Association of symptoms with Helicobacter pylori infection in children

The fourth Mexican consensus on Helicobacter pylori

Important advances have been made since the last Mexican consensus on the diagnosis and treatment of Helicobacter pylori (H. pylori) infection was published in 2007. Therefore, the Asociación Mexicana de Gastroenterología summoned 20 experts to produce "The Fourth Mexican Consensus on Helicobacter pylori". From February to June 2017, 4 working groups were organized, a literature review was performed, and 3 voting rounds were carried out, resulting in the formulation of 32 statements for discussion and consensus. From the ensuing recommendations, it was striking that Mexico is a country with an intermediate-to-low risk for gastric cancer, despite having a high prevalence of H. pylori infection. It was also corroborated that peptic ulcer disease, premalignant lesions, and histories of gastric cancer and mucosa-associated lymphoid tissue lymphoma should be considered clear indications for eradication. The relation of H. pylori to dyspeptic symptoms continues to be controversial. Eradication triple therapy with amoxicillin, clarithromycin, and a proton pump inhibitor should no longer be considered first-line treatment, with the following 2 options proposed to take its place: quadruple therapy with bismuth (proton pump inhibitor, bismuth subcitrate, tetracycline, and metronidazole) and quadruple therapy without bismuth (proton pump inhibitor, amoxicillin, clarithromycin, and metronidazole). The need for antimicrobial sensitivity testing when 2 eradication treatments have failed was also established. Finally, the promotion of educational campaigns on the diagnosis and treatment of H. pylori for both primary care physicians and the general population were proposed.

Helicobacter pylori infection in Icelandic children

OBJECTIVE

The prevalence of Helicobacter pylori (HP) infection is decreasing in the western world. The seroprevalence among 25-50-year-old Icelandic adults was recently shown to be 30-40%. Information on the seroprevalence in Nordic children is limited. We aimed at ascertaining the infection prevalence among healthy Icelandic children.

METHODS

The infection status in stored frozen blood samples from two cross-sectional studies on the health of 7-9-year-old children (n = 125) and 16-18-year-old adolescents (n = 80) was determined by enzyme-linked immunosorbent assay (ELISA). Information on family demographics and GI symptoms was obtained by standardized questionnaires.

RESULTS

Overall, 3.4% (7/205) of the children were infected with H. pylori. The prevalence was 2.6% (5/190), missing data n = 3, among children with both parents born in a low prevalence country compared to 17% (2/12) among those with at least one parent born in a high prevalence area (p = .026). When at least one parent was born in a high prevalence country, the odds ratio for being H. pylori seropositive was 2.2 (95% CI, 1.02-54.67), when adjusted for the educational status of the mother. There was no significant association between H. pylori infection and gastrointestinal symptoms.

CONCLUSION

Prevalence of H. pylori infection in Iceland has become very low, suggesting a great reduction in transmission from older generations. There was an association between H. pylori infection and origin from high prevalence areas but not with gastrointestinal symptoms. The results mirror recent studies of children of Scandinavian ancestry.

Gastrointestinal symptoms and Helicobacter pylori infection in school-age children residing in Porto Torres, Sardinia, Italy

BACKGROUND

Helicobacter pylori infection is typically acquired in childhood, and following the acute event, it is thought that most infections remain asymptomatic. H. pylori has been suggested to protect against diarrhea in childhood.

AIM

To examine the role of H. pylori in gastrointestinal symptoms in children.

MATERIALS AND METHODS

A cross-sectional sero-epidemiologic study was conducted in Porto Torres, Sardinia, Italy. Demographic information, socioeconomic factors, and the frequency of upper gastrointestinal symptoms during the previous 3 months (e.g., abdominal pain, diarrhea, nausea, heartburn, halitosis, slow digestion, belching, and weight loss) were evaluated by a questionnaire. H. pylori status was determined by ELISA.

RESULTS

Approximately 95% (N = 1741) of school children between the age of 6 and 15 years from Porto Torres participated. The sero-prevalence of H. pylori infection was 13.3% (229/1727) and similar in boys (13%) and girls (14%) (p = .57). Nausea/vomiting (odds ratio (OR) = 2.2 (95% CI = 1.2-5.1)) and diarrhea (OR = 2.1 (95% CI = 1.3-2.8)) were each significantly associated with H. pylori infection, and these associations remained significant after controlling for other study variables. There was no significant association between H. pylori and abdominal pain or heartburn (p > .25).

CONCLUSIONS

The study does not support either a role of H. pylori infection in abdominal pain in children or a protective role against diarrheal illnesses or nausea/vomiting.

Review article: bismuth-based therapy for Helicobacter pylori eradication in children

BACKGROUND

Because of the decrease in the Helicobacter pylori eradication rate after standard triple therapy with a proton pump inhibitor and two antibiotics, bismuth-based therapy has recently been recommended as alternate first-line regimen in children.

AIM

To comprehensively review the clinical, pharmacologic and microbiologic properties of bismuth salts, and to summarise the evidence for the therapeutic efficacy of bismuth-based therapy for H. pylori eradication in children.

METHODS

Bibliographical searches were performed in MEDLINE. Results on the efficacy of bismuth-containing regimens on H. pylori eradication were combined using the inverse variance method.

RESULTS

Bismuth monotherapy showed a very low efficacy. Overall, the mean eradication rate with bismuth-based dual therapy was 68% (95% CI, 60-76%) (intention-to-treat analysis-ITT) and 73% (95% CI, 64-81%) (per protocol-PP). In case series, the overall percentages of children with successful eradication for triple therapy containing bismuth were 82% (95% CI, 76-88%) and 86% (95% CI, 80-92%) according to ITT and PP respectively. In comparative studies, H. pylori eradication rates ranged between 69% and 85% according to ITT and between 74% and 96% PP. Side effects included dark stools, urine discoloration, black tongue, burning tongue, and marked darkness of the gums.

CONCLUSIONS

The evidence in favour of bismuth compounds for treating infected children is still not clear. Well-designed, randomised, multi-centre studies of H. pylori eradication trials in children comparing bismuth-based triple therapy with the best available recommended first-line therapies are needed. The evidence obtained from audited case series that produce an eradication rate of >95% on PP analysis should also be considered.

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.

Meta-analysis: Helicobacter pylori eradication treatment efficacy in children

BACKGROUND

Several meta-analyses assessing the efficacy of anti-Helicobacter pylori treatment in adults have been published but a comparable meta-analysis in children is lacking.

