What is the initial management for a child presenting with severe gastritis?

Management of Severe Gastritis in Children

For a child presenting with severe gastritis, immediately assess for red flag symptoms (projectile vomiting, bilious vomiting, hematemesis, blood in stool, abdominal distension, or systemic features) that require urgent investigation, then initiate dietary modifications and feeding adjustments as first-line therapy, reserving acid suppression with proton pump inhibitors for persistent symptoms after 2-4 weeks of conservative management. 1

Initial Assessment and Red Flags

When a child presents with severe gastritis symptoms, you must actively screen for warning signs that suggest more serious pathology or complications 2:

• Projectile or bilious vomiting - suggests obstruction or surgical pathology 2
• Hematemesis or blood in stool - indicates mucosal injury requiring endoscopy 2
• Abdominal distension or systemic features (fever, lethargy) - may represent alternative diagnoses 2
• Poor weight gain or feeding refusal - distinguishes pathologic GERD from physiologic reflux 3

The presence of any red flags warrants immediate consideration of upper gastrointestinal endoscopy with biopsy to establish the diagnosis and identify the underlying etiology 4.

First-Line Conservative Management

Begin with lifestyle and dietary modifications for 2-4 weeks before considering pharmacologic therapy 1:

Dietary Interventions

• Avoid trigger foods that exacerbate symptoms 1
• Reduce meal size and increase meal frequency to minimize gastric distension 1
• For infants: consider maternal elimination diet or hydrolyzed protein formula 1
• For infants: thickening feedings with rice cereal may reduce regurgitation 1

Important Pitfall

Do not prescribe acid suppression for uncomplicated regurgitation in infants - focus instead on parental education and reassurance about the benign, self-resolving nature of physiologic reflux 3. Unnecessary PPI use increases risks of community-acquired pneumonia, gastroenteritis, and candidemia 1, 3.

Pharmacologic Therapy (If Conservative Measures Fail)

If symptoms persist after 2-4 weeks of lifestyle modifications, escalate to acid suppression therapy 1:

Proton Pump Inhibitors (First-Line Pharmacologic Therapy)

Initiate a 2-week trial of PPIs; if symptoms improve, continue for 8-12 weeks 1:

• Omeprazole: 0.7-3.3 mg/kg/day 2, 1
• Lansoprazole: 0.7-3 mg/kg/day 2, 1

PPIs are superior to H2-receptor antagonists for symptom relief and healing of erosive esophagitis 2.

H2-Receptor Antagonists (Alternative)

If PPIs are not tolerated or available 2:

• Ranitidine: 5-10 mg/kg/day divided in 2-3 doses (ages 1 month-16 years) 2
• Famotidine: 1 mg/kg/day divided in 2 doses (ages 1-16 years) 2

Critical limitation: H2RAs develop tachyphylaxis within 6 weeks, limiting long-term efficacy 2.

Helicobacter pylori Considerations

If endoscopy is performed and reveals gastritis, obtain antral and fundic biopsies for H. pylori testing 4:

• H. pylori is the major cause of primary gastritis in children 4, 5
• Triple therapy for 7-10 days: PPI + two antibiotics (typically amoxicillin and metronidazole or clarithromycin) 4
• Eradication prevents duodenal ulcer recurrence 5

Monitoring and Follow-Up

Evaluate response to therapy after 4-8 weeks 1:

• If symptoms persist despite appropriate therapy, refer to pediatric gastroenterology for upper endoscopy and esophageal biopsy 1
• Reassess and attempt dose reduction of long-term PPI therapy to minimize adverse effects 6
• Weight loss is a crucial warning sign that should trigger immediate escalation of care 3

Critical Pitfalls to Avoid

1. Avoid overtreatment with acid suppressants - particularly in infants with physiologic reflux who need only reassurance 1, 3
2. Do not use upper GI contrast radiology to diagnose or assess severity of gastritis - reserve for specific indications like dysphagia or unexplained bilious vomiting 2
3. Recognize that many conditions mimic gastritis symptoms - careful follow-up of all treated patients is essential 1
4. Do not assume all reflux at peak age (4 months) represents pathologic disease - 90-95% resolve spontaneously by 12 months 3

Severe Dehydration Management (If Present)

If severe gastritis causes significant vomiting with dehydration 2:

• Intravenous isotonic crystalloid boluses (20 mL/kg) until pulse, perfusion, and mental status normalize 2
• Once stabilized, transition to oral rehydration solution (ORS) at 50-100 mL/kg over 3-4 hours 2
• Nasogastric ORS administration may be considered if oral intake is not tolerated 2