BNF for Children 2011-2012

42 1.3 Antisecretory drugs and mucosal protectants BNFC 2011–20121 Gastro-intestinal systemLicensed use not licensed for use in gastro-intestinalstasisIndication and doseGastro-intestinal stasis. By mouthNeonate 3 mg/kg 4 times dailyChild 1 month–18 years 3 mg/kg 4 times daily. By intravenous infusionNeonate 3 mg/kg 4 times dailyChild 1 month–1 year 3 mg/kg 4 times dailyPreparationsSection 5.1.51.3 Antisecretory drugs andmucosal protectants1.3.1 H 2 -receptor antagonists1.3.2 Selective antimuscarinics1.3.3 Chelates and complexes1.3.4 Prostaglandin analogues1.3.5 Proton pump inhibitorsPeptic ulceration commonly involves the stomach, duodenum,and lower oesophagus; after gastric surgery itinvolves the gastro-enterostomy stoma.Healing can be promoted by general measures, stoppingsmoking and taking antacids and by antisecretory drugtreatment, but relapse is common when treatmentceases. Nearly all duodenal ulcers and most gastriculcers not associated with NSAIDs are caused byHelicobacter pylori.The management of H. pylori infection and of NSAIDassociatedulcers is discussed below.Helicobacter pylori infectionEradication of Helicobacter pylori reduces the recurrenceof gastric and duodenal ulcers and the risk ofrebleeding. The presence of H. pylori should be confirmedbefore starting eradication treatment. If possible,the antibacterial sensitivity of the organism should beestablished at the time of endoscopy and biopsy. Acidinhibition combined with antibacterial treatment ishighly effective in the eradication of H. pylori; reinfectionis rare. Antibiotic-associated colitis is an uncommonrisk.Treatment to eradicate H. pylori infection in childrenshould be initiated under specialist supervision. Oneweektriple-therapy regimens that comprise omeprazole,amoxicillin, and either clarithromycin or metronidazoleare recommended. Resistance to clarithromycinor to metronidazole is much more commonthan to amoxicillin and can develop during treatment.A regimen containing amoxicillin and clarithromycin istherefore recommended for initial therapy and one containingamoxicillin and metronidazole is recommendedfor eradication failure or for a child who has beentreated with a macrolide for other infections. There isusually no need to continue antisecretory treatment(with a proton pump inhibitor or H 2 -receptor antagonist);however, if the ulcer is large, or complicated byhaemorrhage or perforation then antisecretory treatmentis continued for a further 3 weeks. Lansoprazolemay be considered if omeprazole is unsuitable. Treatmentfailure usually indicates antibacterial resistance orpoor compliance.Two-week triple-therapy regimens offer the possibilityof higher eradication rates compared to one-week regimens,but adverse effects are common and poor complianceis likely to offset any possible gain.Two-week dual-therapy regimens using a proton pumpinhibitor and a single antibacterial produce low rates ofH. pylori eradication and are not recommended.For the role of H. pylori eradication therapy in childrenstarting or taking NSAIDs, see NSAID-associated ulcers,below.Recommended regimens for Helicobacter pylori eradicationEradication therapy Age range Oral dose(to be used in combination with omeprazole, section 1.3.5)Amoxicillin 1–6 years 250 mg twice daily (with clarithromycin)125 mg 3 times daily (with metronidazole)6–12 years 500 mg twice daily (with clarithromycin)250 mg 3 times daily (with metronidazole)12–18 years 1 g twice daily (with clarithromycin)500 mg 3 times daily (with metronidazole)Clarithromycin1–12 years 7.5 mg/kg (max. 500 mg) twice daily (with metronidazole oramoxicillin)12–18 years 500 mg twice daily (with metronidazole or amoxicillin)Metronidazole 1–6 years 100 mg twice daily (with clarithromycin)100 mg 3 times daily (with amoxicillin)6–12 years 200 mg twice daily (with clarithromycin)200 mg 3 times daily (with amoxicillin)12–18 years 400 mg twice daily (with clarithromycin)400 mg 3 times daily (with amoxicillin)