What are Potential Problems Associated with Helicobacter pylori?

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Patient Presentation
Two pediatricians were talking about the coincidence of each having a family who were concerned about the transmission and testing for H. pylori. Both families had young, asymptomatic children and in one family the mother was affected and in the other family the father was affected. Both parents were being given their initial treatment for H. pylori. Both pediatricians had independently read the recent guidelines for management and had concluded that the children in each family should not be tested currently but be monitored for possible problems.

Discussion
Helicobacter pylori (H. pylori) is a microaerophilis, spiral bacterium that is a prevalent human pathogen. How this infection affects individuals is different in adults and children. Overall seroprevalence rate in children world-wide was estimated to be ~33%, but this seroprevalence rate is decreasing in the developed world for both adults and children. It is acquired in childhood and can persist through colonization throughout life if untreated. Fortunately, it often is asymptomatic and generally does not cause serious disease in children.

Some serotyping data shows that within families children acquire it more often from mothers than from fathers.

Learning Point
H. pylori causes gastritis (chronic), peptic ulcer disease (PUD), gastric adenocarcinoma and MALT (mucosal-associated lymphoid tissue lymphoma) in adults. Many of the studies have been conducted in adults and extrapolating to children is not appropriate. Potential clinical problem may not be caused by H. pylori but rather may only be associated with it in children. Many of those listed below are certainly not specific to H. pylori.

  • PUD can cause upper abdominal pain and potential gastrointestinal bleeding but is not common in children. Testing is recommended if PUD is identified.
  • Functional abdominal pain – testing is not recommended
  • Iron deficiency anemia – testing is not recommended for initial investigation, but may be appropriate for refractory anemia
  • Chronic immune thrombocytopenic purpura – testing may be considered
  • Short stature and failure to thrive – testing is not recommended
  • Henoch-Schonlein purpura – testing is not recommended
  • Obstructive sleep apnea – testing is not recommended
  • Diabetes mellitus – testing is not recommended
  • Asthma/atopic dermatitis – testing is not recommended
  • Celiac disease (having H. pylori possibly has a protective effect)

Guidelines for management for children and adolescents from Europe and North America were published in 2017 (see To Learn More below). Testing of relatives with gastric cancer that were previously included in guidelines have been removed from this iteration. Test and treat strategy for children is not recommended as the clinical goal is to identify the cause of the upper abdominal pain and/or other symptoms rather than identifying H. pylori infection. Patients should have appropriate diagnostic testing (i.e. endoscopy with biopsy, urea breath hydrogen testing, stool antigen testing) with antimicrobial susceptibility testing to guide treatment. Even with biopsies, H. pylori can be an incidental finding. Treatment depends on age, antibiotic susceptibility testing and include antibiotics and proton pump inhibitors for 7-14 days depending on the protocol. Adherence to protocol has been shown to be a key to treatment success and more than 90% adherence is recommended. The main cause of treatment failure is clarithromycin resistance and non-adherence. Post treatment re-testing for treatment success or failure is recommended at least 4 weeks after treatment. There has been a vaccine trial in China with children. The efficacy rate was “…71% and 55% at 12 months and 3 years after vaccination.” One problem was “…that 20% of younger children in the study were not protected [from H. pylori].”

Questions for Further Discussion
1. How common are gastric ulcers? A review can be found here
2. What are the ROME criteria for functional abdominal pain? A review can be found here
3. What causes abdominal pain? A review can be found here

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Helicobacter Pylori infections

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Jones NL, Koletzko S, Goodman K, et al. Joint ESPGHAN/NASPGHAN Guidelines for the Management of Helicobacter pylori in Children and Adolescents (Update 2016). J Pediatr Gastroenterol Nutr. 2017;64(6):991-1003. doi:10.1097/MPG.0000000000001594

Kalach N, Bontems P, Raymond J. Helicobacter pylori infection in children. Helicobacter. 2017;22 Suppl 1. doi:10.1111/hel.12414

Kotilea K, Kalach N, Homan M, Bontems P. Helicobacter pylori Infection in Pediatric Patients: Update on Diagnosis and Eradication Strategies. Paediatr Drugs. 2018;20(4):337-351. doi:10.1007/s40272-018-0296-y

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa

Published