AIMS

To summarize the efficacy of treatments aimed at eradicating H. pylori in children and to identify sources of variation in treatment efficacy across studies.

METHODS

We searched Medline, reference lists from published study reports, and conference proceedings for anti-H. pylori treatment trials in children. Weighted meta-regression models were used to find sources of variation in efficacy.

RESULTS

Eighty studies (127 treatment arms) with 4436 children were included. Overall, methodological quality of these studies was poor with small sample sizes and few randomized-controlled trials. The efficacy of therapies varied across treatment arms, treatment duration, method of post-treatment assessment and geographic location. Among the regimens tested, 2-6 weeks of nitroimidazole and amoxicillin, 1-2 weeks of clarithromycin, amoxicillin and a proton pump inhibitor, and 2 weeks of a macrolide, a nitroimidazole and a proton pump inhibitor or bismuth, amoxicillin and metronidazole were the most efficacious in developed countries.

CONCLUSIONS

Before worldwide treatment recommendations are given for eradication of H. pylori, additional well-designed randomized placebo-controlled paediatric trials are needed, especially in developing countries where both drug resistance and disease burden is high.

A prospective study for the association of Helicobacter pylori infection to a multidimensional measure for recurrent abdominal pain in children

BACKGROUND

There is a controversial association between Helicobacter pylori infection and recurrent abdominal pain (RAP) in childhood and inconsistent information on specific symptomatology of the infection.

AIMS

To examine the prevalence of H. pylori infection among children with RAP compared to asymptomatic children.

METHODS

Two prospective studies were conducted. The first study enrolled 223 children diagnosed with RAP from two pediatric gastroenterology clinics in Houston, Texas. Children were qualified if they were identified by their physician as having RAP. A new multidimensional measure for RAP (MM-RAP) consisting of four scales (pain intensity scale, symptoms scale, disability scale, and satisfaction scale) was administered to each child/parent. The second study enrolled 330 asymptomatic children from the same community who did not have any upper gastrointestinal symptoms. Symptomatic and asymptomatic children underwent (13)C-urea breath testing.

RESULTS

In the first study, the prevalence of H. pylori in children with RAP was 11% and fell with age from 20% at age < or = 5 years to 7% for children > 10 years (OR = 2.7, 95% CI = 0.7-11.2). There was no association between the mother's educational level and H. pylori prevalence; (12% among children whose mothers completed college versus 11% among those who had elementary school, p = .8). No relationship was found between H. pylori and mean scores of the RAP scales. In the second study, the prevalence of H. pylori in asymptomatic children was 17% and increased with age from 11% for children < or = 5 years to 40% for children > 10 years (OR = 5.4, 95% CI = 2.0-13.8). The mother's educational level was inversely correlated with H. pylori (OR = 3.0, 95% CI = 2.2-6.1, p < .01).

CONCLUSIONS

The epidemiologic patterns of H. pylori infection differed significantly between symptomatic and asymptomatic children. Younger children suffering from RAP are more likely to be infected with H. pylori than older children with the same complaint, suggesting that early acquisition may manifest in symptoms that lead to clinic visits.

Helicobacter pylori eradication in childhood after failure of initial treatment: advantage of quadruple therapy with nifuratel to furazolidone

BACKGROUND

Failures of Helicobacter pylori eradication in children are common.

AIM

To evaluate the efficacy of amoxicillin, bismuth subcitrate and omeprazole and nifuratel or furazolidone for H. pylori eradication in children who failed initial treatment with a standard triple therapy.

METHODS

Seventy-six consecutive H. pylori-positive paediatric out-patients (aged 12-16 years; mean age 13.7 +/- 1.4) with chronic abdominal complaints who had failed one attempt of eradication of H. pylori using metronidazole-containing triple therapy were enrolled. It was an open prospective study. Patients were randomized to receive a 2-week course of bismuth subcitrate (8 mg/kg/day, q.d.s.), amoxicillin (50 mg/kg/day, q.d.s.), with either nifuratel (15 mg/kg/day, q.d.s.) or furazolidone (10 mg/kg/day, q.d.s.), plus omeprazole (0.5 mg/kg, once daily).

RESULTS

There were 37 patients in the nifuratel group and 39 in the furazolidone group. Helicobacter pylori was eradicated in 33 of 37 (89%; 95% CI: 74.5-96.9; intention-to-treat) in nifuratel group and in 34 of 39 (87%; 95% CI: 72.5-95.7) in furazolidone group, respectively. Frequency of severe side-effects was greater with furazolidone (21%) than with nifuratel (3%; P = 0.0289).

CONCLUSIONS

Nitrofuran-containing therapies consisting of a proton-pump inhibitor, amoxicillin and bismuth citrate plus either nifuratel or furazolidone produced good cure rates even among those who had failed prior therapy. Nifuratel is preferred because of the lower frequency of side-effects.

Important bacterial gastrointestinal pathogens in children: a pathogenesis perspective

This article focuses on the five most common bacterial enteropathogens of the developed world--Helicobacter pylori, Escherichia coli, Shigella, Salmonella, and Campylobacter--from the perspective of how they cause disease and how they relate to each other. Basic and recurring themes of bacterial pathogenesis, including mechanisms of entry, methods of adherence, sites of cellular injury, role of toxins, and how pathogens acquire particular virulence traits (and antimicrobial resistance), are discussed.

Helicobacter pylori status and symptom assessment two years after eradication in pediatric patients from a high prevalence area

OBJECTIVES

To establish the rate of Helicobacter pylori reinfection in children from an H. pylori high prevalence area, possible clinical features predictive of reinfection and the usefulness of re-treatment.

METHODS

65 consecutive children attending the authors' department between 1998 and 2000 who had proven successful H. pylori eradication were enrolled; 52 took part. Patients and family members were invited to undergo C-urea breath testing and to complete a simple questionnaire regarding symptoms and socioeconomic status. Patients with H. pylori reinfection were offered treatment; eradication was assessed by C-urea breath test 8 weeks after completion of treatment.

RESULTS

Of 52 children, 15 (28.8%) were H. pylori positive. Variables predictive of reinfection were age at primary infection and presence of an infected sibling. Although reinfected children were more frequently symptomatic than non-reinfected patients, no specific symptom was associated with reinfection. Of the nine re-treated patients who returned 8 weeks after completing therapy, the bacterium was eradicated in five (56%).

