Treatment Guidelines for Acute Viral Hepatitis in Pediatric Patients
For pediatric patients with acute viral hepatitis, supportive care remains the mainstay of treatment, with specific antiviral therapy recommended only in select cases based on the viral etiology and disease severity.
General Management Principles
Supportive Care
- Ensure adequate hydration and nutrition with high-calorie diet
- Monitor for signs of liver failure (coagulopathy, encephalopathy)
- Avoid hepatotoxic medications
- Recommend abstinence from alcohol (for adolescents)
- Consider hospitalization for:
- Inability to maintain oral intake due to severe nausea/vomiting
- Signs of hepatic encephalopathy
- Coagulopathy (INR >1.5)
- Hypoglycemia
Specific Management by Viral Etiology
Hepatitis A
- Primarily supportive care as infection is self-limited
- Post-exposure prophylaxis with HAV vaccine for contacts
- Monitor liver function tests every 2-4 weeks until normalization
- No specific antiviral therapy indicated
Hepatitis B
Acute HBV Infection
- Most cases resolve spontaneously with supportive care
- Consider lamivudine 100 mg/day for severe acute hepatitis B with evidence of liver failure 1
- Monitor HBV DNA, HBeAg/anti-HBe, and liver function tests
Chronic HBV Infection
Regular monitoring with physical examination and ALT/HBeAg testing every 6 months 2
For HBeAg-positive patients with elevated ALT, monitor every 3 months for at least one year 2
Treatment indications:
- ALT >1.5× ULN for at least 6 months
- HBV DNA >2000 IU/ml
- Moderate to severe inflammation/fibrosis on biopsy 3
Treatment options:
- Children ≥12 years: Tenofovir (or entecavir if ≥16 years) 2
- Children <12 years with moderate/severe inflammation: Interferon-α or lamivudine 2
- Children with cirrhosis, HBV-related glomerulonephritis, or receiving immunosuppressive therapy should receive antiviral treatment regardless of other parameters 3
Hepatitis C
Acute HCV Infection
- Interferon-alpha therapy may be considered to decrease risk of chronicity, though evidence is limited 3, 1
- Monitor HCV RNA at 1 month of age for infants born to HCV-infected mothers 4
- If negative, perform confirmatory anti-HCV antibody testing between 12-15 months 4
Chronic HCV Infection
FDA-approved regimens for pediatric patients ≥3 years 2:
The HCV guidance panel recommends awaiting approval of pangenotypic regimens unless there is a compelling need for immediate treatment of children aged 3-11 years with genotype 2 or 3 infection 2
Monitoring During Treatment
- Test for active HBV infection (HBsAg, anti-HBc, anti-HBs) prior to initiating HCV DAA therapy due to risk of HBV reactivation 2
- Monitor glucose levels in children with diabetes and INR in those taking warfarin during HCV treatment 2
- For HBV treatment, monitor ALT, HBeAg/anti-HBe status, and HBV DNA levels
Management of Acute Liver Failure
- Occurs in 2-3% of acute viral hepatitis cases 3
- Requires immediate ICU admission
- Management includes:
- Correction of coagulopathy
- Prevention and treatment of cerebral edema
- Management of renal dysfunction
- Consideration for liver transplantation evaluation in severe cases 6
- N-acetylcysteine is recommended routinely in patients with acute liver failure 6
- Protein restriction is not recommended; enteral nutrition is preferred to parenteral nutrition 6
- Criteria for liver transplantation consideration: INR >4 or Factor V concentration <25% 6
Special Considerations
- Lifetime follow-up is warranted even for inactive HBV carriers due to risks of cirrhosis, HCC, and reactivation 3
- HCC surveillance with liver ultrasound every 6-12 months for children with chronic HBV, depending on fibrosis stage 2
- Children with chronic HCV may develop progressive fibrosis/cirrhosis, particularly with obesity and insulin resistance 4