Association between Helicobacter pylori Infection and Iron Deficiency Anemia in School-aged Iranian Children

research paper

Indian Pediatr 2019;56: 387-389

Association between Helicobacter pylori Infection and Iron Deficiency Anemia in School-aged Iranian Children

Mozhgan Zahmatkeshan¹, Mehran karimi², Bita Geramizadeh³, Somayeh Eslaminasab⁴, Atefeh Esmailnejad⁵ and Ali Reza Safarpour¹

From ¹Gastroenterohepatology Research Center, ²Hematology Research Center, ³Transplant Research Center, and ⁴Department of Pediatrics, Shiraz University of Medical Science, Shiraz, Iran; and ⁵Department of Pathobiology, School of Veterinary Medicine, Shiraz University, Shiraz, Iran.

Correspondence to: Dr Ali Reza Safarpour, Department of Internal Medicine, Gastroenterohepatology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.
Email: [email protected]

Received: July 16, 2018;
Initial review: January 03, 2019:
Accepted: March 19, 2019.

Objective: To find the relationship between Helicobacter pylori infection and iron deficiency anemia in school-aged children. Methods: 71 children with dyspepsia, epigastric and vague abdominal pain attending a tertiary medical center in Iran underwent upper gastrointestinal endoscopy and were investigated for H. Pylori infection. Hemoglobin, mean corpuscular volume (MCV), serum ferritin, total iron binding capacity (TIBC) and serum iron levels were compared between children with or without H. pylori infection. Results: H. pylori infection was detected in 42 (59.1%) patients. Proportion of children with iron deficiency anemia was not statistically different between two groups (26.2% vs. 14.3%; P=0.48). While hemoglobin was significantly lower in children with H. pylori infection (P=0.01), there were no significant differences in serum level of ferritin, iron, mean corpuscular volume and total iron binding capacity. Conclusion: Presence of H. pylori does not seem to play an important role in the pathophysiology and development of iron deficiency anemia in school-aged Iranian population.

Keywords: Complications, Endoscopy, School children.

Iron deficiency anemia is among the most common nutritional deficiencies in the world, with an estimated prevalence of more than 50% in children living in developing countries [1]. Although poor nutritional status, lack of access to iron supplements and parasitic infestations have been proposed as major etiologies of iron deficiency anemia in children [1,2], infections agents have also been reported as contributory factors [3]. Epidemiological studies have demonstrated that the prevalence of Helicobacter pylori infection is extremely high in the areas with high prevalence of iron deficiency anemia [4-6]. Patients infected with H. pylori are considered at a higher risk of iron deficiency and reduced iron reserves [7,8]. On the other hand, some studies have shown that resolution of H. pylori infection would not significantly improve the iron status or reduce the iron deficiency anemia in young children [9,10]. Thus, the exact relationship between H. pylori infection and iron deficiency anemia is still a matter of debate. This study aimed to evaluate the association between H. pylori infection and iron deficiency anemia in school-aged Iranian children.

Methods

This cross-sectional study was conducted in the Pediatric Gastroenterology Ward at Namazi Hospital, Shiraz University of Medical Sciences, Iran, between November 2016 and May 2017. All children (age <18 y) who were referred due to dyspepsia, epigastric and vague abdominal pain and had not responded to medical therapy (high dose H2 blockers or proton pump inhibitors (PPI) were included. Patients having celiac disease, chronic or hemorrhagic diseases, weight loss or inappropriate weight gain, chronic diarrhea, intractable vomiting, recent PPI or acid suppression therapy, and gastrointestinal bleeding were excluded. All experimental procedures were approved by the Ethical Committee of Shiraz University of Medical Sciences. Written informed consent was obtained from the parents or guardians.

Detailed dietary history and history of intake of iron supplements in the first two years of life was recorded. All partcipants underwent an upper gastrointestinal endoscopy, and two biopsy specimens were obtained from the gastric antrum. The diagnosis of H. pylori infection was based on presence of H. pylori in the histopathological specimen, and concurrent positive rapid urease examination. According to the above mentioned criteria, patients were divided into two study groups: H. pylori positive and H. pylori negative.

