Guideline Gaps in Paediatric H. pylori Care : Frontline Gastroenterol | May 2026

Introduction

Helicobacter pylori infection remains an important paediatric gastrointestinal infection worldwide, yet its diagnosis and treatment in children differ substantially from adult practice. The joint ESPGHAN–NASPGHAN guidelines advocate a restrictive, endoscopy-based diagnostic strategy with culture-guided therapy and structured eradication confirmation to minimise inappropriate antibiotic exposure and resistance development. This multicentre UK audit evaluated real-world paediatric practice against current international recommendations.

Problem Statement

Despite established paediatric-specific guidance, diagnostic and therapeutic approaches to H. pylori infection in children frequently remain extrapolated from adult pathways. The extent of deviation from guideline-recommended testing, treatment duration and post-treatment follow-up in UK clinical practice has remained poorly characterised.

Summary

This retrospective multicentre audit analysed paediatric H. pylori testing practices across nine NHS trusts between April 2023 and June 2024. More than 1900 stool antigen tests performed in children aged ≤16 years were reviewed, of which 249 (13%) were positive. The mean age of tested children was 9.6 years. Most positive tests represented initial diagnosis (84%), while only 15% were performed for eradication confirmation.

The study demonstrated widespread divergence from ESPGHAN–NASPGHAN recommendations across nearly all stages of care. Stool antigen testing was frequently used as a primary diagnostic tool in symptomatic children, particularly for abdominal pain, despite guidelines discouraging non-invasive “test-and-treat” strategies in paediatric populations. Abdominal pain was the most common indication for testing across both primary and secondary care settings, reflecting persistent misconceptions regarding the causal relationship between H. pylori and functional abdominal symptoms in children.

Treatment practices also showed substantial inconsistency. Empirical eradication therapy was commonly prescribed without endoscopic confirmation or antimicrobial susceptibility testing. Importantly, 88% of first-line treatment regimens and 60% of re-treatment courses deviated from ESPGHAN–NASPGHAN recommendations, most commonly because of inappropriate antibiotic combinations or shortened treatment duration. These findings raise important antimicrobial stewardship concerns, particularly in the context of rising global clarithromycin and metronidazole resistance.

Post-treatment follow-up was similarly suboptimal. Only 53% of children undergoing initial treatment and 64% receiving eradication therapy underwent follow-up stool antigen testing, and testing was frequently performed outside recommended timing windows. This inconsistency limits accurate eradication assessment and may contribute to persistent infection, recurrent symptoms and unnecessary repeated antibiotic exposure.

The audit additionally highlighted variability between primary and tertiary care referral patterns, with symptom profiles and testing indications differing substantially across healthcare settings. Limited awareness of paediatric-specific guidelines, alongside continued reliance on adult management paradigms, likely contributed to these discrepancies.

Overall, this important UK multicentre audit demonstrates major gaps between current paediatric H. pylori practice and international guideline standards. The findings underscore the need for harmonisation of UK national recommendations with ESPGHAN–NASPGHAN guidance, improved clinician education and stronger antimicrobial stewardship frameworks to promote evidence-based, standardised paediatric H. pylori management.