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Important: please update your RDS app to version 4.7.3 Details with newsletter below.

Please update your RDS app to v4.7.3

We asked you in January to update to v4.7.2.  After the deployment planned for 27th February, this new update will be needed to ensure that you are able to download RDS toolkits even when the RDS website is not available. We will wait until as many users as possible have downloaded the new version before switching off the old system for app downloads and moving entirely to the new approach.

To check your current RDS version, click on the three dots bottom right of the RDS app screen. This takes you to a “More” page where you will see the version number. 

To update to the latest release:

 On iPhones – go to the Apple store, click on your profile icon top right, scroll down to see the apps waiting to be updated and update the RDS app.

On Android phones – these can vary, but try going to the Google Play store, click on your profile icon top right, click on “Manage apps and device”, select and update the RDS app.

Right Decision Service newsletter: February 2025

Welcome to the February 2025 update from the RDS team

1.     Next release of RDS

 

A new release of RDS is planned (subject to outcomes of current testing) for week beginning 24th February. This will deliver:

 

  • Fixes to mitigate the recurring glitches with the RDS admin area and the occasional brief user interface outages which have arisen following implementation of the new distributed technology infrastructure in December 2024.

 

  • Capability to embed content from Google calendar, Google Maps, Daily Motion, Twitter feeds, Microsoft Stream into RDS pages.

 

  • Capability to include simple multiplication in RDS calculators.

 

The release will also incorporate a number of small fixes, including:

  • Exporting of form within Medicines Sick Day Guidance in polypharmacy toolkit
  • Links to redundant content appearing in search in some RDS toolkits
  • Inclusion of accordion headers alongside accordion text in search result snippets.
  • Feedback form on mobile app.
  • Internal links on mobile app version of benzo tapering tool

 

We will let you know when the date and time for the new release are confirmed.

 

2.     New RDS developments

There is now the capability to publish toolkits on the web with left hand side navigation rather than tiles on the homepage. To use this feature, turn on the “Toggle navigation panel” option at the top of the Page settings menu at toolkit homepage level – see below. Please note that publication to downloadable mobile app for this type of navigation is still under development.

The Benzodiazepine tapering tool is now available as part of the RDS toolkit for the national benzodiazepine prescribing guidance developed by the Scottish Government Effective Prescribing team. The tool uses this national guidance developed with a wide-ranging multidisciplinary group. This should be used in combination with professional judgement and an understanding of the needs of the individual patient.

3.     Archiving and version control and new RDS Search and Browse interface

Due to the intensive work Tactuum has had to undertake on the new technology infrastructure has pushed back the delivery dates again and some new requirements have come out of the recent user acceptance testing. It now looks likely to be an April release for the search and browse interface. The archiving and version control functionality may be released earlier. We’ll keep you posted.

4.     Statistics

At the end of January, Olivia completed the generation of the latest set of usage statistics for all RDS toolkits. If you would like a copy of the stats for your toolkit, please contact Olivia.graham@nhs.scot .

 

5.     Review of content past its review date

We have now generated reports of all RDS toolkit content that has exceeded its review date by 6 months or more. We will be in touch later this month with toolkit owners and editors to agree the plan for updating or withdrawing out of date content.

 

6.     Toolkits in development

Some important toolkits in development by the RDS team include:

  • National CVD prevention pathways – due for release end of March 2025.
  • National respiratory pathways, optimal cancer diagnostic pathways and cancer prehabilitation pathways from the Centre for Sustainable Delivery. We will shortly start work on the national cancer referral pathways, first version due for release via RDS around end of June 2025.
  • HIS Quality of Care Review toolkit – currently in final stages of quality assurance.

 

The RDS team and other information scientists in HIS have also been producing evidence summaries for the Scottish Government Realistic Medicine team, to inform development of national guidance around Procedures of Limited Clinical Value. This guidance will in due course be translated into an RDS toolkit.

 

7. Training sessions for new editors (also serve as refresher sessions for existing editors) will take place on the following dates:

  • Friday 28th February 12-1 pm
  • Tuesday 11th March 4-5 pm

 

To book a place, please contact Olivia.graham@nhs.scot, providing your name, organisation, job role, and level of experience with RDS editing (none, a little, moderate, extensive.)

 

To invite colleagues to sign up to receive this newsletter, please signpost them to the registration form  - also available in End-user and Provider sections of the RDS Learning and Support area.   If you have any questions about the content of this newsletter, please contact his.decisionsupport@nhs.scot  If you would prefer not to receive future newsletters, please email Olivia.graham@nhs.scot and ask to be removed from the circulation list.

With kind regards

 

Right Decision Service team

Healthcare Improvement Scotland

 

 

Helicobacter pylori infection in children (1096)

Objectives

This guideline aims to lead to a more consistent clinical practice in the diagnosis and management of Helicobacter pylori in children in the West of Scotland.  This guideline is based on the 2016 joint consensus guideline of the European Society of Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) and North American Society of Paediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN)1 and adapted for use locally.

