Management of Viral Hepatitis in Children
The management of viral hepatitis in children primarily involves supportive care for acute cases, while chronic hepatitis requires careful monitoring with selective antiviral treatment based on specific clinical criteria. 1
Diagnosis and Monitoring
Acute Viral Hepatitis
- Most cases of acute viral hepatitis in children are self-limited and resolve without specific treatment 1
- Initial evaluation should include:
- Complete blood count
- Liver function tests (ALT, AST, bilirubin, albumin, PT/INR)
- Hepatitis viral serologies (HAV, HBV, HCV)
- Autoimmune markers if indicated
- Metabolic workup if indicated 1
Chronic Viral Hepatitis Monitoring
- Children with chronic HBV should undergo:
- Physical examination and measurement of ALT and HBeAg/anti-HBe every 6 months 2
- For HBeAg-positive patients with elevated ALT: monitor ALT every 3 months for at least one year 2
- For HBeAg-negative patients: measure ALT and HBV DNA every 4 months during the first year 2
- After confirmation of inactive carrier status (normal ALT and HBV DNA <2000 IU/ml): monitor every 6 months 2
- Full blood count and liver function tests yearly 2
- HCC surveillance with liver ultrasound every 6–12 months (depending on fibrosis stage) 2
Treatment Approach
Acute Viral Hepatitis
- No specific antiviral therapy is recommended for most cases of acute viral hepatitis in children 1
- Supportive care includes:
- Bedrest if very symptomatic
- High-calorie diet
- Avoidance of hepatotoxic medications
- Abstinence from alcohol 3
- For severe acute HBV with concerning presentation, lamivudine 100 mg/day may be beneficial 1, 3
Chronic Hepatitis B Treatment Criteria
Treatment should only be considered if:
Children in the immunotolerant phase (normal/mildly elevated ALT with high viral load) should not receive treatment but should be monitored for immune activation 2, 1
Chronic Hepatitis C Treatment
- Direct-acting antivirals approved for children include:
Special Considerations
Indications for Treatment Despite Not Meeting Standard Criteria
- Antiviral treatment with nucleos(t)ide analogues should be instituted in:
- HBV-infected children undergoing liver transplantation 2
- Recipients of grafts from anti-HBc-positive donors 2
- HBsAg-positive patients receiving immunosuppressive or cytotoxic treatment 2
- Children with cirrhosis, HBV-related glomerulonephritis, or co-infection with HDV, HCV or HIV 2
- Children with family history of HCC, even with mild histological changes 2
Management of Complications
- Acute liver failure (2-3% of cases) requires:
- ICU admission
- Correction of coagulopathy
- Prevention and treatment of cerebral edema
- Management of renal dysfunction
- Consideration for liver transplantation in severe cases 1
Common Pitfalls and Caveats
Premature treatment initiation: Children with elevated ALT should be monitored for at least 6 months before considering antiviral treatment to avoid treating those undergoing spontaneous HBeAg seroconversion 2
Overreliance on invasive procedures: Non-invasive methods to assess hepatic fibrosis (e.g., FibroScan) may be useful but currently cannot substitute for liver biopsy in treatment decisions 2
Inadequate follow-up: Lifetime follow-up is warranted even for inactive carriers due to risks of cirrhosis, HCC, and reactivation of HBV infection 2, 1
Overlooking comorbidities: For overweight/obese children with viral hepatitis, counseling on diet and exercise is essential as obesity can accelerate liver disease progression 1
Inappropriate treatment of immunotolerant phase: Children with normal/mildly elevated ALT and high viral load generally don't respond to interferon treatment alone and are not good candidates for nucleos(t)ide analogue therapy due to resistance risk 2