What is the recommended treatment for Helicobacter pylori (H. pylori) infection in pediatric patients?

H. pylori Treatment in Pediatric Patients

First-Line Treatment Regimens

The American College of Gastroenterology recommends prescribing either PPI-amoxicillin-metronidazole triple therapy, PPI-amoxicillin-clarithromycin triple therapy, or bismuth-amoxicillin-metronidazole therapy for 14 days to treat H. pylori infection in children, with clarithromycin susceptibility testing strongly recommended before using clarithromycin-based regimens. 1

Specific Dosing for Pediatric Patients

• High-dose PPI twice daily is mandatory, equivalent to 40 mg rabeprazole or esomeprazole twice daily in adults, with dosing adjusted for pediatric weight-based dosing 1
• Proper weight-based dosing of amoxicillin and PPI is critical for successful eradication—when amoxicillin was properly weight-dosed, eradication was achieved in 81% versus only 53.8% when improperly dosed 2
• Amoxicillin dosing in children typically ranges from 0.7 to 3.3 mg/kg daily based on clinical studies, though the standard recommendation is 50 mg/kg/day 1, 3
• Treatment duration must be 14 days to maximize eradication rates 1

Critical Medication Restrictions in Children

• Fluoroquinolones, including levofloxacin, cannot be used in children due to concerns about cartilage toxicity 1
• Tetracyclines are contraindicated in children younger than 8 years due to effects on developing teeth and bones 1, 3
• Bismuth subsalicylate should be used with caution in children with suspected viral infections to prevent Reye's syndrome 3

Diagnostic Approach

• The American Academy of Pediatrics recommends obtaining endoscopic antral biopsies for culture and histology as the gold standard for diagnosis in the pediatric population 1
• Stool antigen testing using laboratory-based validated monoclonal assays is an alternative noninvasive option for diagnosing H. pylori infection in children 1
• Testing and eradication therapy are recommended only for the subset of pediatric patients in whom there is a high suspicion of peptic ulcer disease, as most H. pylori infections in children are asymptomatic despite microscopic gastric inflammation 4

Confirmation of Eradication

• The American Gastroenterological Association recommends confirming H. pylori eradication at least 4 weeks after completing treatment using urea breath test or monoclonal stool antigen test 1
• Serology has no role in confirming eradication as antibodies remain positive for months to years 1
• Patients should be tested again after treatment to confirm eradication 4

Adjunctive Therapy

• Probiotics, particularly Lactobacillus species, may be added to reduce antibiotic-related side effects and may modestly improve eradication rates by 5-10% 1
• Available data in children indicate that probiotics are efficacious for the prevention of antibiotic-associated side effects and might help decrease H. pylori density and gastritis 5

Common Pitfalls to Avoid

• Improper weight-based dosing is extremely common—studies show high rates of improper dosing: PPI 31.2%, amoxicillin 31.7%, metronidazole 19.4%, clarithromycin 23.9% 2
• When PPIs were properly weight-dosed, eradication rate was 78.8% that dropped to 62.2% with suboptimal dosing 2
• Treatment should only be conducted by pediatricians in specialist centers 6
• Do not test or treat children with functional abdominal pain without evidence of peptic ulcer disease, as studies do not support the role of H. pylori infection in functional disorders such as recurrent abdominal pain 4

Special Considerations for Antibiotic Selection

• Clarithromycin resistance is increasing globally, making susceptibility testing essential before using clarithromycin-based regimens 1
• If bismuth subsalicylate is unavailable or contraindicated, bismuth subcitrate can be used at appropriate weight-based doses 3
• Tinidazole 20 mg/kg/day can be used with amoxicillin 50 mg/kg/day for 6 weeks if available 3