Appropriate strategies for testing and treating Helicobacter pylori in children: when and how?

Prevalence, Predictors, and Treatment Outcomes of Anemia in Vietnamese School-Age Children With Helicobacter pylori Infection

Background A growing number of studies suggest that anemia caused by Helicobacter pylori (H. pylori) infection is prevalent in developing countries. A combination of H. pylori eradication and iron supplementation may be effective in treating iron deficiency anemia (IDA) caused by H. pylori infection. The aim of this study is to assess the prevalence, risk factors, and treatment outcomes of anemia in Vietnamese school-age children infected with H. pylori Methods A cross-sectional study was conducted from April 2023 to April 2024 involving 112 dyspeptic children from 5 to 16 years old who were admitted to Can Tho Children's Hospital, Vietnam. H. pylori infection was diagnosed with a positive histopathology combined with a rapid urease test. A bivariate and multivariate logistic regression model was used to identify independent variables associated with anemia in H. pylori-infected children. Results The prevalence of anemia and IDA (iron deficiency anemia) among H . pylori-infected children were 28.6% and 53.1%, respectively. The risk factor for anemia was age group from 11 to 16 years of age (OR: 3.24; CI 95%:1.21- 8.70). Iron supplementation (OR: 0.14; CI 95%:0.03 - 0.66) and periodic deworming (OR: 0.29; CI 95%: 0.10-0.89) were protective factors against anemia. After H. pyroli eradication and iron supplementation, all hematological parameters were increased among 32 anemic patients. Hemoglobin increased from 9.9 ±2.1 to 11.9±2.1 g/dL (p<0.001), mean corpuscular hemoglobin increased from 25.1 ± 4.1 to 28.0 ± 3.3 pg (P=0.003), and ferritin (IQR) increased from 16.7 (9.5-45.2) to 27.0 (15.1-47.0) µg/L (p<0.001). Conclusion Anemia in Vietnamese school-age children infected with H. pylori is prevalent. Taking iron supplements and periodic deworming reduces the risk of anemia. H. pylori eradication therapy plus oral iron supplementation will improve iron status in H. pylori-infected children.

Risk of Ischemic Stroke in Relation to Helicobacter pylori Infection and Eradication Status: A Large-Scale Prospective Observational Cohort Study

Background/Aims

: A few studies have suggested the association between Helicobacter pylori (HP) infection and ischemic stroke. However, the impact of HP eradication on stroke risk has not been well evaluated. This study aimed to assess the influence of HP eradication on the incidence of ischemic stroke, considering the potential effect of sex.

Methods

: This prospective observational cohort study was conducted at Seoul National University Bundang Hospital, from May 2003 to February 2023, and involved gastroscopy-based HP testing. Propensity score (PS) matching was employed to ensure balanced groups by matching patients in the HP eradicated group (n=2,803) in a 3:1 ratio with patients in the HP non-eradicated group (n=960). Cox proportional hazard regression analysis was used to evaluate the risk of ischemic stroke.

Results

: Among 6,664 patients, multivariate analysis after PS matching indicated that HP eradication did not significantly alter the risk of ischemic stroke (hazard ratio, 0.531; 95% confidence interval, 0.221 to 1.270; p=0.157). Sex-specific subgroup analyses, both univariate and multivariate, did not yield statistically significant differences. However, Kaplan-Meier analysis revealed a potential trend: the females in the HP eradicated group exhibited a lower incidence of ischemic stroke than those in the HP non-eradicated group, although this did not reach statistical significance (p=0.057).

Conclusions

: This finding suggests that HP eradication might not impact the risk of ischemic stroke. However, there was a trend showing that females potentially had a lower risk of ischemic stroke following HP eradication, though further investigation is required to establish definitive evidence.

Is Helicobacter pylori Anyway Pathogen in Children?

Helicobacter pylori (H. pylori) infection is a continuous challenge for both gastroenterologists and pediatricians. The international guidelines regarding diagnostic and treatment pathways differ between adults and children. The pediatric guidelines are more restrictive because children are rarely affected by serious consequences, particularly in Western countries. Therefore, infected children should be treated only after a careful case-by-case evaluation by a pediatric gastroenterologist. In any case, recent studies are confirming an increasingly all-around pathological role of H. pylori even in asymptomatic children. For these reasons, following the current evidence, we feel that H. pylori-infected children could be treated starting in pre-adolescence, particularly in Eastern countries, because their stomachs have already begun to develop the biomarkers of gastric damage. Therefore, we believe that H. pylori is anyway pathogen in children. Nevertheless, the possible beneficial role of H. pylori in humans has not yet been conclusively disproved.