CONCLUSIONS

The 12.8% per year reinfection rate in childhood at 2 years that we observed should prompt a re-evaluation of H. pylori status even after a successful eradication. Living in an H. pylori high prevalence area increases the annual risk of reinfection by approximately fourfold over the annual risk in H. pylori low prevalence areas.

Helicobacter pylori infection is not associated with specific symptoms in nonulcer-dyspeptic children

OBJECTIVES

To assess symptoms associated with Helicobacter pylori infection in children presenting with nonulcer dyspepsia (NUD).

STUDY DESIGN

A prospective double-blind study was conducted between March 2001 and April 2002 in children at least 6 years old with NUD who had been referred for upper gastrointestinal endoscopy for epigastric pain. A standardized questionnaire was administered blindly by a pediatric gastroenterologist. This questionnaire characterized epigastric pain and associated factors. Infection was confirmed by positive culture and histologic examination of the gastric mucosa.

RESULTS

From 100 children enrolled, 26 proved infected (12 female, 14 male; mean age: 11.4 +/- 2.6 years), and 74 were noninfected (44 female, 30 male; mean age: 10.4 +/- 3.1 years). There were no differences in age or symptom characteristics between groups except for epigastric pain during meals that was more frequent in noninfected than in infected children (25.6% vs 3.8%).

CONCLUSION

There were no specific characteristics of symptoms in nonulcer-dyspeptic H pylori-infected children as compared with noninfected children.

Gastric emptying of solids in children with H. pylori-positive and H. pylori-negative non-ulcer dyspepsia

OBJECTIVE

There is currently no data available in children on possible relationships among Helicobacter pylori, gastric motility and gastric inflammation. This is a prospective study of gastric emptying (GE) in symptomatic children with and without H. pylori who met symptom-based criteria for non-ulcer dyspepsia (NUD).

METHODS

47 consecutive dyspeptic patients (23 males; age range, 7 to 18 years) were enrolled. All patients had extensive negative diagnostic investigations. Scintigraphic solid-phase gastric emptying was assessed.

RESULTS

21 H. pylori-positive and 26 H. pylori-negative patients were identified with non-ulcer dyspepsia. The groups were not different in clinical symptoms except that pain related to feeding was more frequent in infected children (P < 0.03). Nodular antral gastritis was found more frequently in the H. pylori positive group (P < 0.0001). The gastritis score was more severe in H. pylori infected than H. pylori negative patients in both fundic and body mucosa (P < 0.001). Within the H. pylori-positive NUD group, the mean half-time GE of a solid meal was significantly accelerated compared to the non-infected group (P < 0.05). There was no difference in the intragastric food distribution and curves of gastric emptying of both groups. A significant relationship was found between the degree of gastric body inflammation gastric emptying, but not antral inflammation. Gastric emptying rate did not differ by sex or age of the subjects in either group.

CONCLUSIONS

In dyspeptic children with H. pylori, gastric emptying of a solid was significantly accelerated compared with symptomatic H. pylori uninfected patients. This suggests that H. pylori is able to induce gastric emptying acceleration. Our findings add more information on H. pylori infection and gastroduodenal disease.

Functional gastrointestinal disorders in children: an Italian prospective survey

OBJECTIVES

To assess the prevalence and natural history of functional gastrointestinal disorders (FGIDs) in children using the Rome Criteria.

METHODS

Thirteen primary care pediatricians were randomly selected from the Campania region of the Italian National Health Service. Each pediatrician completed a detailed FGID questionnaire on consecutive patients seen during a 3-month period. A total of 9660 patients aged birth to 12 years were enrolled prospectively during this 3-month period. Follow-up was performed at 1-, 3-, and 12-month intervals.

RESULTS

A total of 194 children initially met strict criteria for at least 1 FGID. A total of 72 (37.1%) children had infant regurgitation, 26 (13.4%) had functional dyspepsia, 27 (13.9%) had irritable bowel syndrome, and 66 (34.1%) had functional constipation or other defecation disorders. All children who had a diagnosis of FGIDs were reevaluated at 1, 3, and 12 months to study the natural history of the illnesses. Additional evaluation revealed 5 children who had developed an organic diagnosis. Therefore, 5 (2.5%) of 194 children who had a diagnosis of FGIDs by the Rome criteria had a change in diagnosis to an organic disease during the study period, none of whom experienced permanent sequelae.

CONCLUSIONS

Of 194 children who received a prospective diagnosis of FGIDs using the Rome criteria, 97.5% continued to satisfy the diagnostic criteria or were improved at follow-up. The low prevalence of functional dyspepsia and irritable bowel syndrome in our population is most likely explained by the lack of adolescents in our sample.

Helicobacter pylori and gastrointestinal symptoms in school children in Russia

BACKGROUND AND AIMS

Helicobacter pylori is considered to be the major cause of chronic gastritis and duodenal ulcer disease recurrence in childhood. However, the association between H. pylori and recurrent abdominal pain (RAP) syndrome is still controversial. Therefore, the spectrum of clinical variants of gastrointestinal symptoms associated with H. pylori-positive status was studied in consecutive symptomatic children who were undergoing diagnostic endoscopy.

METHODS

A consecutive series of 225 school children from the Ural area of Russia (mean age 11.1 + 1.4 years, age range 7-15 years) who presented with RAP were investigated using esophagogastroduodenoscopy, including three antral biopsies for histology and polymerase chain reaction. Helicobacter pylori immunoglobulin G antibodies were found using a second-generation enzyme immunoassay. Information about the clinical symptoms was collected using a special questionnaire.

RESULTS

The authors found a high incidence of H. pylori infection (80%) and peptic ulcers (16%) in 225 school children from the Ural area of Russia who were referred for upper gastrointestinal (UGI) endoscopy for chronic abdominal pain. Of the overall 225 symptomatic children who underwent endoscopy, 182 (80,8%) were found to be H. pylori-positive. Duodenal ulcers were detected in 36 H. pylori-positive children. A family history of peptic ulcers was significantly more frequent in the children infected with H. pylori (P < 0.001). Symptom score and duration of symptoms were similar, but night-time pain (P < 0.0001) and fasting pain relieved by food (P < 0.001) were more frequent in the H. pylori-positive children as compared with the H. pylori-negative children.

CONCLUSIONS

The present results provide further evidence for a significant association between H. pylori and some patterns of gastrointestinal symptoms in children who underwent UGI endoscopy in order to exclude an organic cause of severe chronic gastrointestinal disorders.

