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

H. pylori Treatment in Children

First-Line Treatment Recommendation

In children with H. pylori infection, use triple therapy with a PPI, amoxicillin (50 mg/kg/day), and either clarithromycin (30 mg/kg/day) or metronidazole (25 mg/kg/day) for 14 days, avoiding tetracycline and fluoroquinolones which are contraindicated in pediatric populations. 1

Specific Pediatric Treatment Regimens

Primary Option: PPI + Amoxicillin + Metronidazole

• Amoxicillin 50 mg/kg/day (maximum 1 g twice daily) 2, 3
• Metronidazole 25 mg/kg/day (for double-resistant strains, high-dose regimen) 3
• Esomeprazole ~1.5 mg/kg/day (or equivalent PPI twice daily) 3
• Duration: 14 days to maximize eradication rates 1
• This regimen achieved 73% eradication in children with double-resistant strains and 90% eradication for metronidazole-susceptible strains 3, 4

Alternative Option: PPI + Amoxicillin + Clarithromycin

• Amoxicillin 50 mg/kg/day (maximum 1 g twice daily) 5
• Clarithromycin 30 mg/kg/day (maximum 500 mg twice daily) 5
• Omeprazole 0.6 mg/kg/day (or equivalent PPI, maximum 20 mg twice daily) 5
• Duration: 14 days 1
• This regimen achieved 73% eradication with 10-day therapy in pediatric studies 5
• Use only in areas with clarithromycin resistance <15% 1

Critical Pediatric-Specific Contraindications

• Tetracycline is contraindicated in children <8 years due to tooth discoloration and bone growth alterations 2
• Fluoroquinolones (levofloxacin) are not licensed for children and should be avoided 3
• Bismuth subsalicylate requires caution in children with suspected viral infections (Reye's syndrome risk) 2

Optimizing Treatment Success in Children

PPI Dosing

• High-dose PPI twice daily significantly increases eradication efficacy by 6-10% 1
• Esomeprazole or rabeprazole preferred when available 1
• Administer 30 minutes before meals 1

Treatment Duration

• 14-day regimens are superior to 7-day regimens, improving eradication by approximately 5% 1
• Studies show 73% success with 10-day therapy versus 50% with 7-day therapy in children 5

Bismuth-Based Regimens (When Appropriate)

• For children >10 years: Amoxicillin 50 mg/kg/day + bismuth subsalicylate 525 mg four times daily for 6 weeks 2
• For children <10 years: Amoxicillin 50 mg/kg/day + bismuth subsalicylate 262 mg four times daily for 6 weeks 2
• Bismuth resistance is extremely rare, making this effective against metronidazole-resistant strains 1

Second-Line Treatment After Failure

If First-Line Triple Therapy Fails

• Switch antibiotic combinations: If clarithromycin was used first, switch to metronidazole-based regimen (or vice versa) 1
• Avoid repeating previously used antibiotics, especially clarithromycin 1
• Consider high-dose metronidazole regimen (25 mg/kg/day) for 14 days, which can overcome in vivo resistance 3

After Two Failed Attempts

• Antimicrobial susceptibility testing should guide further treatment whenever possible 1
• Susceptibility testing is particularly valuable after treatment failures, though may not significantly improve first-line success rates 4

Adjunctive Therapy

Probiotics

• Consider probiotics to reduce antibiotic-associated side effects, particularly diarrhea 1, 6
• Probiotics reduce adverse events and improve compliance but have limited evidence for increasing eradication rates 1, 6
• Most beneficial when added to standard triple therapy 6

Verification of Eradication

• Confirm eradication with C-urea breath test at least 4 weeks after completion of therapy 1, 4
• Discontinue PPI at least 2 weeks before testing to avoid false-negative results 1
• Never use serology to confirm eradication as antibodies persist long after successful treatment 1

Common Pitfalls and Adverse Effects

Side Effect Profile

• Mild to moderate adverse events occur in approximately 34% of children, including nausea (10.8%), diarrhea (8.9%), vomiting (7.1%), and abdominal pain (5.4%) 3
• Side effects rarely lead to discontinuation (1.6% in studies) 3
• Probiotics can reduce these side effects and improve adherence 1, 6

Treatment Failures

• Clarithromycin resistance (15% of isolates) completely abolishes treatment efficacy when present 4
• Metronidazole resistance (31% of isolates) reduces eradication from 90% to 42% but can be partially overcome with high-dose therapy 4
• Inadequate PPI dosing significantly reduces efficacy—always use twice-daily dosing 1

Special Considerations

• Treatment should only be conducted by pediatric gastroenterologists in specialist centers for optimal outcomes 1
• Penicillin allergy: If amoxicillin cannot be used, consider bismuth-based regimens with metronidazole (avoiding tetracycline in young children) 1, 2
• Body weight >15 kg required for standard dosing regimens 3