What is the recommended treatment for peptic ulcers in children?

Treatment of Peptic Ulcer Disease in Children

Initiate proton pump inhibitor (PPI) therapy immediately at a dose of 1 mg/kg/day (maximum 20-40 mg daily) for 6-8 weeks, test all children for H. pylori infection, and eradicate if positive using standard triple therapy for 14 days. 1, 2

Initial Pharmacological Management

Start PPI therapy as soon as peptic ulcer is diagnosed in children. The most consistently effective initial dose for healing ulcers and providing symptom relief is 1 mg/kg per day, with a typical range of 0.3-3.5 mg/kg/day depending on severity 2. Standard dosing translates to omeprazole 20 mg, lansoprazole 30 mg, or pantoprazole 40 mg once daily for 6-8 weeks to achieve complete mucosal healing 1.

For Bleeding Peptic Ulcers

• Administer high-dose PPI therapy: 80 mg bolus followed by 8 mg/hour continuous infusion for 72 hours, then transition to standard oral PPI therapy 1, 3
• Perform urgent endoscopy for diagnosis and hemostasis—PPIs should not replace endoscopy in active bleeding 1
• Consider pre-endoscopy erythromycin to improve visualization and reduce need for repeat procedures 1, 3

Helicobacter pylori Testing and Eradication

Test all children with peptic ulcers for H. pylori infection, as failure to eradicate leads to 40-50% recurrence rates over 10 years 1, 4. This single omission accounts for the majority of treatment failures 1.

First-Line Eradication Therapy (Low Clarithromycin Resistance Areas)

Standard triple therapy for 14 days 5, 1:

• PPI standard dose twice daily
• Clarithromycin 500 mg twice daily (dose-adjust for pediatric weight)
• Amoxicillin 1000 mg twice daily (dose-adjust for pediatric weight)
• Alternative: Metronidazole 500 mg twice daily if penicillin-allergic

Start this regimen after 72-96 hours of intravenous PPI administration in complicated cases 5, 6.

Sequential Therapy (High Clarithromycin Resistance Areas)

10-day sequential therapy 5, 3:

• Days 1-5: PPI twice daily + Amoxicillin 1000 mg twice daily
• Days 6-10: PPI twice daily + Clarithromycin 500 mg twice daily + Metronidazole 500 mg twice daily

Second-Line Therapy (If First-Line Fails)

10-day levofloxacin-amoxicillin triple therapy 5:

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

Confirm eradication after completing treatment to prevent recurrence 1, 3.

NSAID-Associated Peptic Ulcers in Children

• Discontinue NSAID therapy whenever clinically feasible—this is the most effective intervention, healing 95% of ulcers and reducing recurrence from 40% to 9% 1, 4
• If NSAIDs must be continued, maintain PPI therapy long-term to prevent recurrence 1, 3
• Consider switching to selective COX-2 inhibitors with lower gastric toxicity if age-appropriate 3

Duration of PPI Therapy

• Standard uncomplicated ulcers: 6-8 weeks of PPI therapy 1, 2
• Gastric ulcers >2 cm: May require 8 weeks of treatment 4
• Long-term PPI therapy: Only indicated for children requiring continuous NSAID therapy or those with recurrent ulcers despite H. pylori eradication 1, 3

Critical Pitfalls to Avoid

Never skip H. pylori testing—this accounts for the majority of treatment failures and recurrences 1. The eradication of H. pylori decreases recurrence rates from 50-60% to 0-2% 4.

Do not use PPIs as a substitute for urgent endoscopy in children with signs of active bleeding (hematemesis, melena, hemodynamic instability) 1, 3.

Avoid H2-receptor antagonists as first-line therapy in children—they are ineffective for gastric ulcers at standard doses 1. PPIs have emerged as the most significant advancement in acid-peptic disease management and are superior to H2-receptor antagonists, particularly in children who have failed previous H2-blocker therapy 2, 7.

Be aware of PPI drug interactions—PPIs may reduce absorption of medications requiring acidic environments (ketoconazole, iron, certain antiretrovirals) 1.

Safety Profile in Children

PPIs have been administered to children aged 2 months to 18 years at dosages of 0.2-3.5 mg/kg/day for periods ranging from 14 days to 36 months with a low incidence of adverse effects 2. Few severe adverse events have been reported with omeprazole or lansoprazole use in pediatric populations 8. However, long-term safety studies are still needed in children 8.

Monitoring and Follow-Up

• Most children requiring endoscopic hemostasis for high-risk stigmata should be hospitalized for at least 72 hours, as 60-76% of rebleeding episodes occur within this timeframe 3
• After initial healing, discharge with single daily-dose oral PPI for duration dictated by underlying etiology 3
• Confirm H. pylori eradication after treatment completion to ensure successful therapy 1, 3