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
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