A viewpoint published in JAMA Pediatrics has renewed discussion among pediatricians about whether children who have Helicobacter pylori but no symptoms should be treated earlier in life to lower their risk of stomach cancer later on. The article is an expert opinion—not a report of new pediatric trial data—and its authors argue that long-term adult studies support eradication before gastric mucosal damage occurs, a stage that often precedes adulthood.
The question matters in pediatrics because H. pylori infection is typically acquired early in childhood and can persist for decades. Although most infected children have no symptoms, H. pylori is a known carcinogen in adults and is implicated in the vast majority of noncardia gastric cancers worldwide. In the commentary, corresponding author Y. Dana Neugut, MD, MS, of The Children’s Hospital of Philadelphia, and colleagues note that an estimated 90% of global gastric cancer could have been prevented if H. pylori infection had been avoided or treated. From a life-course perspective, childhood represents the earliest and potentially most effective opportunity to intervene.
Current pediatric guidance is cautious. The 2024 joint European Society for Paediatric Gastroenterology, Hepatology and Nutrition and the North American Society for Pediatric Gastroenterology, Hepatology & Nutrition guidelines advise that when H. pylori is incidentally discovered in a child, treatment “may be considered” after discussion of risks and benefits with the patient and family. That stance reflects the absence of prospective pediatric studies linking eradication in childhood to lower gastric cancer risk later in life.
Dr. Nuegut and coauthors go further. They contend that treatment should be routinely recommended in pediatric patients, largely by extrapolating from adult evidence. Central to their argument are long-term randomized and observational studies showing that eradication of H. pylori before the development of gastric atrophy or intestinal metaplasia significantly lowers subsequent gastric cancer risk. They cite a landmark randomized trial with more than 26 years of follow-up, in adults with normal gastric mucosa who received eradication therapy had a lower incidence of gastric cancer than those given placebo, with the greatest benefit seen in patients without premalignant lesions or dyspeptic symptoms at baseline. Other cohorts have shown that baseline mucosal atrophy predicts residual cancer risk even after eradication, underscoring the importance of treating before damage occurs.
Because most children with H. pylori have not yet developed such mucosal changes, the authors argue that pediatric patients resemble the adult subgroup that derived the greatest long-term benefit. They also cite microbiological data suggesting that prolonged infection can induce epigenetic and inflammatory changes that may persist even after eradication, providing another rationale for earlier treatment.
At the same time, the article acknowledges why pediatricians may feel uneasy. Treating asymptomatic children requires combination antibiotic therapy, raising concerns about antimicrobial stewardship, resistance, and exposing children to medications without immediate clinical benefit. The authors counter that resistance may be greater later in life and that deferring treatment does not eliminate antibiotic exposure but instead postpones it. They also point out practical concerns, such as the chance of getting infected again and the difficulty of sticking to treatment in very young children, suggesting that delaying treatment may be reasonable for some children under age five.
The authors are careful not to frame their position as a new standard of care. Instead, the commentary explains the science behind treating the infection earlier and why some clinicians view pediatric H. pylori treatment as a way to help prevent cancer later in life, even though long-term pediatric outcome data are not yet available.
Dr. Neugut reported having received a grant from the National Institutes of Health National Institute of Diabetes and Digestive and Kidney Diseases.
Source: JAMA Pediatrics