Initial Treatment for Gastritis in a 14-Year-Old
For a 14-year-old with gastritis, start with a proton pump inhibitor (PPI) at 1 mg/kg/day of omeprazole (up to 40 mg/day) taken 30 minutes before meals, and test for H. pylori infection using a non-invasive urea breath test or stool antigen test. 1, 2, 3, 4
First-Line Acid Suppression Therapy
Omeprazole is the most appropriate PPI for pediatric patients, as it has established safety and effectiveness in children aged 2-16 years for treatment of acid-related gastric conditions 5. The initial dosing should be:
- Start with 1 mg/kg/day of omeprazole (maximum 40 mg/day), which has been consistently shown to heal esophagitis and provide symptom relief in pediatric patients 4
- Administer 30 minutes before meals for optimal effectiveness 2, 6
- Treatment duration should be 4-8 weeks initially, with response re-evaluated at that time 1, 2
The FDA has approved omeprazole for pediatric patients 2 years and older, and studies have demonstrated its use in children as young as 2 months with a low incidence of adverse effects 5, 4. Higher-potency PPIs like esomeprazole and rabeprazole are also FDA-approved for patients 1 year and older, but omeprazole has the most extensive pediatric safety data 1, 5.
Mandatory H. pylori Testing
All patients with gastritis must be tested for H. pylori infection using non-invasive methods 2, 6, 3:
- Urea breath test (preferred) 3
- Monoclonal stool antigen test (alternative) 2, 3
- Avoid serological testing as it remains positive after successful treatment and cannot confirm eradication 3
H. pylori infection is the causative agent in the vast majority of pediatric gastritis cases, and eradication prevents progression to peptic ulcers and potentially gastric cancer in adulthood 4, 7.
If H. pylori Positive: Eradication Therapy
If H. pylori is detected, initiate bismuth quadruple therapy for 14 days (not shorter, as this significantly reduces eradication rates) 2, 6, 3:
- PPI (omeprazole 1 mg/kg twice daily, up to 40 mg twice daily) 1
- Bismuth subsalicylate
- Metronidazole
- Tetracycline (if age-appropriate; use amoxicillin as alternative in younger children) 2, 3
Confirm eradication 4-6 weeks after completing therapy using non-serological testing (urea breath test or stool antigen), as relying solely on symptom resolution can lead to persistent infection and complications 6, 3.
If NSAID-Induced Gastritis
Immediately discontinue NSAIDs if possible 2, 6, 3. If NSAIDs must be continued for a compelling medical reason:
- Add PPI therapy for gastroprotection 2, 6
- Test and treat H. pylori before initiating long-term NSAID therapy, especially in patients with prior peptic ulcer history 6, 3
Adjunctive Symptomatic Relief
Antacids can be used on-demand for breakthrough symptoms while awaiting PPI therapeutic effect, as they provide rapid but temporary relief 2, 6, 3.
Critical Pitfalls to Avoid in Pediatric Gastritis
- Do not use PPIs without testing for H. pylori first - missing the infection leads to persistent disease 2, 3
- Do not use antibiotic therapy for less than 14 days - this significantly reduces eradication rates 2, 3
- Do not rely on symptom resolution alone - always confirm H. pylori eradication with objective testing 6, 3
- Do not use H2-receptor antagonists (like ranitidine) as first-line therapy - they are less effective than PPIs for healing gastric lesions and develop tachyphylaxis within 6 weeks 1, 6
- Avoid inadequate PPI dosing - ensure proper timing (30 minutes before meals) and adequate duration (4-8 weeks minimum) 2, 6
Expected Clinical Course
Gradual improvement of symptoms with fluctuations is expected over the 4-8 week treatment period 6. If symptoms persist despite appropriate PPI therapy and confirmed H. pylori eradication, consider endoscopic evaluation to rule out other causes such as autoimmune gastritis, which would require screening for antiparietal cell antibodies, anti-intrinsic factor antibodies, and vitamin B-12/iron deficiencies 6, 3.