hepatitis%20-%20viral%20(pediatric)
HEPATITIS - VIRAL (PEDIATRIC)
The majority of acute viral hepatitis infections are asymptomatic or they can cause an anicteric illness that may not be diagnosed as hepatitis.
Hepatitis A generally causes minor illness in childhood with >80% of infections being asymptomatic. Jaundice and intestinal symptoms usually resolve 2-3 weeks after onset. A patient is infectious 1-2 weeks prior to the clinical illness.
Hepatitis B, C, & D may be symptomatic depending on the mode and time of transmission.
Hepatitis A is predominantly transmitted through oral-fecal by person-person direct transmission and contaminated material or food.
Hepatitis B is transmitted perinatal, horizontal spread, percutaneous, sexual, close person-to-person contact.
Majority of hepatitis C infections are identified in children with repeated exposure to blood products.
Hepatitis D is route of transmission is through sexual, percutaneous especially IV drug use.
Hepatitis E is transmitted primarily through contaminated drinking water and oral-fecal transmission.

Monitoring

Hepatitis B
Monitoring During Therapy

  • Monitor alanine aminotransferase (ALT), HBeAg &/or HBV DNA at least every 3 months
    • Test for ALT levels every 24 weeks in pediatric patients positive for HBeAg with normal ALT levels (<30 IU/L in boys, <19 IU/L in girls) without fibrosis in all diagnostic tests
  • Monitor renal function if Adefovir is used
  • Monitor for adverse effects if Interferons are used

Response to therapy

  • Interferon 
    • Seroconversion from HBeAg to anti-HBe antibody, normalization of serum ALT, HBV DNA clearance during the treatment or at 4, 12, & 24 weeks after therapy is indicative of good treatment response
  • Lamivudine
    • Monitor HBV DNA levels, quantitative HBsAg, HBeAg levels at 12, 24, & 48 week after initiation of therapy, & every 6 month thereafter
    • Test for HBV DNA every 12 week in HBeAg-negative patients on Lamivudine treatment for ≥5 years
  • Tenofovir
    • Test for HBV DNA, quantitative HBsAg & HBeAg levels prior to, at 12, 24, & 48 weeks during, & every 6 month after initiation of treatment
    • May help evaluate patient’s response & adherence to Tenofovir

Prevention & Post-Exposure Prophylaxis of Viral Hepatits

Prevention & Post-Exposure Prophylaxis of Viral Hepatitis
Patient Group for Whom Prevention or Post-exposure Prophylaxis is Recommended Recommended Prevention or Post-exposure Prophylaxis Regimen 
Prevention

Hepatitis A

  • Susceptible persons travelling to HAV endemic areas
  • Household contacts, day-care children & staff
  • Healthcare personnel potentially exposed to HAV
  • Patients who will undergo blood transfusion
  • Immunocompromised children (suboptimal response)
  • Illegal drug users (both injection & non-injection drug users)
  • Persons with chronic liver disease, including persons with chronic
  • HBV & HCV infection who have evidence of chronic liver disease
Hepatitis A Vaccine1

Hepatitis B

  • Unvaccinated infants, children, & adolescents
  • Premature infants with immediate risk of HBV infection
  • Persons with any of the following sexual risk factors: History of STD, multiple sex partners, sex with an injection drug user, victims of sexual assault
  • Illegal intravenous (IV) drug users
  • Household members, sex partners & drug-sharing partners of a person with chronic HBV infection2
  • Persons on hemodialysis, or are receiving clotting factor concentrates, or who have occupational exposure to blood
Hepatitis B Vaccine
Infants should be given 1st dose within 24 hr after birth, then followed by 2-3 more doses based on the recommended immunization schedule
Older children & adolescents should receive 3 doses based on the recommended immunization schedule
Post-exposure Prophylaxis

Hepatitis A

  • Unvaccinated or nonimmune persons exposed to hepatitis A virus (HAV) through eg household or sexual contact or by sharing illegal drugs with a person who has hepatitis A3
Administer a single intramuscular (IM) dose of human immunoglobulin (Ig)4 or hepatitis A vaccine5 as soon as possible but not >2 weeks after exposure

Hepatitis B

  • Unvaccinated or nonimmune sex partners of persons with acute hepatitis B
  • Newborns of HBeAg-positive mothers
Administer Ig within 14 days after the most recent sexual contact
Administer hepatitis B vaccine + Ig within 12-24 hr
Pre- or post-exposure prophylaxis is not recommended for hepatitis C.
1Postvaccination serologic testing is not indicated because most persons respond to the vaccine.
2Vaccination of household contacts (especially children & adolescents) of persons with acute HBV infection is also encouraged. Consider postvaccination testing (anti-HBs) for sex partners of persons with chronic HBV infection. Those found to be antibody negative should receive a second, complete vaccination series.
3A person who has had 1 dose of hepatitis A vaccine at least 1 month before exposure to HAV does not need Ig.
4Preferred for children <12 month, immunocompromised persons, persons diagnosed with chronic liver disease, & those with contraindications to vaccines.
5Preferred over immunoglobulin (Ig) for healthy individuals aged 12 month - 40 years. 

