Management of Viral Hepatitis in an 11 kg Child
Direct-acting antiviral (DAA) treatment with an approved regimen is recommended for all children with hepatitis C virus (HCV) infection aged ≥3 years regardless of disease severity, as they will benefit from antiviral therapy. 1
Hepatitis C Management
Assessment and Treatment Indications
- All children with HCV infection aged ≥3 years should receive antiviral therapy regardless of disease severity 1
- The presence of extrahepatic manifestations (cryoglobulinemia, rashes, glomerulonephritis) or advanced fibrosis should lead to early antiviral therapy to minimize future morbidity and mortality 1
- For an 11 kg child, weight-based dosing of medication is critical for efficacy and safety 1
Treatment Options for HCV
For children aged ≥3 years with HCV genotype 1,4,5, or 6 infection:
For children aged ≥3 years with HCV genotype 2 or 3:
Supportive Care for HCV
- No dosage adjustments are necessary for commonly prescribed medications such as antimicrobials, antiepileptics, and cardiovascular agents 1
- Acetaminophen is safe and effective when dosed per packaging recommendations 1
- NSAIDs and aspirin should be avoided in patients with cirrhosis and esophageal varices due to bleeding and nephrotoxicity risks 1
- Counsel parents about maintaining a healthy body weight for the child due to the deleterious effects of insulin resistance on HCV-related fibrosis progression 1
Hepatitis B Management
Assessment and Treatment Considerations
- Most children with chronic HBV infection are in a high-replication, low-inflammation phase with normal or slightly raised aminotransferases 2, 3
- Treatment decisions should be based on ALT levels, HBV DNA levels, and the severity of liver disease 1
- Liver biopsy may provide important information to guide treatment decisions 1
Treatment Options for HBV
For children aged ≥1 year: Interferon alfa-2b is approved 2
For children aged ≥2 years: Entecavir is approved 2
For children aged ≥3 years: Pegylated interferon alfa-2a and lamivudine are approved 2
For children aged ≥12 years: Adefovir and tenofovir disoproxil fumarate are approved 2
Lamivudine monotherapy is not advisable due to high incidence of resistance 1
For children with moderate to severe hepatitis, combination therapy may be considered 1
Monitoring and Treatment Duration
- Children being treated with nucleos(t)ide analogues should continue therapy for a minimum of 12 months 1
- All children receiving nucleos(t)ide analogues should be monitored for virologic breakthrough by measuring HBV DNA levels every 3 months 1
- Children with HBeAg-positive chronic HBV infection who achieve viral suppression and HBeAg seroconversion should have at least 6 months of consolidation therapy 1
Management of Acute Severe Hepatitis/Acute Liver Failure
- For acute severe autoimmune hepatitis: glucocorticoid therapy (prednisone or prednisolone, up to 2 mg/kg daily in children) is recommended as first-line treatment 4
- For acute liver failure: immediate evaluation for liver transplantation is recommended rather than prolonged medical therapy 4
- Rapid improvement in serum aminotransferase levels within 2 weeks is the most important indicator of favorable outcome 4
- Close monitoring is essential as the condition can deteriorate rapidly 4
Important Considerations and Pitfalls
- Early initiation of antiviral treatment is associated with better sustained response rates 5
- Regular follow-up of children at risk of acquiring HCV infection should assist in early diagnosis 5
- Alcohol abstinence should be strongly advised to reduce the risk of liver disease progression (for caregivers and age-appropriate patients) 1
- Patient adherence to treatment is critical, especially in adolescents, and may be a particular challenge with long-term therapy 1
- Parents should be educated about warning signs requiring immediate medical attention (jaundice, abdominal distension/pain, mental status changes, unusual bleeding/bruising, persistent vomiting, fever) 4