Guidelines for Approaching Suspected Peptic Ulcer Disease or <i>Helicobacter pylori</i> Infection: Where We Are in Pediatrics, and How We Got There

Within the last year or so, pediatric gastroenterologists in North America and Europe have published three sets of guidelines for Helicobacter pylori infection in children The titles of these articles are a little misleading because they suggest that the guidelines refer to children already known to be infected, whereas in fact, the greater part of all the guidelines is directed toward developing an approach to the child with gastrointestinal symptoms or signs – whom to test and how to test for H. pylori. In other words, the guidelines are directions for rational testing. The impetus for these initiatives stemmed from various concerns. Several sets of guidelines for adults had been published, and there was concern that, in the absence of pediatric guidelines, children would be managed by guidelines generated for adults. There was also increasing awareness of the widely disparate clinical practices among us, as pediatric gastroenterologists, one indicator of which was the voluminous correspondence on our website. Furthermore, there was confusion among referring physicians in our own communities. If we, as subspecialists couldn't agree on approaches, how could we purport to be expert advisers to our referring physicians? First out of the blocks with group-derived, detailed consensus guidelines were the Canadians. In November 1998, a meeting was convened in Victoria, BC by the Canadian H. pylori Study Group, which previously had established practice guidelines for adults. The working group included 30 participants from pediatric and adult gastroenterology, infectious diseases, family medicine, epidemiology, government, and industry. After a series of talks on issues related to H. pylori infection, workshop groups met to evaluate the relevant literature and recommend an approach to issues such as selecting patients to be tested, diagnostic tests, selecting patients to be treated, and treatment strategies. The consensus of each working group was then presented to the entire group, and broad consensus achieved after debating each issue. Issues were not voted on, and although the majority agreed with the statements, consensus was not always unanimous. In September 1998, the European Society for Pediatric Gastroenterology, Hepatology and Nutrition [ESPGHN] and the European H. pylori Study Group held a multidisciplinary meeting in Budapest, which included 38 individuals from 19 countries. The group focused on the indications for testing for H. pylori and the roles of different tests in clinical practice. It did not address treatment. Rapid consensus was reached on certain fundamental issues. Subsequently, various statements were proposed and different speakers presented the arguments for and against. A general discussion and a vote on each statement followed. Consensus was deemed to be present if a significant majority agreed. Each recommendation was followed by a summary of points for and against that recommendation; an approach that made the document particularly informative. In December 1998, nine individuals appointed by the North American Society for Pediatric Gastroenterology and Nutrition [NASPGN] began a process to establish clinical practice guidelines. This group, seven pediatric gastroenterologists, a general pediatrician, and an epidemiologist, used an evidence-based approach. Letters, editorials, case reports, abstracts, and reviews were excluded. Evidence tables were prepared based on 16 articles on clinical presentation, 9 articles on diagnostic studies, and 30 articles on therapy. When the pediatric literature was insufficient, the adult literature was considered. Teams prepared draft proposals for discussion on selecting patients for testing and treatment, diagnostic tests, and treatment strategies. Members individually ranked the quality of evidence available. The group convened in several conference calls. One lengthy face-to-face meeting was held, at which presentations and the literature on which they were based were critiqued. The evidence rankings of members was compared. Participants vigorously debated issues, often exhaustively, since the nominal group technique required unanimous consensus. Although consensus was achieved in several areas, it was quickly recognized that in some areas, reliable evidence was insufficient or absent. In these cases, expert opinion was invoked. The committee then wrote up its findings as a draft position paper on behalf of NASPGN. The committee's recommendations were presented to the Annual Meeting of NASPGN in Denver, Colorado, in October 1999. This exchange of views helped the committee recognize the need to clarify certain recommendations. Specifically, requiring clarification was the difference between the committee's recommendation against testing everyone for H. pylori in one section, and recommending treating any patient testing positive for H. pylori, even by a test not recommended for use. The former recommendation against excessive testing and treating is a public health position, the latter recommendation is for a cautious and prudent approach to caring for the individual patient, given the limitations of our current state of knowledge. Some critics viewed the guidelines as useless, given the widespread use of screening for H.pylori in their communities. However, the point that this was exactly why guidelines are required seemed to be accepted by most. The manuscript was then sent for comment to the approximately 600 members of NASPGN. It was subsequently finalized, and sent to the American Academy of Pediatrics, which endorsed the recommendations. The document was published as an official position paper of the Society in November 2000. In November 1999, the Japanese Society for Pediatric Gastroenterology met in Kobe to address issues relevant to that country. The process consisted of a meeting held in conjunction with adult gastroenterologists, but with the group of pediatric gastroenterologists writing up separate guidelines for children. These were recently published in Japanese, and will be published in English in the next year or so [S. Kato. Personal communication]. The three sets of published pediatric guidelines are in agreement on the major issues. This is quite remarkable, given that these comprised the efforts of some 90 individuals from 20 countries, and given the different processes used to reach consensus. The major specific recommendations of the pediatric committees are summarized as follows: Consensus guidelines in adults are in conflict regarding some recommendations. Factors that influence guidelines may include varying interpretations of evidence, health care structures, prevalence of infection and associated diseases. Children differ considerably from adults in the prevalence of peptic ulcer disease, gastric adenocarcinoma, and MALT lymphoma. In addition, most studies in children indicate a weak association between abdominal pain and H. pylori infection. It is likely that the strength of these commonalties in children accounts for the uniformity of the pediatric consensus statements. To be useful, guidelines have to be published promptly and updated regularly. Now that the ground has been broken, updating should be a more rapid process. Obviously, the need to update guidelines depends on the availability of new data from pediatric studies. Recently, there has been a decrease in correspondence regarding H. pylori issues on the PedGI bulletin board. Possibly this simply reflects battle fatigue, with individual physicians doing their own thing regardless of the guidelines. Or, more optimistically perhaps, the lack of discussion means that the guidelines are being used to direct our approach to the issues. Determination of the impact of the guidelines will require monitoring of our clinical practices. The pediatric guidelines are not a substitute for astute clinical judgment individualized to a particular patient or family. However, to ignore the recommendations completely or on a regular basis in favor of an approach based on a personal view, is unlikely to serve the majority of patients.

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