The term Hepatitis indicates inflammation/swelling of the liver. Viral Hepatitis which is a major health care burden in India is caused by 4 major types of viruses – A, B, C, and E. Below is the short overview regarding Viral Hepatitis in children and adolescents.
Hepatitis A: Hepatitis A virus (HAV) is the most common virus causing Hepatitis in children. HAV is found in the stool and blood of an infected person and is responsible for sporadic and endemic cases of acute Viral Hepatitis in the developing world with sanitation and personal hygiene. The virus usually transmitted through faecal-oral route by the ingestion of contaminated food or water. It also transmits from person to person contact with close contact with an infected person. Acute Hepatitis in children and adolescents is mostly due to Hepatitis A. In a small percentage of cases infected with this virus develop acute liver failure. In adults, Hepatitis A is less common but disease severity and fatality are more.
Hepatitis E: Similar to Hepatitis A, Hepatitis E is transmitted by faecal-oral route by the ingestion of contaminated food and water and close contact with an infected person. Hepatitis E mostly infects adults and adolescents, but it is less common in children. Like Hepatitis A, Hepatitis E also responsible for acute hepatitis (short term disease) and rarely acute liver failure. It is one of the common causes of acute liver failure in pregnancy.
Hepatitis B and C: Hepatitis B and C virus are less common in children than Hepatitis A and E. They are common in adults and causes most chronic liver diseases and complications like Cirrhosis and Liver Cancer. Hepatitis B and C are transmitted by parenteral routes – like needle injury, use of a contaminated needle, IV drug abuser, sexual route, and blood transfusion. In children, Hepatitis B and C are mostly acquired during the perinatal period either by vertical route (through the placenta from mother before the birth of the child) or during birth. Acute infection with Hepatitis B can cause both acute and chronic diseases. Infection with Hepatitis C mostly causes chronic disease in children and adolescents.
Manifestations: Patients with acute infection with Hepatitis viruses (Hepatitis A, B, and E) manifests as fever, malaise, nausea, poor appetite, pain abdomen, and vomiting in the prodromal phase (lasted for initial 3 – 7 days). Following this, the patient suddenly develops jaundice (yellowish discoloration of eyes and urine) – icteric phase. Once jaundice appeared, fever and other symptoms usually subside. This icteric phase persists for a variable time (days to weeks) and gradually subsides in most of the cases. Few patients with acute infection develop liver failure (acute liver failure) manifested as alteration of sensorium – like irrelevant talking, agitation, altered sleep cycle, drowsiness and unconsciousness, and bleeding.
Acute viral hepatitis in children below 2 – 5 years of age usually does not develop jaundice at all (Anicteric Hepatitis). They usually manifest as fever, pain abdomen, poor appetite, and vomiting. They need a very high index suspicion for diagnosis.
Chronic Hepatitis (Hepatitis B and C) in children are usually asymptomatic. Commonly, these two viruses are detected incidentally while the child is evaluated for some other reason. Rarely these viruses cause chronic liver diseases like Cirrhosis and Liver Tumor (Hepatocellular Carcinoma) in children and adolescents.
Diagnosis: Diagnosis of viral hepatitis needs a very high index of clinical suspicion especially in younger children. Blood test (Liver function tests) show elevated liver enzymes and serum bilirubin. Confirmation of viruses is done by serological tests (for antibody and antigen depending and viruses) and PCR tests (Hepatitis B and C).
Treatment: Treatment of acute viral hepatitis is symptomatic. No specific antiviral is currently available against Hepatitis A and E virus. Patients with acute viral hepatitis should take good nutrition and multivitamins, etc. Parents have misconceptions about the restriction of diet for children with jaundice. They give only boiled rice and dal and glucose water and fruit juices to the children once they noticed jaundice. This practice is detrimental for the patients as this further decreases the child’s appetite and hence dietary intake. Patients need to be hospitalized in case of persistent vomiting, poor oral intake, altered sensorium, unconsciousness, and bleeding.
Hepatitis B and C are treated with antiviral drugs which are very effective. With the availability of highly effective antiviral medicines, Hepatitis C is almost 98% curable.
In some rare instances, patients may need liver transplantation; in cases where patients develop acute liver failure, and complications of chronic liver disease (Hepatitis B and C infection) like Cirrhosis, Liver Tumor which is usually in adults age (after 40 years of age).
Prevention: As there is no antiviral drug against Hepatitis A and E, prevention is the best strategy. Improvement of sanitation, personal hygiene, avoidance of contaminated food and water (street side foods) are the measures for prevention of Hepatitis A and E viruses. Another effective measure is a vaccination that is available for Hepatitis A. There is no vaccine against Hepatitis E.
Hepatitis B and C can be prevented by avoiding reuse or sharing of a needle and safe sex practice, etc.
Prevention of perinatal transfer of Hepatitis B: Prevention of perinatal transmission of Hepatitis B to the baby is possible with the use of antiviral to the mother during the antenatal period and postnatal period. A baby of Hepatitis B positive mother should be vaccinated against Hepatitis B within 12 hours of birth. With this strategy, the transmission of Hepatitis B from mother to baby can be prevented in almost 95% of cases.
Dr. Mridul Chandra Das | Consultant, Pediatric Gastroenterology | Narayana Superspeciality Hospital Gurugram