Hepatitis in Children

Hepatitis is an inflammation of the liver and can result in liver cell damage and destruction. Hepatitis is a concern because it often originates from a virus and is communicable (can be spread from your child to others). In some cases, liver failure or death can occur. However, not everyone who is infected will experience symptoms.

In the U.S.:

• Hepatitis A rates have declined by 95% since the hepatitis A vaccine first became available in 1995
• An estimated 800,000 to 1.4 million people have chronic hepatitis B infections
• An estimated 3.2 million people have chronic hepatitis C infections

Causes and Risk Factors

Hepatitis in children has many different origins or causes. A child may contract hepatitis from exposure to a viral source. The following is a list of some of the viruses associated with hepatitis:

• Hepatitis viruses. Five main types of the hepatitis virus have been identified, including hepatitis A, B, C, D, and E.
• Cytomegalovirus (CMV). This virus is a part of the herpes virus family that can be transmitted from person to person.
• Epstein-Barr virus (EBV). The virus most commonly associated with infectious mononucleosis.
• Herpes simplex virus (HSV). Herpes can involve the face and skin above the waist, or the genitalia.
• Varicella zoster virus (VZV). Also known as chickenpox, a complication of VZV is hepatitis, although these very rarely cause hepatitis in children or infants. 
• Enteroviruses. A group of viruses commonly seen in children such as coxsackie viruses and echoviruses.
• Rubella. Caused by the Rubivirus, rubella is a mild disease that causes a rash. It can cause problems for the fetus if contracted during pregnancy.
• Adenovirus. A group of viruses that commonly cause colds, tonsillitis, and ear infections in children. They can also cause diarrhea.
• Parvovirus. A virus referred to as fifth disease, which is characterized by a facial rash that is described as having a "slapped-cheek" appearance.

The following is a list of some of the diseases that may cause acute or chronic hepatitis in children:

• Autoimmune liver disease. The body's immune system develops antibodies that attack the liver causing an inflammatory process that leads to hepatitis.

Symptoms and Types

Hepatitis A

This type of hepatitis is usually spread by fecal-oral contact, or fecal-infected food and water, and may also be spread by blood-borne infection (which is rare). The following is a list of risk factors for hepatitis A:

• Consuming food made by an infected person who did not wash his or her hands well after using the bathroom
• Drinking water that is contaminated by infected feces — a problem in developing countries with poor sewage removal
• Getting your hands contaminated by an infected person's feces or dirty diaper, and then transmitting the infection to yourself by putting your hands near or in your mouth
• Outbreaks may occur in child care centers especially when there are children in diapers
• International travel to areas where hepatitis A is common
• Sexual contact with an infected person
• Use of illegal drugs
• Blood transfusions (very rare)

The CDC now recommends the vaccine for hepatitis A to children at age 1. Please consult your physician if you have questions about its use. Those at a high risk for hepatitis A include:

• Children who live in areas where there has been a community outbreak
• Children who have a blood clotting disorder, such as hemophilia
• Children who attend child care centers that have had outbreaks of hepatitis A
• Children with chronic liver disease

The vaccine is not recommended for children younger than age 12 months.

Hepatitis B

Hepatitis B (HBV) has a wide range of clinical presentations. It can be mild, without symptoms, or it may cause chronic hepatitis. In some cases, when infants and young children acquire hepatitis B, they are at high risk for chronic liver disease and liver failure. Transmission of hepatitis B virus occurs when blood from an infected person enters another person's body. Needle sticks, sharp instruments, sharing items (razors, toothbrushes), and sex with an infected person are primary modes of transmission. Infants may also develop the disease if they are born to a mother who has the virus. Infected children can spread the virus to other children if a child has many scrapes or cuts.

The following describes persons who are at risk for developing hepatitis B:

• Children born to mothers who have hepatitis B
• Children who are born to mothers who have immigrated from a country where hepatitis B is widespread such as southeast Asia and China
• Children who live in long-term care facilities or who are disabled
• Children who live in households where another member is infected with the virus
• Children who have a blood clotting disorder such as hemophilia and require blood products
• Children who require dialysis for kidney failure
• Adolescents who participate in high-risk activities such as IV drug use and/or unprotected heterosexual or homosexual contact

A vaccine for hepatitis B does exist and is now recommended as a routine childhood immunization. The CDC now recommends that all infants receive hepatitis B vaccination at birth, except in rare circumstances. It is also recommended for older children, under the age of 19, who have not been previously vaccinated. 

Hepatitis C

The symptoms of hepatitis C are usually mild and gradual. Children often show no symptoms at all. Transmission of hepatitis C occurs primarily from contact with infected blood, but can also occur from sexual contact or from an infected mother to her baby. Although hepatitis C has milder symptoms initially, it leads to chronic liver disease in a majority of people who are infected. According to the CDC, hepatitis C is the leading indication for liver transplantation in adults. With some cases of hepatitis C, no mode of transmission can be identified. The following describes persons who may be at risk for contracting hepatitis C:

• Children born to mothers who are infected with the virus
• People who have a blood clotting disorder such as hemophilia and received clotting factors before 1987
• Children who require dialysis for kidney failure
• Individuals who received a blood transfusion before 1992
• Adolescents who participate in high-risk activities such as IV drug use and/or unprotected heterosexual or homosexual contact with an infected person.