New approaches to Helicobacter pylori infection in children

Helicobacter pylori infection is usually acquired during childhood, and evidence-based guidelines regarding diagnosis and treatment of infected children have been recently published. Diseases associated with H. pylori infection are gastritis, duodenal ulcers, mucosal-associated lymphoid-type (MALT) lymphoma, and gastric adenocarcinoma. The association of specific symptoms with H. pylori infection in children and adults (ie, recurrent abdominal pain and nonulcer dyspepsia) remains controversial. Additionally, the role of H. pylori in gastroesophageal reflux disease or in extra-gastrointestinal diseases (ie, coronary artery disease) lacks sufficient evidence to demonstrate causality. The diagnosis of H. pylori-associated diseases in children can reliably be made through gastroduodenal endoscopy with biopsies. Clinical trials are underway for the validation of noninvasive diagnostic tests for the H. pylori-infected child, and current guidelines recommend eradication therapy for infected children with duodenal and gastric ulcer, gastric lymphoma, and atrophic gastritis with intestinal metaplasia. The natural history of childhood H. pylori infection is poorly described. Moreover, rational approaches to the prevention and control of childhood H. pylori infection are critically needed, requiring characterization of the determinants for acquisition and persistence and the disease outcomes following eradication.

The seroprevalence of Helicobacter pylori in a referral population of children in the United States

OBJECTIVES

The purpose of this study was to determine the prevalence of serum antibodies directed against Helicobacter pylori (H. pylori) in children referred to children's hospitals or medical centers throughout the United States.

METHODS

This multisite cross-sectional prospective study involved 992 children from 12 states using a validated anti-H. pylori IgG enzyme immunoassay. The children were recruited into two groups: those without any GI complaints (non-GI referral, n = 619) and those who were referred for endoscopy because of abdominal pain (GI referral, n = 373).

RESULTS

GI referral children had a higher rate of seropositivity (22.5%) than non-GI referral children (14.1%) from the same geographic regions. In both groups, older children were more likely to be seropositive for H. pylori, as were nonwhite children and those with lower socioeconomic status. H. pylori seropositivity rates were higher in GI referral children with four or more household members (relative risk [RR] = 1.47; CI 1.01-2.14). Multivariate analysis controlling for age, ethnicity, and household income, showed that presence of GI symptoms were associated with a nearly 2-fold risk for H. pylori seropositivity (odds ratio = 1.77, CI 1.27-2.47). Epigastric pain (RR = 2.21; CI = 1.33-3.66) and having three or more episodes of abdominal pain in the last 3 months (RR = 0.59, CI = 0.35-0.99) were the only specific symptoms significantly associated with H. pylori seropositivity.

CONCLUSIONS

The H. pylori seropositivity rate of GI referral children with symptoms of abdominal pain was significantly higher. H. pylori infection in early childhood was found to be associated primarily with the child's household size and socioeconomic status.

A population-based survey on gastrointestinal tract symptoms and Helicobacter pylori infection in children and adolescents

BACKGROUND

Helicobacter pylori infection is a frequent infection mainly acquired in childhood. Even if the infection is almost invariably associated with mild to severe gastro-duodenal lesions, no specific clinical picture has been identified. The aim of this study was to evaluate the presence of dyspeptic symptoms and their relationship with the presence of H. pylori infection in the first two decades of life.

MATERIALS AND METHODS

A school-population sample size of 808 subjects from 6- to 19-year-olds was investigated for the presence of gastrointestinal tract symptoms and evaluated by a 13C-urea breath test for H. pylori infection. The relationship between clinical findings and H. pylori infection was evaluated by chi2 statistic or Fisher's exact test, as appropriate.

RESULTS

Symptoms of dyspepsia were identified in 45% of subjects, while the picture of ulcer-like and dysmotility-like forms were present in 3-4%. H. pylori infection was demonstrated in 95 (11.8%) subjects, 49.5% of them without symptoms. Severe epigastric pain and ulcer-like dyspepsia were significantly associated with H. pylori infection, while recurrent abdominal pain or dysmotility-like dyspepsia were not.

CONCLUSIONS

Dyspeptic symptoms are frequent in children, and its association with H. pylori infection is more evident than with recurrent abdominal pain. The age at which the infection is acquired seems to be under 6 years of age.

Pediatric disorders of the stomach

Disorders of the stomach represent a significant portion of the practice of pediatric gastroenterology. Controversy still exists in the appropriate management of children with abdominal pain and vomiting and large gaps remain in our understanding of the physiology and pathophysiology of the stomach in children. Nevertheless, we have made significant progress in understanding Helicobacter pylori infection and gastric motility in the pediatric population.

[Evaluation of enzyme-linked immunosorbent assay for the diagnosis of Helicobacter pylori infection in children and adolescents]

BACKGROUND

Helicobacter pylori infection is recognized as the most frequent cause of chronic gastritis in adults and children. The diagnosis is accomplished with invasive methods in fragments of endoscopic gastric biopsies and non-invasive methods. The enzyme-linked immunosorbent assay constitutes a simple, fast exam and of low cost with high sensibility in adult patients.

AIM

The purpose of this study was to evaluate the ELISA method for the infection diagnosis for Helicobacter pylori in children and adolescents using the Cobas Core II kit (Roche). Helicobacter pylori was positive when the rapid urease test and the histology were both positive or when the culture was positive and Helicobacter pylori negative when all the tests were negative.

PATIENTS/METHODS

Eleven hundred patients were studied, their age ranged from 3 months and 16 years, (mean = 8y 7m +/-; 4.0; median = 9y 5m). Helicobacter pylori infection was diagnosed in 47.7% (53/111).

RESULT

Sensitivity was 83.0% and 86.0%; specificity was 70.6% and 71.0%, using the cutoff of 7 U/mL and 5 U/mL, respectively. When only the positive culture was used as gold standard and the cutoff of 5 U/mL, the sensitivity was 93.3%. In patients older than 10 years, the sensibility was 90.6% and 96.8%; specificity was 71.0% and 61.9%, with the cutoff of 7 U/mL and 5 U/mL, respectively.

CONCLUSION

ELISA method had good sensitivity in children older than 10 years, using the cutoff 5 U/mL, but the specificity was low.

Childhood peptic ulcer in the Ural area of Russia: clinical status and Helicobacter pylori-associated immune response

BACKGROUND

The relation of between Helicobacter pylori and the symptoms in children is still controversial. Determination of specific immunoglobulin (Ig) G antibodies to H. pylori may represent a useful test to screen the patients with acid peptic disease in childhood. The aim of this study was to investigate the spectrum of clinical symptoms, endoscopic and histologic lesions, and clinical value of serum IgG response to H. pylori in school-aged children residing in the Ural area of Russia for the identification of Helicobacter -related acid-peptic disease.

