Background

Helicobacter pylori is a bacterial infection of the stomach that is usually acquired in the early years of life. Transmission is related to living conditions, particularly crowding. The clinical implications of H. pylori infection in children are unclear, although H. pylori is classed as a grade I carcinogen (for gastric cancer) in adults.¹

H. pylori is asymptomatic in many children, it is unclear whether H. pylori causes abdominal pain without associated peptic ulcer disease.² A meta-analysis found H. pylori was not associated with recurrent abdominal pain in children; there was conflicting evidence for an association with epigastric pain, and some evidence of association with short-term (<3 months) recurrent abdominal pain.³

Prevalence

• The prevalence of H. pylori infection varies between the developed and developing world (40% vs 90% in adults aged 40 years)⁴
• The prevalence of H. pylori is <10% in children and adolescents in Europe/North America⁵
• H. pylori has been found in over 80% of African refugee children in Perth⁶
• No other data are available in refugee children in Australia.

Assessment

• Epigastric pain, nausea, vomiting, early satiety and anorexia.
• Other family members with similar symptoms or a diagnosis of peptic ulcer disease/diagnosis of H. pylori
• Epigastric tenderness
• Iron-deficiency anaemia (which is likely to be multifactorial in refugee children).

Consider other causes of recurrent abdominal pain in refugee children. Differential diagnoses include parasite infection, lactose intolerance, constipation, liver dysfunction/hepatitis and coeliac disease, depending on area of origin.

• Loss of weight is a concerning symptom, it is unlikely to be due to H. pylori infection and requires careful consideration of other causes
• Tuberculosis may present with an abdominal focus.

Screening

• H pylori screening is not part of an initial refugee/asylum seeker health assessment.   There is inadequate evidence to support population screening in children/adolescents
• Screening of asymptomatic children is not recommended, although may be considered if the child has refractory iron deficiency and other causes have been excluded,^2,5 and in chronic immune thrombocytopenic purpura (cITP)
• Consider testing in children with upper GIT symptoms and epigastric tenderness, where parasites have been excluded, especially if multiple family members have a similar history
• Conditions for testing: testing for H. pylori should not be performed within 4 weeks of antibiotics, or within 2 weeks of ceasing proton pump inhibitors.^2,5
  • Endoscopy is the gold standard for diagnosis of H. pylori (with multiple (at least 6) gastric biopsies, rapid urease testing (CLO testing), culture, histopathology), however in many settings this is not readily available. Consensus guidelines^2,5 recommend that endoscopic testing for H. pylori should be completed in children with gastric or peptic ulcers, and otherwise only be completed if treatment will be offered. The same guidelines recommend that children with gastric or peptic ulcer disease and H. pylori should be treated (and eradication confirmed), and in children with other findings and H. pylori, or with incidental H. pylori treatment should be considered. In populations with high prevalence of H. pylori, there is therefore a very high pre-test probability of treatment being considered.
  • Faecal antigen testing is available and highly sensitive/specific. Monoclonal enzyme immunoassay on faecal specimens has > 95% sensitivity/specificity.⁷ Testing accuracy is maintained even with specimens stored at room temperature for 5 days, or frozen for months/years. Rapid stool tests are less accurate
  • Serological testing for H. pylori in children is not recommended. IgG may persist for years after resolution of infection, and a study in African refugee children found lower sensitivity/specificity (58% and 77%) compared to faecal antigen testing⁸
  • 13C-Urea breath testing is sensitive/specific in children >= 6 years (> 75%),⁷ however, availability in the primary care setting for children is limited; and the test capsule contains gelatine, which may be a concern for some patients.

Management

• The goal of therapy is to eradicate H. pylori on the first attempt
  • Triple therapy with two antibiotics and a proton pump inhibitor is recommended
  • Longer duration of therapy (up to 14 days) has been associated with higher eradication rates^2,5
• Current first-line therapy (14 days) in Australia⁹ is (also see drug databases - intranet access required):
  • Amoxicillin 25 mg/kg/dose (max 1000 mg) b.d. AND
  • Clarithromycin 7.5 mg/kg/dose (max 500 mg) b.d. AND
  • Omeprazole 10 mg/dose (10 - 20 kg) or 20 mg/dose (> 20 kg) b.d. OR esomeprazole 0.7 mg/kg/dose (max 20 mg) b.d. OR lansoprazole 1 mg/kg/dose (max 30 mg) b.d. OR pantoprazole 1 mg/kg/dose (max 40 mg) b.d.
  • Medication dosing strengths:
    • Amoxicillin: tablets 250 mg x 20, 500 mg x 20, 1000 mg x 14, or syrup 25 mg/ml, 50 mg/ml, 100 mg/ml (all x 100 ml)
    • Clarithromycin: tablets 250 mg x 14, 500 mg x 14, or syrup 50 mg/ml x 50 ml
    • Omeprazole: tablets 10 mg x 30, 20 mg x 30, some forms can be dispersed
    • Esomeprazole: tablets 20 mg x 30, can be dispersed
    • Lansoprazole: tablets15 mg x 28, 30 mg x 28, available in orally dispersible form, capsule contents can be sprinkled
    • Pantoprazole: tablets 20 mg x 30, 40 mg x 30, needs to be taken whole
• If more than one family member is affected, it is our practice to treat individuals concurrently, to minimise reinfection within the household. If several family members are affected, practice varies as to whether other children in the family are screened or treated.

First line therapy with metronidazole is not recommended due to reported high resistance rates,¹⁰ which are of particular concern in African patients,¹¹ however it may be used in cases of penicillin allergy. Alternate first-line regimens using sequential approaches, or including bismuth salts are sometimes used.

Australian therapeutic guidelines recommend the regimen above (for 7 days), however current international consensus guidelines² recommend a tailoring therapy based on susceptibility testing (i.e. after endoscopy), and where susceptibility is not known, using 14-day regimen of a proton pump inhibitor, amoxicillin and metronidazole OR bismuth-based quadruple therapy.

Follow-up

• Clinical follow-up to check for resolution of symptoms
• Repeat non-invasive testing >4 weeks after completion of therapy to confirm eradication.

References

• References

_{Immigrant health clinic resources. Initial: Melanie Thompson and Georgie Paxton, January 2012, most recent review April 2020. Contact georgia.paxton@rch.org.au}