Standard dosing regimen for treatment naive patients.

Drug	Bodyweight range	Morning dose	Evening dose
PPI The doses of the different proton pump inhibitors are not equivalent. See comment on PPI in recommendation 14.	15 to 24 kg	20mg	20mg
	25 to 34 kg	30mg	30mg
	>35 kg	40mg	40mg
Amoxicillin	15 to 24 kg	500mg	500mg
	25 to 34 kg	750mg	750mg
	>35 kg	1000mg	1000mg
Clarithromycin	15 to 24 kg	250mg	250mg
	25 to 34 kg	500mg	250mg
	>35 kg	500mg	500mg
Metronidazole	15 to 24 kg	250mg	250mg
	25 to 34 kg	500mg	250mg
	>35 kg	500mg	500mg
Bismuth subsalicilate (US market)	<10 years	262mg QID
	>10 years	524mg QID

High Dosing Regimen for Amoxicillin

Bodyweight range	Morning dose	Evening dose
15 to 24 kg	750mg	750mg
25 to 34 kg	1000mg	1000mg
>35 kg	1500mg	1500mg

Rescue therapies in pediatric patients who failed therapy.

Initial Antibiotic Susceptibility	Past treatment- Regimen	Rescue Treatment
Clarithromycin and metronidazole susceptible	Triple therapy using amoxicillin and clarithromycin Triple therapy using amoxicillin and metronidazole	Triple therapy using amoxicillin and metronidazole Triple therapy using amoxicillin and clarithromycin
Clarithromycin and metronidazole susceptible	Sequential therapy	Consider performing a second endoscopy and use a tailored treatment for 14d or treat like double resistance. PPI-AMO-MET 14d high dose for AMO OR bismuth-based OR in adolescents levofloxacin or tetracycline may be considered.
Clarithromycin resistant	Triple therapy using metronidazole	Treat like double resistance PPI-AMO-MET 14d high dose for AMO OR bismuth-based OR in adolescents levofloxacin or tetracycline may be considered.
Metronidazole resistant	Triple therapy using clarithromycin	Consider performing a second endoscopy and use a tailored treatment for 14 days or treat like double resistance. PPI-AMO-MET 14d high dose for AMO OR bismuth-based OR in adolescents levofloxacin or tetracycline may be considered.
Primary antimicrobial susceptibility unknown	Triple therapy or sequential therapy	Consider performing a second endoscopy to assess secondary antimicrobial susceptibility or treat like double resistance. PPI-AMO-MET 14d high dose for AMO OR bismuth-based OR in adolescents levofloxacin or tetracycline may be considered.

Synopsis of ESPGHAN/NASPGHAN guidelines recommendations.

1. We recommend that the primary goal of clinical investigation of gastrointestinal symptoms should be to determine the underlying cause of the symptoms and not solely the presence of H pylori infection.

2a. We recommend that during endoscopy additional biopsies for RUT and culture should only be taken if treatment is likely to be offered if infection is confirmed.

2b. We suggest that if H pylori infection is an incidental finding at endoscopy, treatment may be considered after careful discussion of the risks and benefits of H pylori treatment with the patient/parents.

2c. We recommend against a ‘‘test and treat’’ strategy for H pylori infection in children.

3. We recommend that testing for H pylori be performed in children with gastric or duodenal ulcers. If H pylori infection is identified then treatment should be advised and eradication be confirmed.

4. We recommend against diagnostic testing for H pylori infection in children with functional abdominal pain.

5a. We recommend against diagnostic testing for H pylori infection as part of the initial investigation in children with iron deficiency anemia.

5b. We suggest that in children with refractory IDA in which other causes have been ruled out, testing for H pylori during upper endoscopy may be considered.

6. We suggest that noninvasive diagnostic testing for H pylori infection may be considered when investigating causes of chronic immune thrombocytopenic purpura (ITP).

7. We recommend against diagnostic testing for H pylori infection when investigating causes of short stature.

8. We recommend that before testing for H pylori, waiting at least 2 weeks after stopping proton pump inhibitor (PPI) and 4 weeks after stopping antibiotics.

9a. We recommend that the diagnosis of H pylori infection should be based on either (a) histopathology (H pylori–positive gastritis) plus at least 1 other positive biopsy-based test or (b) positive culture.

9b. We recommend that for the diagnosis of H pylori infection at upper gastrointestinal endoscopy, at least 6 gastric biopsies be obtained.

10. We recommend against using antibody-based tests (IgG, IgA) for H pylori in serum, whole blood, urine, and saliva in the clinical setting.

11. We recommend that antimicrobial sensitivity be obtained for the infecting H pylori strain (s), and eradication therapy tailored accordingly.

12. We recommend that the effectiveness of first-line therapy be evaluated in national/regional centers.

13. We recommend that the physician explain to the patient/family the importance of adherence to the anti–H pylori therapy to enhance successful eradication.

14. We recommend first-line therapy for H pylori infection as listed in Table 2.

15. We recommend that the outcome of anti–H pylori therapy be assessed at least 4 weeks after completion of therapy using one of the following tests. (a) The 13C-urea breath (13C-UBT) test or (b) a 2-step monoclonal stool antigen test.

16. We recommend that when H pylori treatment fails, rescue therapy should be individualized considering antibiotic susceptibility, the age of the child, and available antimicrobial options.