METHODS

During 1998, 129 pediatric outpatients (mean age, 12.1 +/- 2.3 years; age range, 10-15 years; 41 boys, 88 girls) were undergoing gastroduodenal endoscopy for evaluation of chronic abdominal pain. H. pylori colonization was determined by histology, urease test, and polymerase chain reaction. H. pylori IgG antibodies were found by using an enzyme-linked immunosorbent assay.

RESULTS

There was a high prevalence of H. pylori infection (80%) and peptic ulcers (24%) among the study group. Duodenal ulcers were detected in 31 of the children; all of them were H. pylori positive. Family history of peptic ulcers, nighttime pain associated with nocturnal awakening, fasting pain relieved by food, pain associated with meals, postprandial pain, bitter taste, and heartburn were the clinical signs that helped to distinguish the ulcer-positive children from the ulcer-negative H. pylori group. Duodenal ulcer patients had higher anti- H. pylori IgG titers compared with the levels of IgG antibodies in the infected children without ulcers ( P < 0.001). Peptic ulcer disease was a more common finding in the Ural ethnic group of Asians (Bashkirs) compared with the pediatric population of Russian origin.

CONCLUSIONS

These results provide further evidence for a causal relation between H. pylori -associated peptic ulcer disease in childhood and relevant clinical symptoms. High titers of anti- H. pylori IgG might serve as a useful noninvasive indicator of ulcer disease.

Helicobacter pylori infection in children

A number of scientific breakthroughs since H pylori first became recognized as a human pathogen have increased our understanding of the pathogenesis of gastroduodenal disease. In particular, advances in molecular bacteriology and the complete sequencing of the H pylori genome in 1999, and soon thereafter the human genome, provide tools allowing better delineation of the pathogenesis of disease. These molecular tools for both bacteria and host should now be applied to multicenter pediatric studies that evaluate disease outcome. More recent developments indicate that a better understanding of the microbial-host interaction is critical to furthering knowledge with respect to H pylori-induced diseases. Studies are needed to evaluate either DNA-based or more traditional protein-based vaccines, to evaluate more specific antimicrobials that confer minimal resistance, and to evaluate probiotics for the management of H pylori infection. Multicenter multinational studies of H pylori infection in the pediatric population, which include specific, randomized controlled eradication trials, are essential to extend current knowledge and develop better predictors of disease outcome.

Helicobacter pylori infection and recurrent abdominal pain in Turkish children

BACKGROUND

Helicobacter pylori infection is primarily acquired in childhood. However, the association between H. pylori infection and recurrent abdominal pain (RAP) remains unclear.

MATERIALS AND METHODS

One hundred and forty-one children with and 21 without RAP underwent upper gastrointestinal endoscopy. At least five antral gastric biopsies were obtained from each patient and the presence of H. pylori infection was accepted when at least two out of four tests (histology, direct antral smear, culture, and rapid urease test) were positive. Patients with H. pylori infection underwent triple therapy with omeprazole, clarithromycin, and metronidazole.

RESULTS

Eighty-five out of 141 (60.3%) patients with RAP were H. pylori positive whereas 5 out of 21 (20.8%) patients without RAP were (p =.0037). Symptoms were disappeared in 87% of children whose H. pylori infection was eradicated compared with 41% of those in whom the infection was not eradicated (p =.0035).

CONCLUSIONS

It was concluded that children with RAP and H. pylori infection appear to benefit from eradication therapy in Turkey.

Is Helicobacter pylori infection in childhood a risk factor for gastric cancer?

Helicobacter pylori infection is associated with chronic gastritis and peptic ulcer disease. Furthermore, the World Health Organization has classified this organism as a carcinogen for gastric cancer. H pylori infection is mainly acquired in childhood. Children with H pylori infection are asymptomatic except for a very small number that develop peptic ulcer disease. However, if H pylori gastritis is associated with gastric cancer, do pediatricians need to screen children for this infection and treat those who are infected? In an attempt to determine the significance of the association between H pylori and gastric cancer, we have reviewed all of the English language literature on this topic. H pylori infection seems to be associated with an increased risk of developing gastric cancer. However, only a small number of infected individuals (~1%) will develop gastric cancer. Furthermore, there are potential cofactors other than H pylori that could be equally important. The effect of the eradication of H pylori alone on the development of gastric cancer is unknown. Based on our knowledge to date, we suggest that it is not indicated to treat all children with H pylori infection because of the risk of developing gastric cancer or to institute a screening and treatment program.

Gastrointestinal infections in children

Gastrointestinal infections in children are a major cause of morbidity and mortality worldwide. Children living in developing countries are particularly susceptible to infectious diarrhea because of poor standards of hygiene and sanitation. Although the magnitude of diarrheal illnesses in developed countries is less, costly hospital admissions are still frequent. The causal agent of infectious diarrhea is most frequently related to age, geographical location, lifestyle habits, use of antibiotics, associated medical conditions, social circumstances, and degree of immune competence. In this article we present some of the most important articles published in the field during the last year. The role of Helicobacter pylori in the pathogenesis of gastritis and peptic ulcer disease has been shown in adults and children. Information about the natural history of H. pylori, symptomatology, and diagnostic therapeutic approaches for children are being generated constantly; we discuss some of the most relevant information in this review.

A systematic review of Helicobacter pylori eradication treatment schedules in children

METHODS

We systematically reviewed all available data in the paediatric literature on treatment for Helicobacter pylori infection to determine overall efficacy of different schedules. A comprehensive search of all published articles and letters from 1987, and of abstracts presented at three main meetings on this topic between 1997 and 1999, was carried out. Results from all English and French papers, letters and abstracts were extracted and analysed.

RESULTS

Only 30 full articles and 16 abstracts were found, with results on eradication of H. pylori in 870 and 1552 children, respectively. Monotherapy or dual therapy with an antisecretory drug plus one antibiotic showed a very low efficacy. Dual therapies with bismuth plus one antibiotic (either amoxycillin or a nitro- imidazole) or two antibiotics when administered for 2 or more weeks were as effective as either bismuth-based or proton pump inhibitor-based triple therapies. Triple therapies were less effective than in adults, and while bismuth-based triple therapies were more effective when given for 2 weeks than for one week, proton pump inhibitor-based triple therapies have a similar efficacy irrespective of the duration.

