What are the management and follow-up recommendations for an infant born to a mother with Hepatitis C (HCV) who tests negative for anti-HCV (Hepatitis C antibody) at birth?

Management of Infants Born to HCV-Positive Mothers with Negative Anti-HCV at Birth

A negative anti-HCV test at birth in an infant born to an HCV-positive mother is expected and does not rule out infection, as maternal antibodies cross the placenta and can persist up to 18 months—definitive testing should be performed at or after 18 months of age with anti-HCV antibody testing, or earlier with HCV RNA testing at 2-6 months if there is concern for loss to follow-up. 1

Understanding the Initial Negative Result

• Maternal antibodies are passively transferred across the placenta to all infants, making anti-HCV antibodies detectable in 96.8% of infants at birth, regardless of actual infection status 1
• These passively acquired antibodies gradually disappear: 15.3% remain positive at 12 months, 1.6% at 18 months, and only 1.0% at 24 months 1
• A negative anti-HCV at birth does NOT exclude HCV infection and requires appropriate follow-up testing 1

Recommended Testing Algorithm

Primary Recommendation: Anti-HCV Testing at ≥18 Months

• Test all infants born to HCV-positive mothers with anti-HCV antibody at or after 18 months of age 1
• This timing allows maternal antibodies to clear, making a positive result diagnostic of true infant infection 1
• If anti-HCV is positive at ≥18 months, confirm chronic infection with HCV RNA testing after age 3 years, as 25-50% of vertically infected infants spontaneously clear the virus by age 4 1

Alternative: Early HCV RNA Testing

• HCV RNA testing can be performed as early as 2 months of age if there is concern about loss to follow-up 1
• Testing at 2-6 months has high sensitivity and specificity for mother-to-child transmission 1
• Repetitive HCV RNA testing prior to 18 months is NOT recommended 1
• A single negative HCV RNA test in early infancy does not definitively exclude infection; follow-up antibody testing at ≥18 months remains necessary 1

Breastfeeding Guidance

• Breastfeeding is safe and should not be altered based on maternal HCV status alone 1, 2
• Breastfeeding does not increase the risk of vertical HCV transmission based on systematic review of 14 cohort studies 1
• The only exception: mothers should abstain from breastfeeding if nipples are cracked or bleeding 1, 3
• In cases of cracked or bleeding nipples, breast milk should be expressed and discarded until healing occurs 1, 3

Risk Counseling for Parents

• The overall risk of vertical transmission is approximately 5% (range 3.6-5.6%) 2, 4, 5
• Transmission occurs primarily at the time of birth, with no preventive interventions currently available 1
• Transmission only occurs from mothers who are HCV RNA-positive (viremic), not from mothers who are only antibody-positive 6, 4
• Higher maternal viral load correlates with increased transmission risk, though no specific threshold has been established 1, 5

General Precautions in the Home

• HCV is NOT transmitted by casual contact—infants pose no risk to other children or family members through normal daily activities 1
• Parents should implement universal precautions: avoid sharing toothbrushes, razors, nail clippers, or other items that might have blood on them 1
• Cover any cuts or sores on the infant's skin to prevent blood exposure 1
• Clean blood-contaminated surfaces with dilute bleach 1

Sibling Testing

• All siblings born to the same HCV-positive mother should be tested for HCV infection if not previously tested 1

Common Pitfalls to Avoid

• Do not assume a negative anti-HCV at birth means the infant is uninfected—this simply reflects maternal antibody status 1
• Do not perform multiple HCV RNA tests in the first 18 months—this is not recommended and adds no clinical value 1
• Do not restrict normal childhood activities based on HCV exposure risk—children can participate fully in school, sports, and all activities 1
• Do not discourage breastfeeding unless nipples are actively cracked or bleeding 1, 2