What is the recommended management of gastritis in children, including indications and dosing for proton pump inhibitors?

Management of Gastritis in Pediatric Patients

For true gastritis in children (not GERD), PPIs are indicated when H. pylori infection is confirmed or when gastritis is drug-induced or stress-related, typically as part of combination therapy for H. pylori eradication or for 6-8 weeks in non-H. pylori cases. 1, 2

Distinguishing Gastritis from GERD

The provided evidence focuses heavily on GERD management, but gastritis requires a different diagnostic and therapeutic approach:

• Gastritis presents with epigastric pain influenced by meals, nausea, vomiting, and weight loss 1
• Diagnosis requires upper GI endoscopy with antral and fundic biopsies for histopathology and culture 1
• Main etiologies include drug-induced gastritis, stress-related gastritis, and H. pylori infection 1

When to Use PPIs in Pediatric Gastritis

H. pylori-Positive Gastritis

• PPIs are essential components of H. pylori eradication therapy, combined with two antibiotics for 7-10 days 1
• Standard dosing for omeprazole is 0.7-3.3 mg/kg/day, given twice daily 3, 4
• Treatment duration for eradication is 7-10 days as part of triple therapy 1
• H. pylori testing is only justified in children with digestive symptoms requiring endoscopy 1

Non-H. pylori Gastritis (Drug-Induced or Stress-Related)

• PPIs or H2 blockers should be given for 6-8 weeks along with long-term maintenance therapy if needed 2
• Secondary ulcers in young children (drug or stress-related) typically do not recur once the underlying cause is addressed 2

PPI Dosing Specifics for Pediatric Gastritis

• Omeprazole: 0.7-3.3 mg/kg/day divided twice daily for children 2-16 years 4
• Administer approximately 30 minutes before meals for optimal effect 5
• Available as sprinkle capsules that can be opened and placed on soft foods 4
• Treatment duration should be limited to 4-8 weeks, with reassessment after each course 3, 4

Critical Safety Considerations

Risks of PPI Use in Children

• Increased risk of community-acquired pneumonia, gastroenteritis, and candidemia 3, 5
• Potential for vitamin B12 deficiency and bone fractures with prolonged use 3
• In infants, particularly increased risk of lower respiratory tract infections 3
• Risk of necrotizing enterocolitis in preterm infants—avoid in this population 3

H. pylori-Specific Concerns

• Long-term PPI therapy in H. pylori-positive patients induces corpus-predominant pangastritis and accelerated gland loss 6, 7
• This pattern is associated with increased gastric cancer risk 6
• H. pylori eradication reverses gastritis and may induce partial regression of pre-existing gland loss 6

Treatment Algorithm for Pediatric Gastritis

Step 1: Diagnostic Confirmation

• Perform upper GI endoscopy with biopsies from antrum and fundus 1
• Obtain tissue for histopathology and H. pylori culture 1
• Identify etiology: H. pylori, drug-induced, or stress-related 1

Step 2: Etiologic-Specific Treatment

For H. pylori-positive gastritis:

• Initiate triple therapy: PPI (omeprazole 0.7-1 mg/kg twice daily) + two antibiotics for 7-10 days 1
• Use non-invasive testing only for confirmation of eradication, not initial diagnosis 1

For drug-induced or stress gastritis:

• Discontinue offending agent if possible 1, 2
• Initiate PPI or H2-blocker for 6-8 weeks 2
• Consider maintenance therapy if symptoms recur 2

Step 3: Monitoring and Follow-Up

• Reassess after 4-8 weeks of therapy 3, 4
• For H. pylori cases, confirm eradication with non-invasive testing 1
• Refer to pediatric gastroenterology if symptoms persist despite optimal therapy 5

Common Pitfalls to Avoid

• Do not use PPIs for uncomplicated physiologic reflux—this is distinct from gastritis 3
• Do not prescribe PPIs without endoscopic confirmation of gastritis in symptomatic children 1
• Avoid prolonged PPI therapy beyond 8 weeks without reassessment and clear indication 3, 4
• Do not combine H2RAs with PPIs—use sequential therapy if switching is needed 4
• Never use PPIs in preterm infants due to necrotizing enterocolitis risk 3
• In H. pylori-positive patients requiring long-term acid suppression, eradicate H. pylori to prevent corpus-predominant gastritis 6