CONCLUSION

In children dual therapies seemed as effective as triple therapies, and longer courses of proton pump inhibitor-base triple therapies are not better than shorter ones.

A comprehensive review of the natural history of Helicobacter pylori infection in children

Across populations of children, Helicobacter pylori prevalence ranges from under 10% to over 80%. Low prevalence occurs in the U.S., Canada, and northern and western Europe; high prevalence occurs in India, Africa, Latin America, and eastern Europe. Risk factors include socioeconomic status, household crowding, ethnicity, migration from high prevalence regions, and infection status of family members. H. pylori infection is not associated with specific symptoms in children; however, it is consistently associated with antral gastritis, although its clinical significance is unclear. Duodenal ulcers associated with H. pylori are seldom seen in children under 10 years of age. H. pylori-infected children demonstrate a chronic, macrophagic, and monocytic inflammatory cell infiltrate and a lack of neutrophils, as compared with the response observed in adults. The effect of H. pylori infection on acid secretion in children remains poorly defined. The events that occur during H. pylori colonization in children should be studied more thoroughly and should include urease activity, motility, chemotaxis, adherence, and downregulation of the host response. The importance of virulence determinants described as relevant for disease during H. pylori infection has not been extensively studied in children. Highly sensitive and specific methods for the detection of H. pylori in children are needed, especially in younger pediatric populations in which colonization is in its early phases. Criteria for the use of eradication treatment in H. pylori-infected children need to be established. Multicenter pediatric studies should focus on the identification of risk factors, which can be used as prognostic indicators for the development of gastroduodenal disease later in life.

Peptic ulcer disease in children

A peptic ulcer in a child looks the same as it does in an adult, and many of the aetiologies of peptic ulcer disease in children are similar to those in adults. However, there are many differences between children and adults, especially in the areas of clinical presentation, the prevalences of different types of ulcer disease, and the prevalence of complications of ulcer disease. Therefore the approach to diagnosis and management in children is often at variance with that in adults. One important example is the approach to suspected Helicobacter pylori (H. pylori) disease in children, in which consensus groups have advised a considerably different approach in children. While the chapter deals with the full range of peptic ulcer disease in children, the focus is on those aspects in which there are differences between adults and children.

Natural outcome of Helicobacter pylori infection in asymptomatic children: a two-year follow-up study

BACKGROUND AND OBJECTIVES

It is known that Helicobacter pylori can be acquired in early childhood. There is not enough data to know whether or not infected children should be treated. A better knowledge of the natural outcome and implications of H pylori infection may provide evidence that eradication therapy is beneficial in childhood. This prospective study looks at clinical symptoms, endoscopic, microbial, and histologic changes during a 2-year period in infected asymptomatic children. It is hoped that some prognostic indicators will be found that select out the children that later need therapy.

PATIENTS AND METHODS

During epidemiologic study of the prevalence of H pylori infection, 18 children aged 7 +/- 4 years (mean +/- 1 SD) were discovered to have H pylori infection and enrolled in the 2-year follow-up study. These patients had received no eradication therapy because they were asymptomatic. The follow-up for each patient consisted of an initial assessment, a clinical examination every 6 months, and an endoscopic reevaluation at the end of the first and second years. Gastric mucosal samples were analyzed for bacteriologic and histologic changes. Various factors were initially recorded: individual factors included sex, age, and housing conditions; microbial factors included bacterial load and the presence of the CagA gene. Inflammatory changes were also noted, such as the presence of active gastritis and nodular formation, and these were correlated with the histology which was described using the Sydney classification. Typing polymerase chain reaction-restriction fragment length polymorphism was performed to check the persistence of the same strain of H pylori in each patient.

RESULTS

All of the children were still infected after 2 years with the same strain as in the initial assessment with the exception of 1 child whose infection cleared spontaneously. The density of antral and fundal mucosal colonization with H pylori also remained stable. There were progressive inflammatory changes in this cohort, particularly between the first and second year (histologic score, 3.5 +/- 1.3 vs 5 +/- 1). Active antral gastritis occurred in 3 out of 14 and 1 out of 8 children during the first and second year, respectively. Gastritis became active in the fundus in 2 out of 14 and 2 out of 8 children during the same period. Increases in the histologic score were found particularly in male children, and children colonized by cagA- strains of H pylori during the follow-up. The frequency of nodular gastritis significantly rose from 11% (2 out of 18 children) to 64% (9 out of 14 children) after 1 year, and to 80% (8 out of 10 children) after 2 years.

CONCLUSION

These findings demonstrate a deterioration in the histologic features of the gastric mucosa of infected children despite stable H pylori colonization and the absence of symptoms.

Low rates of Helicobacter pylori reinfection in children

BACKGROUND & AIMS

Reinfection after treatment for Helicobacter pylori is uncommon in adults. It is more likely to occur in children because they acquire primary infection. The aim of this study was to determine whether children are likely to become reinfected with H. pylori and if there are any risk factors for reinfection.

METHODS

A prospective study of children who had documented evidence of successful treatment for H. pylori infection was performed. Sixty children were eligible for inclusion; results for 52 are presented. Children, parents, and siblings underwent [(13)C]urea breath tests. Details of family size and socioeconomic status were documented. Cox logistic regression analysis was used to determine the risk factors for reinfection.

RESULTS

The duration of follow-up was 103.8 patient-years (mean +/- SD, 24 +/-14.0 months). Forty-six (88.5%) of the index children remained clear of infection, and 6 (11.5%) children were reinfected. The mean age of those who became reinfected was 5.8 +/- 5.6 years compared with 12.3 +/- 3.0 years for those who remained clear of infection (P = 0.00001). Only 2 of 46 (4.3%) children older than 5 years of age were reinfected, although 80.8% had 1 infected parent and 65% of siblings were infected. Reinfection rate was 2.0% per person per year in children older than 5 years. Living with infected parents and siblings and low socioeconomic status were not risk factors for reinfection. In logistic regression analysis, age was the only risk factor for reinfection.

CONCLUSIONS

Reinfection with H. pylori occurs rarely in children older than 5 years of age regardless of socioeconomic group or number of infected family members. These findings also indicate that it is not necessary to treat all family members to achieve long-term eradication of H. pylori.