Treatment of Helicobacter pylori infection in children: A systematic review

BACKGROUND

Helicobacter pylori (H. pylori) infection is predominantly acquired in childhood. When indicated, the most accepted treatment for H. pylori eradication in this age group is first-line triple therapy. However, the increasing resistance to clarithromycin and nitroimidazoles has been associated with treatment failure, and thus, alternative treatment regimens have been proposed.

AIM

To perform a systematic review of randomized controlled trials on treatment regimens for H. pylori infection in children.

METHODS

We surveyed relevant articles published in English from 2010 to April 2020 in the PubMed and MEDLINE databases. Keywords included “Helicobacter pylori”/”children or childhood”/”treatment or eradication.” The risk of bias was evaluated according to the Cochrane Handbook of Systematic Reviews for Interventions.

RESULTS

Among the 1144 records identified through the database, 20 articles were selected. Four studies compared the eradication rates of H. pylori infection between standard triple therapies, changing only the main antibiotic used. Seven studies evaluated the effectiveness of standard triple therapy with the addition of probiotics. One study investigated the relationship between the effectiveness in the eradication rates of standard triple therapy and vitamin E levels. Six studies analyzed the eradication rates of sequential therapy.

CONCLUSION

The findings suggest that although standard triple therapy is the most recommended regimen for children by the current guidelines, other therapeutic schemes have shown promising results and may also be recommended for clinical practice in the future.

The association of recurrent abdominal pain and Helicobacter pylori infection in correlation with esophagogastroduodenoscopy findings

Abstract: Aim: The aim of this research was to determine the association of recurrent abdominal pain and Helicobacter pylori (H. pylori) infection in childhood, in correlation with the finding of an upper endoscopy. Introduction: Recurrent abdominal pain (RAP) was defined according to Apley and Naish's criteria from the year 1959 as at least three or more episodes of abdominal pain lasting longer than three months in children older than 3 years, and severe enough to prevent normal activities in child. The association of RAP and H. pylori has been analyzed in several different researches, and there are conflicting results about their interconnection. However, the etiological association of the presence of H. pylori with the onset and development of acute and chronic active gastritis and duodenal ulcer is known. Material and method: The research protocol included a total of 77/183 (42.07%) children divided by age into three subgroups: preschool age (3 to 6.9 years), school-age (7 to 10.9 years) and adolescent age (11 to 15 years) in whom the diagnosis of RAB was determined by meeting the criteria according to Apley and Naish (1959), and the American Academy of Pediatrics (2005). H. pylori infection was confirmed by enzyme-linked immunosorbent assay (ELISA), while esophagogastroduodenoscopy was performed by the device for upper endoscopy type Olimpus GIF Type Q156, in the endoscopic cabinet of the Clinic for Internal Medicine, University Clinical Center Tuzla. Results: Of the total number of examined children (77), the analyse of Helicobacter pylori infection presence showed the biggest number of positive findings in school age 91.3%, in adolescent age 78.0%, while the smallest number was in preschool age (25.0%). The most common findings of upper endoscopy and microscopic findings were described as: antritis acuta in 16%, gastritis chronica activa et erosiva in 32%, and duodenitis acuta (12%). Conclusion: A significant association of H. pylori infection and RAP are confirmed by positive finding of esophagogastroduodenoscopy, leading to conclusion that immunological testing for the presence of this bacteria is justified. After obtaining a positive finding with confirmed infecion, it is necessary to start with the treatment.

Impact of Age, Gender, and Addition of Probiotics on Treatment Success for Helicobacter pylori in Children

The primary objective of this study was to evaluate the effect of age, gender, and the use of probiotics with standard treatment regimen on Helicobacter pylori eradication. Based on endoscopic findings and clinical presentation, selected patients were treated with standard triple therapy (omeprazole, clarithromycin, and amoxicillin). Those who failed were offered a repeat treatment with omeprazole, metronidazole, and amoxicillin. After the publications of the possible advantages of probiotic treatment on H pylori eradication, the probiotic agent “Probiotica Forte” was routinely added to the treatment. Eradication was noted for 94/130 patients (72%) and for 128/197 patients (65%) with or without probiotic agent, respectively (P = .23). For second-line treatment eradication was noted in 33/46 (72%) and in 9/20 (45%) with or without probiotic agent, respectively (P = .053). The addition of probiotics may improve eradication success especially in addition to second-line treatment.

Influence of Helicobacter pylori infection on ghrelin levels in children

AIM: To compare ghrelin levels in plasma and gastric mucosa before and after Helicobacter pylori (H. pylori) treatment in children with H. pylori-associated functional dyspepsia.

