What is the treatment for peptic ulcer disease in a child?

Treatment of Peptic Ulcer Disease in Children

The treatment of peptic ulcer disease in children should follow a stepwise approach with proton pump inhibitors (PPIs) as the primary pharmacological therapy, along with H. pylori eradication when indicated.

First-Line Pharmacological Therapy

Proton Pump Inhibitors (PPIs)

• Dosing recommendations:

  • Omeprazole: 0.7-3.3 mg/kg/day (maximum 80 mg/day) 1
  • Lansoprazole: 0.7-3.0 mg/kg/day (maximum 30 mg/day) 2
  • Esomeprazole: 0.7-3.3 mg/kg/day 1
  • Rabeprazole: 20 mg daily (only FDA approved for children 12-17 years) 1

• Duration: Initial treatment for 4-8 weeks, with gastric ulcers potentially requiring 8 weeks of treatment 3

• Formulations: Available as tablets, capsules that can be opened and sprinkled on soft foods, and oral suspensions for younger children 1

H2-Receptor Antagonists (H2RAs)

May be used as alternative therapy, though less effective than PPIs:

• Ranitidine: 5-10 mg/kg/day divided in 2-3 doses 1
• Famotidine: 1 mg/kg/day divided in 2 doses 1
• Cimetidine: 30-40 mg/kg/day divided in 4 doses (≥16 years) 1

Note: H2RAs have limitations including tachyphylaxis within 6 weeks of treatment initiation and are less effective than PPIs for symptom relief and healing 1

H. pylori Eradication (When Positive)

First-Line Eradication Therapy

Standard triple therapy for 14 days 1, 4:

• PPI (weight-appropriate dose, twice daily)
• Amoxicillin (1000 mg twice daily for adolescents; weight-based for younger children)
• Clarithromycin (500 mg twice daily for adolescents; weight-based for younger children)

Alternative First-Line (High Clarithromycin Resistance Areas)

Sequential therapy for 10 days 1, 4:

• Days 1-5: PPI + Amoxicillin
• Days 6-10: PPI + Clarithromycin + Metronidazole

Second-Line Therapy (If First-Line Fails)

10-day levofloxacin-based triple therapy 1, 4:

• PPI (standard dose twice daily)
• Levofloxacin (500 mg once daily or 250 mg twice daily)
• Amoxicillin (1000 mg twice daily)

Special Considerations

For Bleeding Ulcers

• Start with intravenous PPI administration
• Transition to oral triple therapy after 72-96 hours 1, 4

Age-Specific Considerations

• Infants (<1 year): Limited FDA approval for PPIs; omeprazole, lansoprazole, and esomeprazole approved for ages 1 year and older 1, 5
• Children 1-12 years: Weight-based dosing of PPIs
• Adolescents (12-17 years): Adult dosing may be appropriate based on weight

Monitoring and Follow-up

• Assess symptom improvement after 2 weeks
• Consider endoscopic follow-up for complicated cases or non-responders
• For H. pylori, confirm eradication with urea breath test or stool antigen test 4-8 weeks after completing therapy

Common Pitfalls and Caveats

1. Overuse of PPIs in infants: PPIs have not demonstrated superiority over placebo for reduction in irritability in infants and should be used cautiously 1

2. Adverse effects of PPIs: Headaches, diarrhea, constipation, and nausea occur in up to 14% of children 1

3. Long-term PPI use concerns: Enterochromaffin cell hyperplasia has been demonstrated in up to 50% of children receiving PPIs for more than 2.5 years 1

4. Acid suppression risks: Both H2RAs and PPIs may increase risk of community-acquired pneumonia, gastroenteritis, and other infections in children 1

5. H. pylori testing: Ensure proper testing before initiating eradication therapy to avoid unnecessary antibiotic exposure

By following this treatment approach, peptic ulcer disease in children can be effectively managed with high healing rates of 80-100% within 4-8 weeks 3.