Follow Up

Hepatitis A

  • Considered a benign disease but may progress to fulminant liver failure & death
  • Hepatitis A virus (HAV) infection does not result in a carrier state nor chronic infection
  • Exposure to HAV induces immune response that confers lifelong protection

Hepatitis B

End of Therapy

  • Monitor alanine aminotransferase (ALT) & hepatitis B virus (HBV) markers (including HBV DNA) monthly x 3 months to detect relapse
  • Then every 3 months in patients with cirrhosis or HBeAg/HBV DNA positive
  • May monitor every 6 months in patients who responded to therapy
  • Further monitoring in non-responders is recommended to recognize delayed response & to plan retreatment if required

HBeAg positive chronic hepatitis B with alanine aminotransferase (ALT) ≤2x upper limit of normal (ULN)

  • Obtain lover function tests (LFTs) every 3-6 months
    • If ALT >1-2x ULN, recheck every 1-3 months
  • If ALT >2x ULN x 3-6 months, HBeAg positive & HBV DNA >105 copies/mL
    • Consider retreatment
  • If persistent ALT at high normal values, with family history of hepatocellular carcinoma (HCC)
    • Consider liver biopsy
    • Initiate pharmacotherapy if biopsy shows significant fibrosis or moderate to severe inflammation, & if viral DNA >20,000 IU/mL

Low Replicative Chronic Hepatitis B Virus Infection

  • Obtain LFT every 6-12 months
    • If ALT >1-2x ULN, check serum HBV DNA level & exclude other causes of liver disease
    • Monitor complete blood count & liver function tests annually
  • Screen for HCC in relevant populations
    • Obtain an ultrasound scan & AFP levels every 6-12 month & every 3 month in high-risk patients with cirrhosis
    • Contrast-enhanced CT & MRI may be used to confirm lesions seen during ultrasound in high-risk cirrhotic patients

Chronic Hepatitis C

  • Measure HCV RNA at 4 weeks after start of therapy, at the end of therapy & 24 weeks later
    • If undetectable, sustained virologic response has been achieved
    • Consider reduced duration of therapy of 12-16 weeks
  • Other laboratory tests used during monitoring may include complete blood count with prothrombin time, hepatic panel, fasting blood sugar, thyroid function test, urinalysis

Hepatitis E

  • Mortality is low in endemic groups except for the pregnant women
  • Currently, no effective therapy exists
  • Immune serum globulin does not prevent symptoms
Digital Edition
Asia's trusted medical magazine for healthcare professionals. Get your MIMS JPOG - Malaysia digital copy today!
DOWNLOAD
Editor's Recommendations
Most Read Articles
Jairia Dela Cruz, 13 Oct 2016
Children born to obese mothers are at increased risk of developing autism spectrum disorder (ASD) compared with children born to normal-weight mothers, according to data from a review and meta-analysis.
Yap Te-Lu, Anette Sundfor Jacobsen, 01 Oct 2013

Antenatal hydronephrosis (ANH) is a general term used to describe the dilatation of the fetal renal pelvis and/or its calyces. In pelviectasis, there is only dilatation of the renal pelvis; while in caliectasis, there is dilatation of the calyces. ANH is the most commonly diagnosed congenital urinary tract anomaly, which is detected by prenatal screening in 1–5% of all pregnancies

Yap Te-Lu, Anette Sundfor Jacobsen, 01 Dec 2012

Antenatal hydronephrosis (ANH) is a general term used to describe the dilatation of the fetal renal pelvis and/or its calyces. In pelviectasis, there is only dilatation of the renal pelvis; while in caliectasis, there is dilatation of the calyces. ANH is the most commonly diagnosed congenital urinary tract anomaly, which is detected by prenatal screening in 1–5% of all pregnancies.

Yap Te-Lu, Anette Sundfor Jacobsen, 01 Apr 2011

Antenatal hydronephrosis (ANH) is a general term used to describe the dilatation of the fetal renal pelvis and/or its calyces. In pelviectasis, there is only dilatation of the renal pelvis; while in caliectasis, there is dilatation of the calyces. ANH is the most commonly diagnosed congenital urinary tract anomaly, which is detected by prenatal screening in 1–5% of all pregnancies.