Seroprevalance of Helicobacter
pylori in undernourished children: A hospital based study
Malik S1, Sharma S2 ,
Dwivedi R3
1Dr Shikha Malik, Associate Professor, Department of Pediatrics, 2Dr
Shweta Sharma, Assistant Professor, Department of Pediatrics, 3Dr
Rashmi Dwivedi, Professor & Head. All are affiliated with
Gandhi Medical College Bhopal MP India.
Address for
Correspondence: Shikha Malik Associate Professor,F1
Doctors Quarter,Hamidia Hospital Campus, Bhopal, MP, India,E-mail
id:gohiyapoorva@gmail .com
Abstract
Introduction:
Helicobacter pylori is a gram negative, spiral flagellated bacillus
that persistently colonizes the human stomach. H.pylori incidence in
most of the developing countries including India is around 80% and most
of the infection is acquired by 10 years of age. In children it is
associated with anaemia and undernutrition..We have taken up this study
to find out its seroprevalance in undernourished children aged 6-12
years admitted in the hospital for various reasons. Material and Methods:
This is a cross sectional study done over a period of one year in the
pediatric department of a teaching hospital. After ethical committee
clearance and parental consent, data was collected in a pretested
proforma and serology was done for Ig G antibodies against
H.pylori.(ELISA) in which a titre of >12micrograms/ml was
considered positive. Results:We
studied 60 children who fulfilled our inclusion criteria. The male to
female ratio was comparable in the different age groups,with total29
males and 31 females.63.3% of the children tested positive for
antibodies against H.pylori. The seropositive children had
significantly high tendencyof having symptoms of H.pylori infection.
The relation between H.pylori seropositivity and low BMI was
significant (p<0.005).72.7% of children who regularly consumed
raw vegetables were seropositive but this association was not
statistiticallysignificant. Low SES and increased overcrowding
indexstatus was significantly associated with seropositivity. LowHb as
per age and sex and low PCV were associated with seropositivity. Conclusion:Our
study showed seroprevalance of H.pylori to be 63.3% in undernourished
children. LowSES, overcrowding,open field defecation were significantly
associated with H pylori infection. Low BMI, anemia and low PCV
werestrongly associated with H.pylori seropositivity. Thus we conclude
that H.pylori contributes to morbidity of already undernourished
children therefore H pylori eradication regimen should be considered in
undernourished children with suggestive symptoms.
Key Words:
Overcrowding, Seropositivity, Anaemia, Low SES
Manuscript received:
04th Feb 2016, Reviewed:
12th Feb 2016
Author Corrected;
18th Feb 2016, Accepted
for Publication: 26th Feb 2016
Introduction
The acidic environment of stomach is incompatible with growth of most
of the micro organisms. Helicobacter pylori is a gram-negative
flagellate bacteria which is highly prevalent in developing countries.
Its ubiquitous and infects more than half of global population[1]. H
pylori when initially isolated was implicated in active and chronic
gastritis, peptic ulcer disease and adenocarcinoma [2].Over the years
with increasing expertise in diagnosing causal organisms for different
diseases, H pylori has been found to be causally related to recurrent
abdominal pain, gastric mucosa associated lymphoid tissue lymphoma,
gastro esophageal reflux disease, obesity growth retardation and more
recently extra gastric diseases like glaucoma, coronary heart disease
and idiopathic thrombocytopenic purpura[3,4].
H.pylori infection is acquired early in life and persists into
adulthood[2].Mode of transmission is feco -oral or oro-oral. There are
lots of adult studies on role of H.pylori as a causative agent of
different diseases. Prevalence of H. pylori is more in the developing
countries than the developed nations. Up to 80% children in the
developing world are infected under the age of 10 years. The prevalence
of infection in India is 22%,56% and 87% in 0-4,5-9 and 10-19 yearsage
group respectively [5]. The diagnostic potential of direct microscopy,
culture, rapidUrease test (RUT) of endoscopic antral biopsy tissues,
urea breathtest and enzyme-linked immunosorbent assay (ELISA)
ofanti-Helicobacter pylori antibody in serum for the detection ofH.
pylorihas been demonstrated [6].We have taken up this study to find out
the sero prevalence of H.pylori in the undernourished children
belonging to 6-12 years age group who were admitted due to various
reasons.