There is no vaccine for hepatitis C. People who are at risk should be checked regularly for hepatitis C. People who have hepatitis C should be monitored closely for signs of chronic hepatitis and liver failure.

Hepatitis D

This form of hepatitis can only occur in the presence of hepatitis B. If an individual has hepatitis B and does not show symptoms or shows very mild symptoms, infection with D can put that person at risk for liver failure that progresses rapidly. Hepatitis D can occur at the same time as the initial infection with B, or it may show up much later. Transmission of hepatitis D occurs the same way as hepatitis B, except the transmission from mother to baby is less common. Hepatitis D is rare in children born in the U.S. due to the common use of hepatitis B vaccine in infancy.

Hepatitis E

This form of hepatitis is similar to hepatitis A. Transmission occurs through fecal-oral contamination. It is less common in children than hepatitis A. Hepatitis E is most common in low resource countries and rarely seen in the United States. There is no vaccine for hepatitis E at this time.

What are the symptoms of hepatitis?

The following are the most common symptoms for hepatitis. However, each child may experience symptoms differently and some children may experience no symptoms at all.

Symptoms of acute (abrupt onset) hepatitis may include the following:

• Flu-like symptoms
• Jaundice (yellow color in the skin and/or eyes)
• Fever
• Nausea and/or vomiting
• Decreased appetite
• Not feeling well all over
• Abdominal pain or discomfort
• Diarrhea
• Joint pain
• Sore muscles
• Itchy red hives on skin
• Clay-colored stools
• Dark urine

Later symptoms include dark-colored urine and jaundice (yellowing of the skin, and eyes). The symptoms of hepatitis may resemble other conditions or medical problems. Always consult your child's doctor for a diagnosis.

Diagnosis and Tests

In addition to a complete medical history and examination by your doctor, diagnostic procedures and other tests to determine the extent of the disease may include the following:

• Blood testing for the following:
  • Liver enzymes
  • Liver function studies
  • Antibody and polymerase chain reaction (PCR) studies (to check for the type of viral hepatitis if present) 
  • Cellular blood counts
  • Coagulation tests, such as an international normalized ratio (INR) 
• Computed tomography scan (CT scan). This diagnostic imaging procedure uses a combination of X-rays and computer technology to produce horizontal, or axial, images (often called slices) of the body. A CT scan shows detailed images of any part of the body, including the bones, muscles, fat, and organs. CT scans are more detailed than general X-rays.
• Magnetic resonance imaging (MRI). MRI is a diagnostic procedure that uses a combination of large magnets, radiofrequencies, and a computer to produce detailed images of organs and structures within the body. The patient lies on a bed that moves into the cylindrical MRI machine. The machine takes a series of pictures of the inside of the body using a magnetic field and radio waves. The computer enhances the pictures produced. The test is painless, and does not involve exposure to radiation. Because the MRI machine is like a tunnel, some people are claustrophobic or unable to hold still during the test, and may be given a sedative to help them relax. Metal objects cannot be present in the MRI room, so persons with pacemakers or metal clips or rods inside the body cannot have this test done. All jewelry must be removed before the procedure.
• Liver biopsy. A small sample of liver tissue is obtained with a special biopsy needle and examined for abnormalities.

Treatment

Specific treatment for hepatitis will be determined by your child's diagnosis and health care provider based on:

• Your child's age, overall health, and medical history
• Extent of the disease
• Your child's tolerance for specific medications, procedures, or therapies
• Expectations for the course of the disease
• Your opinion or preference

Treatment for hepatitis varies depending on the underlying cause of the disease. The goal of treatment is to stop damage to the liver and alleviate symptoms. Treatment may include one, or more, of the following:

• Antiviral medications if it is a virus 
• Immune drugs if the diagnosis is an autoimmune disease 
• Supportive care (healthy diet and rest)
• Medications (to help control itching)
• Maintaining adequate growth and development
• Avoiding alcohol and drugs
• Preventing the spread of the disease (if the cause is viral hepatitis)
• Interferon drug therapy (a medication referred to as a "biologic response modifier" that can affect the immune system and has virus-fighting activities)
• Frequent blood testing (to determine disease progression)
• Hospitalization (may be required in more severe cases)
• Liver transplantation (may be recommended for end-stage liver failure)
• Proactive nutrition support 

How can viral hepatitis be prevented?

Proper hygiene is the key to preventing the spread of many diseases, including hepatitis. Other preventive measures include:

• Vaccinations. Vaccinations are available for hepatitis A and B.
• Blood transfusion. Blood transfusions are routinely screened for hepatitis B and C to reduce the risk of infection.
• Antibody preparation. If a person has been exposed to hepatitis A or B, an antibody preparation (immunoglobulin) can be administered to help protect them from contracting the disease.