What is the recommended treatment regimen for Helicobacter pylori (H. pylori) infection in children?

H. pylori Diagnosis and Treatment in Children

Diagnostic Approach in Pediatric Patients

In children with suspected H. pylori infection, obtain endoscopic antral biopsies for culture and histology, as this remains the gold standard for diagnosis in the pediatric population. 1, 2

• Endoscopic biopsy-based testing is the preferred diagnostic method in children, allowing for both culture and histologic examination of antral specimens 2
• Serologic testing can be used as a sensitive and specific indicator of H. pylori infection, but children's sera must be used to standardize the assay for accurate results 2
• Urea breath tests (13C) are highly accurate noninvasive options but are expensive and may be less practical in pediatric settings 2
• Stool antigen testing using laboratory-based validated monoclonal assays is an alternative noninvasive option 1, 3

Critical Testing Considerations

• Discontinue any acid-suppressing medications (PPIs, H2-blockers) or sucralfate for at least 4 weeks before testing to avoid false-negative results 3
• Antibiotics should be stopped at least 4 weeks prior to testing 3

First-Line Treatment Regimens for Children

For pediatric H. pylori infection, prescribe either PPI-amoxicillin-metronidazole triple therapy, PPI-amoxicillin-clarithromycin triple therapy, or bismuth-amoxicillin-metronidazole therapy for 14 days, with clarithromycin susceptibility testing strongly recommended before using clarithromycin-based regimens. 1

Specific Pediatric Treatment Options

• PPI + amoxicillin + metronidazole for 14 days is a first-line option 1
• PPI + amoxicillin + clarithromycin for 14 days, but only after confirming clarithromycin susceptibility 1
• Bismuth salts + amoxicillin + metronidazole for 14 days is an effective alternative 1
• Sequential therapy may be considered as a first-line option 1

Critical Pediatric Limitations

• Fluoroquinolones (including levofloxacin) cannot be used in children due to concerns about cartilage toxicity 1
• Tetracyclines are contraindicated in children due to effects on developing teeth and bones 1
• These restrictions significantly limit treatment options compared to adults, making first-line success even more critical 1

Dosing Considerations

• Use high-dose PPI twice daily (equivalent to 40 mg rabeprazole or esomeprazole twice daily in adults; adjust for pediatric weight-based dosing) 3
• Amoxicillin dosing in children typically ranges from 0.7 to 3.3 mg/kg daily based on clinical studies, though specific pediatric ulcer studies show effective ranges 1
• Treatment duration should be 14 days to maximize eradication rates 1, 3

Second-Line Treatment After First-Line Failure

After first-line treatment failure in children, prescribe bismuth-containing quadruple therapy for 14 days if not previously used, as this avoids fluoroquinolones and tetracyclines that are contraindicated in pediatric patients. 1

• Bismuth quadruple therapy (bismuth + PPI + metronidazole + tetracycline in adults) must be modified for children by substituting amoxicillin for tetracycline 1
• Susceptibility testing is strongly recommended after first-line failure to guide antibiotic selection 1
• Avoid repeating antibiotics the child has already been exposed to 1

Third-Line and Rescue Therapy

After two treatment failures, obtain gastric biopsy specimens for H. pylori culture and antimicrobial susceptibility testing to guide further therapy. 1, 3

• Culture-directed therapy is essential at this stage because resistance patterns become unpredictable 1
• Consider increasing both dose and duration of therapy for rescue attempts 1
• Rifabutin-based regimens may be an option in children after multiple failures, though data are limited 3

Confirmation of Eradication

Confirm H. pylori eradication at least 4 weeks after completing treatment using urea breath test or monoclonal stool antigen test. 1, 3

• Wait at least 4 weeks after completing eradication therapy before testing 1, 3
• Ensure the child is off PPIs, H2-blockers, antibiotics, and bismuth for at least 4 weeks before confirmation testing 3
• Serology has no role in confirming eradication as antibodies remain positive for months to years 1
• If the child had a gastric ulcer or MALT lymphoma, endoscopic follow-up with biopsy-based testing is necessary 1, 3

Adjunctive Therapy

• Probiotics (particularly Lactobacillus species) may be added to reduce antibiotic-related side effects, especially diarrhea, and may modestly improve eradication rates by 5-10% 1
• Probiotics are particularly useful in children who may have difficulty tolerating multi-drug regimens 1

Key Clinical Pitfalls to Avoid

• Never use fluoroquinolones or tetracyclines as first- or second-line therapy in children 1
• Do not test for H. pylori while the child is on acid suppression or within 4 weeks of stopping it 3
• Do not use clarithromycin empirically in areas of high resistance (>15%) without susceptibility testing 1
• Do not rely on serology to confirm eradication 1
• Do not prescribe treatment durations shorter than 14 days as this significantly reduces eradication success 1, 3

Special Considerations in Pediatric H. pylori

• Most infected children remain asymptomatic, making the decision to test and treat more nuanced than in adults 2
• Testing is most appropriate in children with documented peptic ulcer disease, unexplained iron deficiency anemia, or first-degree relatives with gastric cancer 3, 2
• Intrafamilial clustering is common, so consider testing household contacts if one child is infected 2
• Children in underdeveloped countries or poor social conditions have much higher infection rates at younger ages 2