Materials
and Methods
Study Design:
Prospective cross sectional study.
Study Population: Undernourished
children in age group 6-12 years admitted for various etiologies in
department of pediatrics of a teaching hospital.
Study Period 1 year.
Inclusion Criteria:
• Undernourished children (BMI
<5th centile as per WHO charts. [7]
• Age group 6-12 years.
• Children whose parents gave
consent to participate in study along with blood sample collection for
serum IgG antibody (against H.pylori) assessment.
Exclusion criteria:
• Children with BMI >5th
centile.
• Children with comorbities like
HIV infection, immuncompromised state, on long-term steroids, taking
antibiotics for >7 days.
• Children whose parents did not
give consent for sample collection for serum IgG assessment.
Institutional ethical committee approved the study. Serum collection
was done at the hospital and samples were sent to Religare laboratory
for serum IgG antibodies against H.pylori. IgGantibodytiters of
>12micrograms/ml were considered as positive.This is 77.3-78%
sensitive and 91-93% specific[8].
A pretested proforma was used to collect the data of study population.
The socio epidemiological factors, anthropometry, history of
symptomssuggestive of H pylori infection were recorded. Complete blood
picture and peripheral smear of all the subjects were sent for lab
assessment.Data was processed using Microsoft Excel and SPSS 18
version. P value <0.05 was considered significant. Chi Square
test and student T test were applied as test of significance.
Results
We studied 60 undernourished children who fulfilled the inclusion
criteria. There were 29 males and 31 females (Table1)and 53.3% of
children were in 8-10 years age group.
Table 1: Age distribution
of Seronegative and seropositive children
|
Age in Years
|
Sero negative
|
Seropositive
|
Total
|
|
6
|
4
|
1
|
5
|
|
7-8
|
11
|
12
|
23
|
|
9-10
|
7
|
25
|
32
|
|
Total
|
22
|
38
|
60
|
Table- 2:Anthropometry
and its correlation with H pylori titers
|
|
Group
Ig G Titres
|
N
|
Mean weight
|
Std Deviation
|
Std Error of mean
|
|
weight
|
<12
|
22
|
18.568
|
2.44
|
0.52
|
|
>12
|
38
|
18.249
|
2.17
|
0.35
|
|
height
|
<12
|
22
|
120.00
|
7.20
|
1.53
|
|
>12
|
38
|
123.19
|
6.79
|
1.1
|
|
BMI
|
<12
|
22
|
12.86
|
0.51
|
0.11
|
|
>12
|
38
|
11.99
|
0.47
|
0.07
|
Table 3: Socioeconomic
Status (SES) and Hpylori titre, Decreasing SES is significantly
associated with seropositivity (p<0.05)
|
SES
|
Seronegative
|
Seropositive
|
Total
|
|
1
|
3(100%)
|
0
|
3
|
|
2
|
9(69.2%)
|
4(30.8%)
|
13
|
|
3
|
9(42.9%)
|
12(57.1%)
|
21
|
|
4
|
1(6.3%)
|
15(93.8%)
|
16
|
|
5
|
0
|
7(100%)
|
7
|
|
|
22
|
38
|
60
|
Table
4:Hematological Parameters
|
|
Group
AsperIgGtitres
|
N
|
MEAN
|
STD. Deviation
|
|
HEMOGLOBIN
|
<12
|
22
|
11.150
|
1.5108
|
|
>12
|
38
|
9.261
|
1.3114
|
|
PCV
|
<12
|
22
|
33.42
|
4.703
|
|
>12
|
38
|
27.27
|
4.519
|
|
MCV
|
<12
|
22
|
70.486
|
2.5100
|
|
>12
|
38
|
81.826
|
8.7372
|
|
PLT
|
<12
|
22
|
1.9900
|
.25302
|
|
>12
|
38
|
1.55553
|
032890
|
|
RDW
|
<12
|
22
|
19.200
|
2.3011
|
|
>12
|
38
|
22.916
|
3.7688
|
The sero- positivity of H pylori was 63.3%. 65.7% of sero -positive
children were of 8-10 years and 55.3% of positive children were females
though this difference was not statistically significant.71% of sero
-positive children had gastrointestinal symptoms suggestive of H pylori
infection as opposed to 7% in the sero -negative group.This difference
was statistically significant with a p value =0.003.The mean BMI of
seropositive children was 11.99 and of seronegative was 12.868, this
difference was statistically significantwith p <0.005
(Table2).72% of children who consumed raw vegetables regularly i.e. for
5 days in a week, were sero-positive.We used Kuppuswamy classification
to define socioeconomic status (SES) (Table 3) and 100% of children in
SES 1 were sero negative whereas all were positive in SES 5, this
difference was statistically significant. Mean overcrowding index of
seropositive children was 2.7 as opposed to 1.6 of sero negative
children, and the difference was statistically significant. Peripheral
smear (Table 4) showed microcytic picture in 84% of seropositive
children. Mean hemoglobin in sero-positive children was 9.2 whereas it
was 11.15 in sero negative children. Mean red cell distribution width
(RDW) was 22.9 in seropositive children and 19.2 in sero negative
children p =0.003.