Scope

This guideline should be followed by all healthcare professionals that are involved in the management of children with H. pylori infection in the West of Scotland. 

Audience

Health care professionals working in the West of Scotland, managing patients with possible H. pylori infection.

Helicobacter pylori is a microaerophilic Gram-negative bacterium that inhabits the mucus layer above the gastric mucosa. The bacterium typically infects the host in early childhood and remains part of the gastric microbiome throughout adult life.2

While 90% of people remain asymptomatic, it is a major source of morbidity and mortality worldwide due to the well-described complications of atrophic gastritis, mucosal-associated lymphoid tissue (MALT) lymphoma, gastric adenocarcinoma and peptic ulcer disease (PUD).3 H. pylori were classified in the recent Kyoto consensus4 as an infectious disease. Although H. pylori-associated malignancy rarely manifests in childhood, failure to treat correctly exposes the individual to a recognised WHO class I carcinogen. If identified, it is the clinician’s responsibility to ensure eradication with mandatory post-treatment testing.

The natural history in the majority of children is asymptomatic carriage.5 Infection can result in either high, low or neutral gastric acid states depending on the area of the stomach infected and the pathogenicity of the strain.6 In those with hyperacidity in the stomach, symptoms of gastritis or peptic ulcer disease can develop. 

H. pylori does not cause gastroesophageal reflux or functional abdominal pain. However, children are often unable to provide precise descriptions of the location and characteristics of pain, so diagnostic delineation on history alone can be challenging. In practice, it is often hard to distinguish between gastroesophageal reflux disease and dyspeptic disease symptoms.

Rates of antibiotic-resistant H. pylori have rapidly increased over the past 20 years corresponding to a decline in the efficacy of standard treatment regimens.1 Responsible antibiotic stewardship by careful selection of the most effective treatment regimen is essential to maintain treatment effectiveness.

Aims of assessment and treatment

  1. Test only when there is an indication
  2. Use an appropriate test
  3. Use the best possible first-line treatment regimen
  4. Confirm eradication

H. pylori infection rarely causes symptoms in children in the absence of peptic ulcer disease. Symptomatic children should be tested to diagnose the cause of specific symptoms rather than simply identify H. pylori.7 Further evaluation should be reserved for when epigastric pain is closely associated with the intake of food or when there are associated ‘red flag’ features (Table 1). Testing is not indicated for suspected functional abdominal pain or gastroesophageal reflux disease. Parents should be counselled that, in the absence of PUD, eradication may not relieve symptoms however is still probably required to reduce the carcinogen risk. We do not currently advocate for routine tolerance of detected H. pylori given the “known carcinogen” status of the organism, but this is an active debate within the literature and the position may shift with time.

Table 1: Symptoms of PUD and ‘red flag’ features in GI disease

Symptoms associated with Gastritis/PUD

GI Red Flag Symptoms (not necessarily H. pylori-related)

Haematemesis or melaena

Localised epigastric pain

  • Pain may worsen with empty stomach, particularly pre-mealtime as gastric acid secretion rises in anticipation
  • Pain may be improved with eating and drinking or taking an antacid medication
  • Pain associated with mealtimes/eating is often all that can be elicited by history in peptic ulcer disease, particularly in young children.

Localised epigastric pain
Right upper or right lower quadrant pain
Dysphagia
Odynophagia
Persistent vomiting
Overt gastrointestinal blood loss
Weight loss
Decelerating linear growth
Delayed puberty
Unexplained fever
Family history of inflammatory bowel disease, coeliac disease or PUD

Special Situations

  • Testing in patients with functional abdominal pain or gastroesophageal reflux is not recommended
  • Iron deficiency anaemia is no longer an indication for testing
  • There is no evidence that testing and treating family members for H. pylori infection reduces the risk of reinfection
  • A family history of gastric cancer is no longer an indication for testing
  • Patients with idiopathic thrombocytopenic purpura should be considered for testing

Upper gastrointestinal endoscopy with biopsy for histology is the recommended gold standard, largely because of its ability to formally diagnose PUD and so help stratify acid suppressant treatment thereafter.  Pragmatically, however, the balance of general anaesthetic risk and procedural expense means a great many children could be spared endoscopy with a simpler first-line approach.  We therefore recommend first-line diagnosis based on stool antigen testing, followed by eradication if positive.  Children should only be referred for gastroenterology opinion and endoscopy when they have failed to have a successful primary eradication of H. pylori confirmed by a positive repeat stool antigen test.

Our recommendation would be to use stool antigen testing for both the initial diagnosis of H. pylori infection and for confirmation of eradication. 

Patients should be off acid suppression for at least two weeks and antibiotics for four weeks before testing.  The use of Gaviscon preparations should not affect test results.

