H. pylori Treatment in Pediatric Patients
The recommended first-line treatment regimen for pediatric patients with H. pylori infection is a 14-day triple therapy consisting of a proton pump inhibitor (PPI) with amoxicillin and clarithromycin, with dosing adjusted by weight. 1
First-Line Treatment Options
Triple Therapy (Preferred First-Line)
- PPI: 1-2 mg/kg/day divided twice daily (max 40 mg twice daily)
- Amoxicillin: 50 mg/kg/day divided twice daily (max 1g twice daily)
- Clarithromycin:
- Children <10 years: 7.5 mg/kg twice daily (max 250 mg twice daily)
- Children ≥10 years: 500 mg twice daily
- Duration: 14 days
This regimen has shown better eradication rates when used for a full 14-day course compared to shorter durations 1, 2.
Alternative First-Line (for penicillin allergy or high clarithromycin resistance areas)
- Bismuth-based quadruple therapy:
- PPI: 1-2 mg/kg/day divided twice daily
- Bismuth subsalicylate:
- <10 years: 262 mg four times daily
- ≥10 years: 525 mg four times daily
- Metronidazole: 20 mg/kg/day divided twice daily
- Alternative to tetracycline (which is contraindicated in children <8 years): Amoxicillin 50 mg/kg/day divided twice daily
- Duration: 14 days
Treatment Considerations
Antibiotic Resistance
- Clarithromycin resistance is increasing globally and significantly reduces eradication rates 1
- In areas with high clarithromycin resistance (>15-20%), bismuth-based quadruple therapy should be considered as first-line 1
- Antibiotic susceptibility testing should be considered after first-line treatment failure 1
Age-Specific Considerations
- Children <8 years: Avoid tetracycline due to risk of tooth discoloration and bone growth alterations 3
- Adolescents: Can follow adult dosing guidelines when appropriate by weight 1
Medication Cautions
- Bismuth subsalicylate should be used with caution in children with suspected viral infections due to risk of Reye's syndrome 3
- Monitor for side effects, which commonly include nausea (10.8%), diarrhea (8.9%), vomiting (7.1%), and abdominal pain (5.4%) 4
Second-Line Treatment (Salvage Therapy)
For patients who fail first-line therapy:
- High-dose triple therapy:
- Amoxicillin: 75 mg/kg/day divided twice daily
- Metronidazole: 25 mg/kg/day divided twice daily
- PPI (e.g., esomeprazole): 1.5 mg/kg/day divided twice daily
- Duration: 14 days
This high-dose regimen has shown 73% eradication rates in per-protocol analysis for children with double-resistant H. pylori strains 4.
Follow-Up Testing
- Test for eradication at least 4 weeks after completing treatment 1
- Stop PPI at least 2 weeks before testing to avoid false negatives 1
- Preferred tests:
- 13C-Urea Breath Test (sensitivity 95%, specificity 90%)
- Monoclonal stool antigen test
Adjunctive Therapy
- Probiotics may be considered as adjunctive therapy to reduce side effects and potentially improve eradication rates, though more research is needed 5
- Patient/parent education about medication adherence is critical, as poor compliance significantly reduces eradication rates 1
Common Pitfalls to Avoid
- Inadequate treatment duration: 14-day regimens are superior to 7-day regimens 1, 6
- Inappropriate antibiotic selection: Using clarithromycin in high-resistance areas without susceptibility testing
- Insufficient PPI dosing: Higher-potency PPIs at appropriate weight-based doses improve eradication rates 1
- Poor adherence: Thorough patient/parent education is essential to ensure completion of the full treatment course 1
- Premature follow-up testing: Testing before 4 weeks post-treatment or while still on PPI can lead to false-negative results 1