Discussion
Our study on undernourished children (BMI<5th percentile) had
shown 63.3% sero-positivity of H. pylori in 6-10 years old children.
Our results are comparable to other Indian studies [9,10]. Studies
focused on asymptomatic children [11,12] had shown sero-positivity
between 23%-38%.The sero-positivity in other developing countries is
strikingly low[13,14]. As our study was done on undernourished
hospitalized children, we had a high sero positivity which suggests
that undernourished children should be evaluated for H pylori
infection. H pylori sero-positivity had no sex difference in our study
which is in accordance to other studies [15,16,17].
Upper gastrointestinal symptoms, recurrent abdominal pain, dyspepsia
all are said to be associated with H.pylori. Thisassumption has been
supported by some studies done in developing countries
[18,19,20,21,22].Our study has also found statistically
significant(p=0.003) association of symptoms of upper GI discomfort,
dyspepsia and recurrent abdominal pain to be associated with H pylori
sero-positivity. This observation should be considered in management of
undernourished children with recurrent abdominal pain.The mean BMI of
seropositive children was 11.99, which is less than 5th centile, as
well as significantly (p<0.005)low as compared to seronegative
children. This observation suggests that H.pylori infection further
compromises the already undernourished state of children. Therefore
undernourished children management guidelines should alsoincorporate
eradication of H pylori from stomach.The proportion of undernourished
children belonging to lower socioeconomic status was sero-positive for
H pylori whereas upper class children even when undernourished were
seronegative. This association of socioeconomic status with
sero-positivity is significant, which is corroborated in other studies
done in developing countries[23,15].Our studyfound significant relation
of overcrowding with H pylori sero-positivity. The mean over crowding
index was 2.7 in seropositive children. This relation of overcrowding
with seroprevalance is significant as our study had undernourished
children only.The factors, which contribute to prevalence of
undernourishment, were present in both sero-positive and sero-negative
group therefore the association of overcrowding with H pylori
sero-positivity cant be associated with malnutrition only.Study from in
Bangladesh [21] compared malnourished and non-malnourished children
have concluded that factors contributing to malnourishment are also
associated with H. pylori seroprevalance. Hematological parameters,
which we studied, were hemoglobin levels, RDW and peripheral smear. The
mean Hemoglobin was significantly less in undernourished children who
were seropositive as compared to seronegative children. The association
of anemia with H pylori has been well established in various studies
and is attributed to, mal-absorption of iron because of increase in
gastric pH and interference in ascorbic acid secretion [24].
Conclusion
We conclude that H pylori infection in already undernourished children
further compromises their nutritional status and hematological
parameters. As ours is a hospital based study the results can not be
extrapolated for community but this can help in planning larger
community based studies so as to make policy which will incorporate the
regimen for H pylori eradication in the management of undernourished
children who present with gastrointestinal symptoms.
Funding:
Nil, Conflict of
interest: Nil
Permission from IRB:
Yes
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How to cite this article?
Malik S, Sharma S, Dwivedi R, Seroprevalance of
Helicobacter pylori in undernourished children: A hospital based study
: Iraq: Int J Pediatr Res 2016;3(3):148-152.
doi:10.17511/ijpr.2016.3.03.