Hematological studies included hemoglobin (Hb), hematocrit, mean corpuscular volume (MCV), mean corpuscular hemoglobin (MCH), and mean corpuscular hemoglobin concentration (MCHC) were recorded for all patients. Serum ferritin level was measured using electro chemiluminescence (Elec Sys 2010 analyzer; Roche Diagnostics, Mannheim, Germany), and Serum iron level and total iron binding capacity (TIBC) were determined by CobasIntegra700 analyzer (Roche Diagnostics, Basel, Switzerland). Iron deficiency anemia (IDA) was defined as serum ferritin level of <10 µg/L along with hemoglobin level <-2SD for age [11].

Statistical analyses were performed using SPSS software, version 19 (SPSS Inc., Chicago, IL, USA). Independent student t test was used for comparison of quantitative variables between groups. Chi-square or Fisher’s exact test was used to compare the proportions. P<0.05 was considered statistically significant.

Results

Seventy-one children (27 boys) with a mean (SD) age of 8 (4.2) years were evaluated. Demographic characteristics of all patients are presented in Table I. H. pylori infection was detected in 42 (59.1%) participants. Proportion of children with IDA was comparable between H. pylori positive and negative patients (26.2% vs. 14.3%; P=0.48). Serum level of hemoglobin was significantly different between two study groups (P=0.01). No significant differences were observed regarding MCV, TIBC, serum ferritin and serum iron levels between H. pylori positive and negative patients (Table II).

TABLE I	Demographic Characteristic of H. pylori Positive and Negative Iranian School Children

	H. pylori positive	H. pylori negative	P value
	(n=42)	(n=29)
Age (y)*	8.5 (4.2)	8.9 (4.3)	0.88
Male sex*	16 (38.1)	11 (37.9)	0.33
Weight	26.6 (12.9)	31.2 (14.1)	0.40
Body mass index	16.7 (3.2)	17.1 (3.2)	0.62

TABLE II	Hematological Indices in H. pylori Positive and Negative Iranian School Children

	H. pylori positive	H. pylori negative	P value
	(n=42)	(n=29)
Low (<10 µg/L) ferritin*	0	5 (14.3)	0.06
Low serum iron*	14 (34.1)	9 (31.1)	1.00
MCV	87.9 (5.99)	77.9 (6.71)	0.85
Hemoglobin (g/dL)	12.1 (1.3)	12.9 (1.2)	0.01
Low TIBC*	1 (2.4)	0	1.00
Data presented as mean (SD) on n (%); MCV: mean corpuscular volume; TIBC: total iron binding capacity.*

Discussion

In the present study, no significant association was found between H. pylori infection and iron deficiency anemia in a group of Iranian school-aged children. Though the mean hemoglobin was lower in H.pylori positive cases, the difference was not significant for other hematological parameters, including serum ferritin, MCV and TIBC.

These results should be interpreted with caution in view of small sample size and observational data. Larger studies and interventional trials may further clarify association between iron deficiency and H. pylori infection in children. These results are in contrast with some recent studies indicating some associations between H. pylori infection and iron deficiency anemia [7,8]. However, in agreement with our findings, H. pylori seropositivity was not associated with iron deficiency in Estonian children aged 7–18 years [9]. H. pylori infection was neither a cause of iron deficiency anemia nor a reason for treatment failure of iron supplementation in Bangladeshi children [10]. Zamani, et al. [12] also reported no significant association between serum ferritin level and antibody titer against H. pylori bacteria in school-aged children in Tehran province, Iran. Variations among different studies might be as a result of confounding variables such as different species of H. pylori bacteria. Cag-PAL positive isolates are mostly associated with peptic ulcer and gastrointestinal symptoms, while some H. pylori species are related to the gastric ulcer and iron deficiency anemia [13]. Furthermore, serum ferritin which is used for identifying the iron deficiency anemia is an acute phase protein and its level is influenced by other factors besides iron deficiency.

In conclusion, presence of Helicobacter pylori may not play an important role in the pathophysiology and development of iron deficiency anemia in school-aged Iranian population. At present, severity for H. pylori infection in children with iron deficiency anemia is not justified.

Contributors: MZ and BC: conception and design of study, interpretation of data; MK: acquisition, analysis, and interpretation of data; BG: design of study, interpretation of data; SE: acquisition of data, drafting the manuscript; AE: experimental procedures, statistical analysis of the manuscript; ARS: conception and design of study, critical revision of the manuscript for important intellectual content. He could also be approached for access to the raw data. All authors contributed to, and approved the final version of the manuscript.

Funding: None; Competing interest: None stated.

What This Study Adds?

• The presence of Helicobacter pylori infection may not play an important role in the pathophysiology and development of iron deficiency anemia in children.

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