METHODS: Children with H. pylori-associated functional dyspepsia were enrolled in this study. H. pylori infection was confirmed by positive bacterial culture results. All of the children received triple H. pylori eradication therapy (a 2 wk course of omeprazole, amoxicillin, and clarithromycin). The children were divided into two groups based on the success of the H. pylori treatment: group 1 (eradicated) - patients who had a negative 13C-urea breath test 2 mo after the end of therapy; and group 2 (non-eradicated) - patients who had a positive 13C-urea breath test. Plasma ghrelin, gastric ghrelin mRNA, and the body mass index were evaluated in both groups before and after the H. pylori treatment. The plasma ghrelin levels were measured by a radioimmunoassay. The expression of gastric ghrelin mRNA was determined by real-time reverse transcription polymerase chain reaction.

RESULTS: A total of 50 children with H. pylori-associated functional dyspepsia were treated with triple H. pylori eradication therapy. The mean age of the children was 5.52 ± 0.83 years, and there were 28 males and 22 females. Among the 50 H. pylori-positive children, 30 successfully achieved eradication, and 20 did not. The mean plasma ghrelin levels of group 1 were 22.17 ± 1.73 ng/L and 26.59 ± 2.05 ng/L before and after the treatment, respectively, which was a significant increase (P = 0.001). However, the mean plasma ghrelin level of group 2 before and after the H. pylori treatment was 21.34 ± 2.40 ng/L and 22.24 ± 2.10 ng/L (P = 0.785). The plasma ghrelin levels increased substantially after treatment in group 1 but showed only minor changes in group 2. Similarly, the gastric ghrelin mRNA expression in group 1 before treatment was 2.84 ± 0.08. After treatment, the level was 3.11 ± 0.65, which was significantly different (P = 0.023). The gastric ghrelin mRNA expression in group 2 did not change significantly during the treatment (2.82 ± 0.44 vs 2.79 ± 0.31, P = 0.875). The plasma ghrelin and gastric ghrelin mRNA levels in group 1 increased substantially after the treatment but did not do so in group 2. In addition, the body mass index the two groups did not differ significantly 2 mo before and after the H. pylori treatment.

CONCLUSION: H. pylori eradication increases the plasma and tissue ghrelin levels in children with H. pylori-associated functional dyspepsia.

Consequences of Helicobacter pylori infection in children

Although evidence is emerging that the prevalence of Helicobacter pylori (H. pylori) is declining in all age groups, the understanding of its disease spectrum continues to evolve. If untreated, H. pylori infection is lifelong. Although H. pylori typically colonizes the human stomach for many decades without adverse consequences, children infected with H. pylori can manifest gastrointestinal diseases. Controversy persists regarding testing (and treating) for H. pylori infection in children with recurrent abdominal pain, chronic idiopathic thrombocytopenia, and poor growth. There is evidence of the role of H. pylori in childhood iron deficiency anemia, but the results are not conclusive. The possibility of an inverse relationship between H. pylori and gastroesophageal reflux disease, as well as childhood asthma, remains a controversial question. A better understanding of the H. pylori disease spectrum in childhood should lead to clearer recommendations about testing for and treating H. pylori infection in children who are more likely to develop clinical sequelae.

Helicobacter pylori: prevalence and relationship with abdominal pain in school children in Makkah City, western Saudi Arabia

BACKGROUND/AIM

The published data on Helicobacter pylori (H. pylori) prevalence and its relationship with abdominal pain in Saudi Arabia is scarce. This study was carried out to determine the prevalence of H. pylori and its relationship with chronic recurrent abdominal pain (RAP) among school students in Makkah City, Saudi Arabia.

MATERIALS AND METHODS

Three hundred and fourteen school students, 103 at the intermediate level (grades 7-9) aged 12-15 years and 211 at the secondary level (grades 10-12) aged 15-18 years were tested for H. pylori. Urea breath test (UBT) was used for this purpose. Children with chronic RAP were identified as per the Apley criteria.

RESULTS

Overall, the UBT was positive in 86/314 (27.4%) students. It was positive in 45/103 (43.7%) intermediate school students and 41/211 (19.4%) secondary students. Out of the 55 students with chronic RAP, 40 (73%) were positive for H. pylori. Further, 62.9% and 82.1% were positive among the intermediate and secondary school students with RAP, respectively. The overall and specific odds ratios of RAP were 12.35 [95% confidence interval (C.I.) 6.30-24.22] and 10.40 (95% C.I. 1.75-11.73) for the intermediate school students and 22.69 (95% C.I. 7.99-64.44) for the secondary school students.

CONCLUSION

The prevalence of H. pylori among the school children in Makkah, Saudi Arabia, is relatively low compared with developing countries. The prevalence was found to be higher among the younger age group. Further, there was a significant relation between H. pylori infection and RAP among the school students.

Low prevalence of Helicobacter pylori infection in Canadian children: a cross-sectional analysis

BACKGROUND

The incidence and prevalence rates of childhood Helicobacter pylori infection vary greatly by nation, with infection rates of 8.9% to 72.8% reported in developed and developing countries, respectively. To date, few studies have assessed the prevalence of H pylori in Canadian children, with studies limited to Aboriginal communities and single tertiary care centres from Ontario and Quebec.

