Hospital Admission Criteria for Children with Hepatitis A
Most children with hepatitis A can be managed as outpatients with supportive care, but admission is indicated for those with signs of hepatic decompensation, severe dehydration, coagulopathy, or inability to maintain oral intake.
Indications for Hospital Admission
Absolute Indications
Coagulopathy or signs of hepatic decompensation: Admit any child with elevated INR (>1.5) or prolonged PT/aPTT, as these indicate impaired hepatic synthetic function and potential progression to fulminant hepatitis 1, 2, 3
Encephalopathy: Any altered mental status requires immediate hospitalization, as this signals acute liver failure 4
Severe vomiting or inability to maintain hydration: Vomiting is the most common reason for hospitalization (58.7% of admitted cases), particularly when it prevents adequate oral intake 2
Clinical signs of fulminant hepatitis: Though rare (approximately 0.9-1.3% of pediatric cases), fulminant hepatitis carries significant mortality risk and requires intensive monitoring 2, 3
Relative Indications Requiring Clinical Judgment
Markedly elevated transaminases (AST/ALT >1000 IU/L): These children have significantly higher rates of vomiting, abdominal pain, and coagulopathy, warranting closer observation 2
Severe abdominal pain: Present in 28% of hospitalized patients and may indicate complications such as acalculous cholecystitis or ascites 2, 5, 3
Evidence of extrahepatic complications: Including pleural effusion (14.1% of cases), ascites (44.9%), acute renal failure, or cardiac involvement, though these are uncommon 4, 5, 3
Age considerations with underlying conditions: Children with pre-existing chronic liver disease are at higher risk for fulminant hepatitis and should have a lower threshold for admission 6, 1
Outpatient Management Criteria
Children can be safely managed at home if they meet ALL of the following:
- Able to maintain adequate oral hydration 1
- Normal or minimally elevated INR/PT 1
- No encephalopathy 1
- Reliable caregiver with access to follow-up care 7
- No signs of hepatic decompensation 1
Monitoring During Admission
Serial assessment of coagulopathy (INR) and mental status to detect early hepatic decompensation 1
Nutritional support ensuring adequate caloric intake, as malnutrition can complicate recovery 1
Avoid all hepatotoxic medications during the acute phase 1
Mean hospitalization duration is approximately 5.2 days (range 1-40 days), with no significant difference by age 2
Critical Clinical Pitfalls
Peak infectivity occurs 2 weeks BEFORE jaundice onset, meaning the child has already been maximally contagious when presenting with jaundice 6, 7
Children shed virus for up to 10 weeks after symptom onset, requiring infection control precautions even during recovery 6, 7, 1
Relapsing hepatitis occurs in 10-15% of cases and can last up to 6 months, but this does NOT indicate chronic infection or require admission unless decompensation occurs 6, 1
Hepatitis A never causes chronic hepatitis—complete recovery is the rule, so do not mistake prolonged cholestatic phase for chronic disease 1
Hematologic abnormalities including thrombocytopenia (2.6-5.1%), leukopenia (16.6%), and coagulopathy (11.9-15.4%) can occur and require monitoring 2, 3