Helicobacter pylori gastritis in children: efficacy of 2 weeks of treatment with clarithromycin, amoxicillin and omeprazole

Thirty-eight children with Helicobacter pylori gastritis diagnosed by histopathology, and/or bacteriological culture were treated with omeprazole, amoxicillin and clarithromycin. Follow-up endoscopy was performed in 34 children. Outcome was measured by negative histology and culture for H. pylori. Six patients were excluded. Of the 32 remaining children eradication was achieved in 75% (95% confidence interval 60-90%).

Diagnosis of Helicobacter pylori gastritis in children using the 13C urea breath test

The clinical recognition of Helicobacter pylori gastritis in children with recurrent abdominal pain is difficult. We assessed the value of a simplified 13C urea breath test (13C-UBT) in a selected group of children with nocturnal waking and disruptive recurrent abdominal pain who fulfilled criteria for endoscopy. Gastric antral biopsies were examined histologically and by the quick urease test and were compared with H. pylori serology and the 13C-UBT in a prospective study of 50 children referred to a tertiary center. Thirty-two patients had gastritis and of these, 19 had histologically proven H. pylori gastritis. Seventeen of these 19 patients had a positive 13C-UBT. The sensitivity and specificity of the 13C-UBT compared with the histologic diagnosis of H. pylori was 89 and 90% respectively. The 13C-UBT was more specific than the H. pylori serology. The 13C-UBT using two breath collections is a reliable and noninvasive diagnostic test for H. pylori infection in children.

Effect of Helicobacter pylori eradication on the natural history of duodenal ulcer disease

BACKGROUND

Duodenal ulcer disease is strongly associated with Helicobacter pylori infection of the gastric mucosa. Eradication of H pylori from the gastric mucosa in adults is associated with long term healing of ulcers.

AIMS

To follow a cohort of children with duodenal ulcer disease for a minimum of two years after the eradication of H pylori.

PATIENTS AND METHODS

Over a three year period, all children diagnosed with duodenal ulcer disease had their symptoms documented and their H pylori status evaluated. The histories of these children were carefully screened to determine previous symptoms and to document previous treatment regimens.

RESULTS

Sixteen children were diagnosed with ulcers and 15 were available for treatment and long term follow up. The median age at which symptoms first occurred was 10.5 years (range, 6-14) and the median duration of symptoms was 24 months (range, 2-60). Ten of the children had been treated with H2 receptor antagonists for a median of 3.5 months (range, 1-60). Duodenal ulcers healed in all children after eradication of H pylori and all children have remained asymptomatic for a median of 37 months (range, 26-62). No child has required subsequent admission to hospital.

CONCLUSION

Eradication of H pylori is very effective in the long term healing of duodenal ulcer disease. H pylori eradication should be the standard treatment for all infected children who present with duodenal ulcer disease.

Helicobacter pylori and abdominal symptoms: a population-based study among preschool children in southern Germany

OBJECTIVE

To determine the relation of Helicobacter pylori infection with gastrointestinal symptoms in a healthy population-based sample of children.

DESIGN

Population-based cross-sectional study of preschool children.

SETTING

Screening examination for school fitness by physicians of the Public Health Service in Ulm, a city with 100 000 inhabitants in southern Germany.

PARTICIPANTS

One thousand two hundred one preschool children.

MAIN OUTCOME MEASURES

Infection status was determined by 13C-urea breath test. Information on gastrointestinal symptoms was collected from children's parents by a standardized questionnaire and integrated into a symptom score. Results. Nine hundred forty-five children participated in the study (response rate, 79%). Overall, 127 children (13.4%) were infected. H pylori infection was not positively related to specific gastrointestinal symptomatology. Infected children had even fewer symptoms when compared with uninfected children.

CONCLUSIONS

Our results indicate that H pylori infection in children is mostly asymptomatic and not associated with specific gastrointestinal symptoms.

Cost-effectiveness of noninvasive testing and treatment strategies for H. pylori infection in children with dyspepsia

OBJECTIVE

We sought to model the cost-effectiveness of endoscopy, noninvasive testing and treatment strategies for Helicobacter pylori infection in children with recurrent abdominal pain in two health care systems, those of the United States and Finland.

METHODS

Initial serological testing and treatment was compared to empirical treatment with antimicrobials, endoscopy with rapid urease testing, and 13C urea breath testing. Key assumptions and ranges were obtained from the published literature. Costs were determined for the acquisition of various tests and actual reimbursement figures were used for procedural costs.

RESULTS

The disease management costs were very similar for both endoscopy ($643.00) and serology ($646.00) in the United States. In Finland, endoscopy ($173.00) was less expensive than serology ($192.00). The 13C urea breath test was the most expensive procedure in the United States. Sensitivity analysis demonstrated that serological testing became the preferred path if its cost was < $42 in the United States. Empirical treatment of children with dyspepsia was not cost-effective in either country. Sensitivity analysis showed that when prevalence of infection was > 53% in children with recurrent abdominal pain, empirical therapy with endoscopy reserved for failures was the optimal path.

CONCLUSIONS

In developed countries like the United States and Finland, significant cost savings are unlikely with an initial test and treat strategy based on serology. Noninvasive testing and treatment of H. pylori infection can be cost-effective in populations with highly prevalent rates of infection.

Carbon 13-labeled urea breath test for the diagnosis of Helicobacter pylori infection in children

Helicobacter pylori infection is mainly acquired in childhood, and studies on the epidemiology of this infection depend on the availability of a noninvasive diagnostic test for use in children. The aim of this study was to determine whether the carbon 13-labeled urea breath test (UBT) can be used in children by evaluating: (1) its sensitivity and specificity compared with either culture or both rapid urease test and histologic examination, (2) whether a test meal or a prolonged fast is required, (3) the usefulness after treatment for H. pylori. Eighty-eight children (mean age, 10.6 +/- 4.19 years) who were undergoing upper endoscopy were studied while fasting, not fasting, and after treatment. Children were given 50 mg of 13C-urea if they weighed less than 50 kg or 75 mg of 13C-urea if they weighed more than 50 kg with 50 mg of a glucose polymer solution in 7.5 ml of water. Breath samples were collected at baseline and at 15, 30, 45, and 60 minutes. In 63 fasting children the UBT was 100% sensitive and 97.6% specific at 30 minutes with a cutoff value of 3.5 delta 13CO2 per mil. Nonfasting tests in 23 children, performed between 1 and 2 hours after their usual meal, were 100% sensitive and 91.6% specific. In 13 children fed directly before the UBT, the sensitivity of the test was reduced to 50%. Thirty minutes was the optimal sampling time. There was a significant decrease in specificity when samples were obtained at 15 minutes, possibly caused by the interference of oral urease-producing organisms. The test was 100% sensitive and specific in 20 children after treatment for H. pylori infection. The UBT is a highly sensitive and specific test for the diagnosis of H. pylori infection in children. Neither a prolonged fast nor a test meal is required.

