Management of Acute Viral Hepatitis in Pediatrics
The primary approach to managing acute viral hepatitis in pediatrics is supportive care, as most cases are self-limited and resolve without specific antiviral therapy. Supportive management should focus on maintaining adequate hydration, nutrition, and monitoring for complications.
Etiology and Diagnosis
- Hepatitis A virus (HAV) is the most common cause of acute viral hepatitis in children (85% of cases) 1
- Other causes include:
- Hepatitis B virus (HBV)
- Hepatitis E virus (HEV)
- Hepatitis C virus (HCV)
- Other viral infections
Initial Management Algorithm
Step 1: Assessment of Disease Severity
- Monitor for signs of acute liver failure:
- Altered mental status
- Coagulopathy (INR >1.5)
- Hypoglycemia
- Metabolic acidosis
Step 2: Supportive Care Measures
- Hydration: Ensure adequate fluid intake; IV fluids if oral intake is compromised
- Nutrition: High-calorie diet with adequate protein intake 2
- Medication management:
- Avoid hepatotoxic medications
- Complete abstinence from alcohol
- Discontinue herbal medications (associated with prolonged cholestasis) 1
Step 3: Monitoring and Follow-up
- Monitor liver function tests every 3 months for at least 6 months 3
- Regular assessment of:
- Complete blood count
- Coagulation profile
- Blood glucose levels
- Electrolytes
Special Considerations
Hospitalization Criteria
- Inability to maintain oral hydration due to severe nausea/vomiting
- Any signs of altered mental status suggesting evolving liver failure
- INR >1.5 or other signs of severe liver dysfunction
- Age <1 year
Specific Viral Hepatitis Management
Hepatitis A
- Self-limited disease in most children
- Post-exposure prophylaxis with HAV vaccine is effective for contacts 4
- Consider HAV vaccination for unvaccinated children
Hepatitis B
- For acute HBV infection with severe presentation, lamivudine 100 mg/day may be beneficial 2
- For chronic HBV infection:
Hepatitis C
- Consider interferon-alpha therapy in acute hepatitis C to decrease risk of chronicity 2
- For children with chronic HCV infection, combination therapy with pegylated interferon-alpha and ribavirin is effective, particularly for genotypes 2 and 3 4
Complications and Their Management
Secondary Bacterial Infections
- Associated with increased duration of illness 1
- Treat with appropriate antibiotics, especially in patients with ultrasound evidence of prominent biliary tree 1
Acute Liver Failure
- Uncommon but serious complication (2-3% of cases) 6, 1
- Management includes:
- ICU admission
- Correction of coagulopathy
- Prevention and treatment of cerebral edema
- Management of renal dysfunction
- Consider referral for liver transplantation evaluation in severe cases 6
Pitfalls to Avoid
- Unnecessary testing: Avoid extensive testing in children with mildly elevated ALT and known etiology 3
- Premature treatment: Children with chronic HBV in the immunotolerant phase should not be treated but monitored for immune activation 5, 3
- Inappropriate use of herbal medications: Associated with prolonged cholestasis 1
- Failure to recognize early signs of liver failure: Monitor for subtle changes in mental status, coagulation parameters, and glucose levels 6
Follow-up Recommendations
- Regular monitoring of liver function until complete normalization
- Ultrasound examination if ALT remains elevated after 6 months 3
- For chronic viral hepatitis, lifetime follow-up is warranted due to risk of complications 5
By following this structured approach to the management of acute viral hepatitis in children, clinicians can ensure optimal outcomes while minimizing unnecessary interventions and potential complications.