Acid suppression inhibits the growth of H.pylori therefore will result in a higher false negative rate. A negative test on acid suppression should be repeated. A positive test on acid suppression should be considered genuine.

Note:

  • Non-invasive tests: stool antigen testing is as reliable as the urease breath test and is much easier to do in younger patients.
  • Blood-based serology tests are NOT reliable for use in routine paediatric practice (their use in adults is pragmatic based on the high use of acid suppressants and the difficulty with other investigations in this setting).

Rising antibiotic resistance means it is essential to maximise the success of first-line treatment regimens. Compliance is key and should be carefully discussed and reinforced with families; the high eradication rates with recommended treatment regimens rely on >90% compliance (<3 doses missed in a 14-day regimen). A twice-daily dosing regimen is given to maximise compliance. 14-day regimens are now recommended due to increased efficacy above 10- and 7-day regimens. Ideally, antibiotic choice would be based on culture and sensitivity though this is impractical in the majority of cases. Molecular biopsy-based techniques or stool PCR may be used in the future to identify antibiotic-resistant strains before choosing antibiotics, however this is not currently the standard of care.

First-Line Treatment Regimen

For patients where the antibiotic sensitivity and resistance patterns are not known (the majority of non-biopsied patients) our recommendation is triple therapy for 14 days with:

Omeprazole, HIGH DOSE amoxicillin and metronidazole

The doses recommended are given below and are given in the ESPGHAN/NASPGHAN H. pylori Guidelines (reference below). If asking GP to prescribe these doses, a reference may be required due to deviation from the BNFc. Higher dose PPI improves treatment success. Where peptic ulcer is strongly suspected, 3 months of acid suppression should also be used to promote healing.

Table 2: Recommended medication doses based on the ESPGHAN H.pylori guidelines1

HIGH DOSE recommended as the first line when antibiotic sensitivities are not known (most cases)

** If oral suspension of metronidazole is employed, the dose can be divided to be equal every 12 hours

Second-Line Treatment Regimen

To maximise treatment effectiveness, second-line treatment should be discussed with your local gastroenterology team

Patients who have previously taken clarithromycin and/or metronidazole should be considered at high-risk for resistance.

Confirmation of eradication

  • The long-term risk and uncertainty regarding gastric carcinoma mean confirmation of eradication is MANDATORY.
  • Eradication of H. pylori infection should be confirmed 4-8 weeks after treatment using stool antigen testing.
  • Patients should be off acid suppression for at least two weeks and antibiotics for four weeks before testing – peptic ulcer patients should complete their 3-month acid suppression course before confirming eradication.

Referral to Gastroenterology

Patients with H. pylori should be referred for opinion and endoscopy when they have failed to have a successful eradication with confirmatory positive post-treatment stool antigen test.

Persistence of dyspeptic symptoms after a trial of appropriately dosed acid suppression or dependence on long-term acid suppressants with/without H. pylori are further indicators for consideration of endoscopy.

Editorial Information

Last reviewed: 17/07/2023

Next review date: 31/05/2026

Author(s): Wands D, Sullivan A, Morrison K, Bland R, Hansen R.

Author email(s): David.wands4@ggc.scot.nhs.uk.

Approved By: RHC GI & Paediatric Departments

Document Id: 1096

References
  1. Jones NL, Koletzko S, Goodman K, et al. Joint ESPGHAN/NASPGHAN Guidelines for the Management of Helicobacter pylori in Children and Adolescents (Update 2016). J Pediatr Gastroenterol Nutr. 2017;64(6):991-1003. doi:10.1097/MPG.0000000000001594
  2. Rowland M, Daly L, Vaughan M, Higgins A, Bourke B, Drumm B. Age-specific incidence of Helicobacter pylori. Gastroenterology. 2006;130(1):65-72. doi:10.1053/J.GASTRO.2005.11.004
  3. Moodley Y, Linz B, Bond RP, et al. Age of the association between Helicobacter pylori and man. PLoS Pathog. 2012;8(5). doi:10.1371/JOURNAL.PPAT.1002693
  4. Sugano K, Tack J, Kuipers EJ, et al. Kyoto global consensus report on Helicobacter pylori gastritis. doi:10.1136/gutjnl-2015-309252
  5. Hansen R, Russell RK, Muhammed R. Recent advances in paediatric gastroenterology. doi:10.1136/archdischild-2014-307089
  6. Pariente B, Cosnes J, Danese S, et al. Development of the Crohn’s disease digestive damage score, the Lémann score. Inflamm Bowel Dis. 2011;17(6):1415. doi:10.1002/IBD.21506
  7. Wands DIF, El-Omar EM, Hansen R, Gastroenterology P. Helicobacter pylori: getting to grips with the guidance Education. Gastroenterology. 2021;12:650-655. doi:10.1136/flgastro-2020-101571