Helicobacter pylori: challenges for the paediatrician

During the last 15 years, a great body of knowledge about Helicobacter pylori has been accumulated. Much, however, remains to be studied, particularly in relation to children. The vast majority of infections occur in childhood. It is towards children that any widespread screening, prevention or treatment strategies would need to be aimed. In this annotation, we discuss the epidemiology, symptomatology, diagnosis and treatment of H. pylori in children.

Long-term follow-up of childhood duodenal ulcers

PURPOSE

This study reports the long-term results in children who have duodenal ulcers diagnosed by endoscopy who were treated with H2-receptor antagonist.

METHODS

The medical records of 32 children admitted into The Queen Mary Hospital with endoscopically proven duodenal ulcers between 1975 and 1988 were reviewed to evaluate the long-term outcome of childhood duodenal ulcers after initial treatment with H2-receptor antagonist (H2RA). Follow-up details were updated and patients who had been lost to follow-up were recalled. The age of the 22 boys and 10 girls at the time of diagnosis of the ulcers ranged from 3 to 16 years (mean, 11.8 yrs). The duration of follow-up ranged from 8.5 to 21 years (mean, 11.6 yrs).

RESULTS

Their primary presentations included epigastric pain (n = 9, 28.0%); nonsteroidal antiinflammatory drug (NSAID)-induced gastrointestinal bleeding (GIB, n = 6, 18.7%); unprovoked GIB (n = 12, 37.5%); perforation (n = 4, 12.5%); and pyloric obstruction (n = 1, 3.0%). All 13 patients who had NSAID-induced ulcers (pain and bleeding) responded to H2RA therapy and required no further treatment. All 14 patients who had unprovoked ulcers who presented with pain or bleeding did not respond to H2RA treatment. Ulcer healing was achieved only after eradication of Helicobacter pylori with antibiotics (n = 8) or definitive surgery involving either truncal vagotomy and pyloroplasty (VP, n = 4) or proximal gastric vagotomy (PGV, n = 2). The patient who had gastric outlet obstruction had vagotomy and antrectomy. All four patients who had perforation were initially treated with patch repair, but two had persistent ulceration despite H2RA treatment and required PGV. Complications developed in none of the four patients who had PGV, whereas two of the four patients with VP had problems (diarrhea, n = 1; bezoar obstruction, n = 1).

CONCLUSIONS

Unprovoked childhood duodenal ulcer is associated with significant long-term morbidity and requires continued follow-up. The majority of the ulcers are resistant to H2RA treatment alone and ultimately require either eradication of H. pylori or surgery. In the absence of obstruction, PGV may be enough to resolve the ulcer diathesis.

Helicobacter pylori infection in children with abdominal ailments in a developing country

Helicobacter pylori commonly infects children in developing countries. To determine the frequency of this infection and its potential role in specific gastrointestinal entities, all patients requiring upper gastrointestinal endoscopy for the evaluation of abdominal ailments in a gastroenterology practice in Lima, Peru, were evaluated during a 1-year period. Gastric biopsies were obtained for each child and were stained with hematoxylin-eosin and Warthin-Starry stains. Of the 107 evaluable patients (mean age 7.4 years, 58% boys), 52 (49%) were infected. The infection rate increased with older patients (P = 0.004). Children with recurrent abdominal pain (P = 0.04), an endoscopic finding of nodular gastritis (P = 0.007), and a histologic finding of chronic active gastritis (P < 0.0001) were infected more commonly.

Helicobacter pylori in an institution for disabled children in Hong Kong

Anti-Helicobacter pylori antibodies were determined in 157 institutionalised Cantonese children, mean age 9.5 +/- 3.9 (SD) years, with profound neurodevelopmental disabilities. Eighty-seven (55.4%) were H. pylori seropositive compared with four of 50 (8%, P > 0.0002) of an age-matched control group, mean age 7.2 +/- 4.3 (SD) years. Eight of 15 seropositive children with a recent history of upper gastrointestinal bleeding underwent endoscopy and in all cases gastric infection with H.pylori was confirmed. Anthropometric data from institutionalised children revealed marked malnutrition but showed no significant difference between seropositive and seronegative children. Disabled children receiving long-term residential care in Hong Kong are confirmed to be at increased risk of H.pylori infection.

One week treatment for Helicobacter pylori infection

Helicobacter pylori is associated with primary antral gastritis, duodenal ulceration, and gastric cancer. Current regimens for treating infection in children using bismuth and antibiotics for two to six weeks are cumbersome. The aim of this study was to evaluate a one week course of treatment. All children undergoing endoscopy were assessed for the presence of H pylori by culture, histology, rapid urease test, and 13C urea breath test. Infected children received a one week course of colloidal bismuth subcitrate 480 mg/1.73 m2/day (maximum 120 mg four times a day), combined with metronidazole 20 mg/kg/day (maximum 200 mg three times a day), and clarithromycin 15 mg/kg/day (maximum 250 mg twice a day). To optimise compliance, drugs were dispensed in a 'Redidose' box containing a compartment for each day, and subcompartments marked 'breakfast', 'lunch', 'dinner', and 'bedtime'. Compliance and side effects were assessed immediately after treatment. A urea breath test was performed at least one month after treatment. Twenty two children infected with H pylori were entered into the study; 20 of these took all doses; two children suffered significant side effects (diarrhoea and vomiting). H pylori was eradicated in 21 of the 22 children (95.45%; 95% confidence interval 77% to 100%). This study shows that H pylori infection in children can be cleared by a one week course of treatment.

Recurrent abdominal pain and Helicobacter pylori in a community-based sample of London children

Helicobacter pylori is accepted as an important factor in the pathogenesis of peptic ulcer disease. Infection is probably most commonly acquired in early life but there is still limited information on the prevalence or symptomatology of H. pylori infection in childhood. The aim of the present study was to establish the prevalence of H. pylori infection in a large sample of urban school children and to determine its relationship, if any, to a history of recurrent abdominal pain. Using a commercial ELISA significant levels of anti-H. pylori IgG antibody were detected in 107/640 (16.7%) of school children (M, 383; F, 257; mean age 9.15 years, range 4-13). No relationship was demonstrated between H. pylori seropositivity and a personal or family history of recurrent abdominal pain or the nature of the pain.