect the supplement usage of children is closely related to the education received by their parents. A previous study demonstrated associations between parental probiotic supplement usage, higher maternal education, and income with probiotic usage for children (Irwin N et al 2020).

The purposes of probiotic supplements usage for children are presented in Fig. 1(A). The top five reasons reported by users’ parents were “treating gastrointestinal disorders” (49.05%), “regulating child’s appetite” (48.78%), “promoting daily health” (39.30%), “immunity enhancement” (36.04%), and “gastrointestinal disease prevention” (34.42%). These findings align with previous research indicating that most individuals or parents use probiotic products for general digestive or overall health reasons (O’Connor LE et al 2021; Irwin N et al 2023). Parental willingness to provide their children with probiotics might depend on whether they interpret the purpose of the probiotics as preventive or therapeutic, on their interpretation of the product itself, or on their health beliefs in general (Mansour ME et al 2000). Also, reasons why parents do not provide probiotic supplements for children were present in Fig. 1 (B). The most common reason is that 36.95% of parents believe their children do not need them, while over 30% think they lack sufficient knowledge about probiotic supplements. Additional factors include perceptions that probiotic supplements are not food, but rather medication, and concerns about the cost and effectiveness of these supplements. It's crucial to underscore that these findings align with previous studies reporting barriers to probiotic usage among parents, such as lack of knowledge and concerns about safety and effectiveness (Partty A et al 2015; Kothari D et al 2019). This highlights the importance of addressing these barriers through targeted education and awareness campaigns to promote informed decision-making regarding probiotic supplementation for children.

Fig. 1. 
Rationale behind parents providing or withholding probiotic supplements to their children.

Table 2 showed the difference between dietary behavior of users and non-users. Over 40% of parents reported picky eating habits of their children, which can have significant detrimental impacts on growth, nutritional status, development, physical activity, and health status (Chao HC 2018; Cole NC 2018). Additionally, more than 60% of parents stated that their children require adult supervision during meals, suggesting potential challenges in mealtime behaviors. Only one-third (24.62%) of parents reported that their children consume more than 12 different types in a day. However, most children (86.24%) meet the recommendations for vegetable and fruit intake and water consumption. Moreover, probiotic supplement users exhibit higher dietary behavior scores, characterized by fewer breakfast skipping, greater food diversity, and more appropriate intake of milk, vegetables, and fruits. This finding may suggest that the better the children’s dietary habits, the more likely their parents are to provide probiotic supplements to their children as parents have higher aspirations for their children’s overall health (Liu L et al 2018).

Table 3 displays the perception scores regarding the benefits and risks of probiotic supplements. Parents of probiotic supplement users showed a more positive attitude compared to the non-users’ parents, as evidenced by higher scores for benefits but lower scores for risks of probiotic supplementation. Parents of users scored an average of 3.59 for those 12 items by combining perceived benefits and reversely-coded risks of probiotic supplements, and this is comparable to the average score of 3.43 for non-users (p<0.001). The average perception scores of the parents of users were significantly higher than parents of non-user for six items out of the ten benefit associated items about probiotic supplements (p<0.05). The highest score among these benefits was for ‘adjustment of the digestive system’, with users’ parents scoring 3.98 points compared to non-users’ parents scoring 3.70, suggesting widespread recognition of probiotic supplements for digestive health (Slykerman RF et al 2018). Taken together, the disparity in the perceptions of parents of users and non-users might be attributed to some parents’ concerns about potential risks associated with probiotic supplements, leading them to refrain from using supplements for their children. Alternatively, parents of probiotic supplements users might have insufficient understanding of the risks associated with probiotic supplementation, which could contribute to their overly optimistic attitude towards probiotic usage. This finding is consistent with the study in Alberta, Canada, most mothers (73.1%) think probiotics were beneficial but none thought they were harmful (Bridgman SL et al 2014). On one hand, the limited availability and accessibility of high-quality, evidence-based information on probiotics could contribute to parents’ uncertainty and confusion regarding their usage (Jeon HJ et al 2022). On the other hand the diverse range of probiotic products available in the market, each with varying strains and dosages, may contribute to the inconsistencies in parents’ perceptions (ARC I 2024). The lack of standardized guidelines for probiotic supplements usage in children may also play a role in this variability (Forster CS et al 2021). This emphasizes the need for healthcare professionals and researchers to provide tailored guidance and education on the potential benefits and risks of probiotics for children.

Multiple linear regression results (Table 4) suggest that children’s probiotic supplements usage (β=0.157, p=0.002), parents’ experience of nutrition education (β=0.132, p=0.020), and child’s ages of 5 to 6 years (β=0.152, p=0.026) tend to positively predict parents’ positive perceptions of probiotic supplements, after adjusting for significant confounding variables. This may indicate that parents are familiar with these several possible benefits of probiotic supplements and expect the corresponding benefits for their children using probiotics (Andersen SS et al 2018). This finding was similar to maternal perspectives on the usage of probiotics in infants, which pointed out parents play a crucial role in the decision to use probiotic supplements for their children, and their perceptions of the benefits and risks associated with these products may influence their choices (Bridgman SL et al 2014). Future studies should continue to explore the relationship between probiotic supplements usage, perceptions, and individual characteristics to provide a more comprehensive understanding of the topic.

While this study has provided valuable insights into probiotic supplement usage among 3-6-year-old Chinese children and their parents’ perceptions of the associated benefits and risks, several limitations warrant consideration for future research. Firstly, the study utilizes a cross-sectional design, precluding the establishment of causality. Future studies should employ longitudinal or randomized controlled trial designs to better assess the relationship between probiotic supplement usage and parental perceptions. Secondly, this study focused exclusively on probiotic supplements and did not consider probiotics derived from food sources. To provide a more comprehensive assessment of children’s probiotic intake, future research should include both food and supplement sources. Additionally, the study’s sample was limited to healthy children aged 3 to 6 from the Chongqing region, potentially limiting the generalizability of the findings. Future studies should include diverse regions and children of varying age groups to yield more representative results. Furthermore, dietary behavior scores were based on the 2016 Chinese dietary guidelines for children aged 3-6 years, which may not reflect the latest recommendations. Given that the 2020 edition of these guidelines was not available during the questionnaire administration, future studies should use the latest version for more accurate dietary behavior assessments. Lastly, the questionnaire survey may introduce recall bias, potentially leading to overreporting or underreporting of probiotic usage and healthy behaviors. Future research should employ objective methods such as observation in home or kindergartens to validate parental-reported data.

The present cross-sectional study indicates that high prevalence of probiotic supplementation among children aged 3—6 in Chongqing, China and emphasizes the association between parental perception and probiotic supplements usage in children. Parents of users demonstrate a positive attitude towards probiotic supplement usage compared to non-users’ parents, which reflected in the higher scores regarding the perceived benefits and risks (reversely coded) of probiotic supplementation. These findings revealed a need of further investigation on the associations between probiotic supplementation, nutrient intake and dietary behaviors of young children in a longitudinal manner and tailored nutrition education for parents.