OBJECTIVES

To determine the prevalence of H pylori in consecutive children referred to three Canadian tertiary care academic centres for upper gastrointestinal (GI) endoscopy due to upper GI symptoms, and to determine the sensitivity and specificity of the carbon-13-labelled urea breath test, the rapid urease test and the H pylori stool monoclonal antigen test.

RESULTS

Two hundred four patients were recruited. The prevalence of H pylori was 7.1%. Of the H pylori-positive patients, 41.7% were male, with a mean age of 10.3 years. Ethnic minorities accounted for 42% of the H pylori-positive patients. Consistent with previous observations, the sensitivity and specificity of the carbon-13-labelled urea breath test were 1.0 and 0.98, respectively. The sensitivity and specificity of the rapid urease test were 1.0 and 0.99, respectively. Stool samples were collected from 34 patients from one centre, with a sensitivity and specificity of 1.0 and 0.68, respectively. No defining symptoms of H pylori infection were evident and no peptic ulcer disease was demonstrated.

CONCLUSION

H pylori infection rates in Canadian children with upper GI symptoms are low, and are lower than those reported for other developed countries. Further studies are required in Canada to determine the prevalence in the general population and specifically in the populations at risk.

A seroepidemiology survey on Helicobacter pylori infection in rural families

AIM: To estimate the prevalence of H. pylori infection in rural families, and to investigate the transmission route of H. pyloriinfection.

METHODS: A cross-sectional study was carried out among 263 villagers from 71 families in September 2004 in Zunhua city, Hebei province. Each subject was interviewed using a unified questionnaire. Blood sample of 5 mL was collected for the antibody examination by enzyme-linked immunosorbent assay (ELISA). Western blot analysis was performed to distinguish the infected strains, and compared with two standard strains NCTC 11637 and CAPM N111, respectively. Similarity analysis was then carried out with Quantity one 4.1.1 software, which is special for photographs of electrophoresis.

RESULTS: The seroprevalence of H. pylori infection in residents of this area was of medium level in our country, and it was not associated with gender. In this area, the risk factors of infection were bad living conditions, overcrowding and possession of pigs during childhood, as well as several generations eating together, less vinegar and fruit intake. The overall prevalence and serum level of anti-H. pylori antibodies in 263 subjects was 57.41% and 0.911 ± 0.810 mg/L, respectively. In males, they were 60.50% and 0.948 ± 0.843 mg/L, while 54.86% and 0.880 ± 0.748 mg/L in females, respectively (P > 0.05). Infection clustered within families, and 60% and 51.35% of the children with two or at least one infected parent were H. pylori-positive, while the prevalence rate in the children with both parents uninfected was only 11.11% (P < 0.05). Western blot showed that the antibodies of the residents living in the area were similar in bands (F = 1.22, P > 0.05).

CONCLUSION: The prevalence of H. pylori in residents of this area was of medium level in our country. Infection clusters within families, and the status of parents' infection can affect that of the children.

Therapeutic choices in reflux disease: defining the criteria for selecting a proton pump inhibitor

Gastroesophageal reflux disease (GERD) is among the most common disorders of the gastrointestinal tract, with symptoms affecting a substantial proportion of the US population on a daily basis. Heartburn and related symptoms arise from a number of pathophysiologic mechanisms, including dilated intercellular spaces, increased duration of acid reflux, greater proximal extent of reflux, and esophageal sensitivity. Chronic reflux may result in serious complications, such as esophageal erosions or ulceration, stricture, and Barrett esophagus. The goals of GERD therapy are to relieve patients' symptoms and prevent complications. Proton pump inhibitors (PPIs) represent the most effective treatment option for GERD, relieving symptoms, healing erosions, and maintaining a healed mucosa. Differences in the pharmacokinetics and pharmacodynamics among the PPIs may result in differences in intragastric pH holding time as well as the onset of symptom relief. Lansoprazole and esomeprazole produce similar degrees and onset of symptom relief, with both providing greater symptom relief as compared with omeprazole. Although manufactured as capsules containing enteric-coated granules, lansoprazole, omeprazole, and esomeprazole maintain their high level of pharmacologic efficacy when the capsule contents are emptied into soft foods or various liquids. Lansoprazole and pantoprazole also are manufactured as intravenous formulations, and lansoprazole is available as strawberry-flavored granules for oral suspension and as an orally disintegrating tablet. These alternative routes of administration are particularly beneficial in the management of acid-related disorders in infants, children, the elderly, and patients of all ages who have difficulty swallowing or are unable to swallow intact capsules or tablets and those in the critical care setting.