Helicobacter pylori (H.pylori) infection
Assessment and management of H.pylori infection in childhood (age < 15 years)
Key points
H.Pylori infection is common in childhood but most infected children are asymptomatic and do not require investigation or treatment.
Primary infection usually occurs early in childhood through the faecal- oral route. Once infected, spontaneous resolution is rare.
In adults and occasionally in children, H.pylori may cause gastric and duodenal ulcer disease and confers a minor malignancy risk.
Functional abdominal pain is common in paediatrics and may co-exist with asymptomatic H.pylori carriage. Treatment of H.pylori carriage does not improve functional abdominal pain in children.
The carriage of H.pylori may reduce the incidence of autoimmune conditions later in life
Investigation and treatment for H.pylori should be limited to children with clinical symptoms suggestive of H.pylori disease and should be diagnosed endoscopically with biopsy for histology and a rapid urease test +- culture¹.
Screening children with non-invasive markers of H.pylori (blood, stool or breath hydrogen) is NOT recommended.
Who is at risk?
There is a higher incidence of H.pylori infection in young people of Pacific Island, Maori and Asian ethnicity, economic disadvantage and refugee status².
Who should be investigated for H.pylori?
Investigation and subsequent treatment should be limited to patients with a high level of suspicion of peptic ulcer disease.
Peptic ulcer disease typically causes left upper quadrant pain, alters with eating and may be nocturnal. Proton pump inhibition will reduce the symptoms and these will reoccur on cessation of treatment.
Patients with iron deficiency that responds to supplementation and then re-occurs on an iron replete diet may be referred for endoscopy if there is no other source of blood loss evident.
Asymptomatic household contacts do not routinely require screening or treatment.
How to investigate for H.pylori in paediatrics
H.pylori should be diagnosed endoscopically with two biopsies for histology from the gastric fundus and body. A urease based test (i.e. CloTest) should be performed.
A biopsy for culture should be taken if there is any concern about antibiotic resistance.
Non-invasive testing (stool, blood, breath hydrogen) should not be used to diagnose H.pylori in children but may be used to document successful eradication.
In children without symptoms consistent with H.pylori, a positive blood or stool screening test for H.pylori does not require further investigation. A positive test is unlikely to be reassuring to patients and carers.
How to treat H.pylori?
Omeprazole + amoxicillin + clarithromycin for 14 days.
Second line treatment or penicillin allergy : Omeprazole + clarithromycin + metronidazole
Colloidal Bismuth can be utilised as fourth agent for the treatment for resistant organisms
| First line investigation for H. pylori | ||
|---|---|---|
| Agent | Age range | Oral dose |
| Omeprazole | 1-12 years | 1-2mg/kg once daily (maximum 40mg) |
| 12-15 years | 40mg once daily | |
| Amoxicillin | 1-6 years | 250mg twice daily with clarithromycin 125mg three times daily with metronidazole |
| 6-12 years | 500mg twice daily with clarithromycin 250mg three times daily with metronidazole | |
| 12-15 years | 1g twice daily with clarithromycin 500mg three times daily with metronidazole | |
| Clarithromycin | 1-12 years | 7.5 mg/kg (maximum 500 mg) twice daily (with metronidazole or amoxicillin) |
| 12-15 years | 500 mg twice daily (with metronidazole or amoxicillin) | |
| Metronidazole | 1-6 years | 100 mg twice daily (with clarithromycin) 100 mg three times daily (with amoxicillin) |
| 6-12 years | 200 mg twice daily (with clarithromycin) 200 mg three times daily (with amoxicillin) | |
| 12-15 years | 400 mg three times daily (with amoxicillin) 400 mg twice daily (with clarithromycin) | |
https://www.nzfchildren.org.nz/nzf_732 accessed 18/12/2019
How to follow-up
Follow-up is important as there is a high primary failure rate of H.pylori eradication.
At a minimum of four weeks after conclusion of triple therapy a stool or blood antigen test should be done.
If negative there is no formal follow-up. Families should be counselled that re-infection is possible although rare.
If again positive:
Confirm compliance with initial course – if uncertain then further education and repeat treatment
If compliance confidently established then second line treatment
After either second course of treatment repeat stool antigen four weeks after conclusion of treatment.
If still positive after second course of treatment then discussion with infectious diseases +- gastroenterology is recommended to guide need for repeat treatment of further endoscopy for sensitivities to guide therapy