Viral hepatitis in children

Jaundice in children.
Jaundice- it is the yellow coloration of the skin,
mucus membrane and sclera.
There are a good number of causes of jaundice in
children. But jaundice in neonates needs special
attention as it varies from physiological to
pathological state and is a separate entity.
Aside from any causes of jaundice , viral hepatitis
is more common in children and some times life
threatening.
 Viral hepatitis.
Viral hepatitis is major health problem both in develop and
developing countries.
The disorder is commonly caused by six hepatotrophic viruses
( A,B,C,D,E and G).
All are RNA viruses except D which is DNA.
Hepatitis A and E only causes acute hepatitis but B,C and D
causes chronic liver disease.
Transmission- B, C, D and G by hematogenus and A and E by
faeco- oral route.
Other viruses causes hepatitis are- Herpes simplex,
Cytomegaloviruses, Epstein-Bar-viruses,HIV,
Rubella ,Adenoviruses, Enteroviruses etc.
Other causes-
In acute hepatitis there is inflammation of hepatocytes
followed by dammage or necrosis of the cells. This
injury generally followed by complete recovery but in
prolong inflammation may followed by fibrosis and may
progress to cirrhosis.
The hepatotrophic viruses are heterogenus infectious
agents but they cause almost similar acute illness. Acute
phase causes no or mild clinical disease . Morbidity
mostly related to rare cases of acute liver failure in
susceptible patient and to chronic disease state and
attenuated complications that of 3 viruses (B,C and D).
Clinical manifestations
Asymptomatic – only rise of serum transaminases.
Anicteric- No jaundice but suffer from anorexia, Nausea,
Vomiting and mild fever and malaise.
Classical presentation-
Prodromal phase- non specific symptoms like malaise,
anorexia,nausea, vomitting, fever, headache ,myalgia etc.
last for 1-2 weeks.
Icteric phase- Jaundice, tender hepatomegaly, right
hypochondric pain. Urine become high color.
Recovery phase- constitutional symptoms disappear but
mild hepatomegaly and biochemical abnormalities may
persist
 Diagnosis.
Based on clinical features and laboratories investigation

Liver function test- All the parameters are elevated

Serum bilirubin.
SGPT
Prothrombin time (PT)
Alkaline phosphatase .
USG of abdomen to asses the liver ecogenicity and
ascitis.
 Investigations

Viral markers-
Anti HAV IgM
Anti HEV IgM
Anti HCV
HBsAg,
Hbc Ag and Anti HBc
Hbe Ag. And
Anti HBs Ag, Anti HBc IgM and IgG .
HBV DNA.
 General treatment
Counsel with parents about the natural history and
outcome of the disease.
Supportive treatment-
Rest- Restricted out door activities.
Diet- Normal or high calorie diet.
IV fluid if there is vomiting or difficult to
tolerate oral feed.
Vitamin K1 if INR >1.5.
Gut sterilizer, lactulose if necessary.
 Complications.
•Fulminating hepatic failure or
• Acute liver failure with coagulopathy,
Encephalopathy and cerebral oedema.
•Chronic liver disease caused by by
hepatitis B and C and D infection leads to
Cirrhosis and primary hepatocellular
carcinoma.
 Prevention.

•Maintenance of personal hygiene.

•Hand washing practice.
•Safe drinking water and sanitary disposal
of excreta.
•Screening before transfusion of blood
and blood products.
•Vaccination for Hepatitis B and A.
 Infant born to HBsAg positive or unknown HBsAg
status of mother.
HBV is present in high concentration in blood, serum
and serous exudates and in moderate concentration
in saliva, vaginal fluid and semen. HBsAg has been
demonstrated in human milk of infected mother.
Breast feeding by infected mother does not appear
to confer a greater risk of hepatitis on the offspring,
despite the possibility that cracked nipples may
result in ingestion of contaminated blood by nursing
infant.
The most important risk factor for chance of
transmission occurs through placental tear, trauma
during delivery, contact of infants mucus membrane
with infected maternal fluid.
Intrauterine transmission occur (2.5%) very rear.
The risk of transmission is greatest if the mother is
HBeAg positive.
Infant born to HbsAg positive mother should receive
first dose of hepatitis B vaccine (HBV) immediately
after birth and should be accompanied by 0.5ml of
HBIG as soon as after delivery ( within 12 hours)
because the effectiveness decreases rapidly with
increase time after birth.
If vaccination status is unknown, HBV vaccine should be
administered within 12 hours of regardless the birth
weight of the baby.
If Birth weight <2000 gm should be given HBIG and HBV
within 12 hours of birth.
Post vaccination testing to be done after 9-18 months.
If the baby is not vaccinated for HBV immediately
after birth, 95% the chance perinatal infection leads
to chronic infection.
In compare to adult chance of chronicity following
acute attack 5-10% .
 Hepatitis B
HBV , unlike the other hepatotrophic viruses, is
predominantly noncytopathogenic virus that causes
injury mostly by immune mediated process. Stronger
the immune response associated with greatest
likelihood of viral clearance and most severe
hepatocytes injury.
This immune response is also responsible for extra
hepatic condition of HBV infection. These are
polyarteritis nodosa, membranous glomerulonephritis,
polymyalgia and Guillain- Barre syndrome.
 Diagnosis and treatment.

Drugs used in the treatment of HBV infection.

•Interferon–alfa2b
•Lamivudine
•Adefovir
•Entacavir
•Tenofavir
•Peginterferon
•HBVIG.