—Alan Franciscus, Editor-in-Chief
It is estimated that Hepatitis C (HCV) occurs in about 0.15% of 6-11 year-olds and 0.4% of 12-19 year-olds. It is estimated that there are 23,000 to 46,000 children in the US with HCV.1 The actual number of children with HCV is unknown because children are not routinely tested for it.
Prior to 1992, the most common transmission route for HCV in children was through blood transfusion, blood products, and organ transplantation. Now that blood products and organs are screened for hepatitis C the most frequent transmission of hepatitis C in infants is mother-to-child transmission. The second most common transmission route in children and teenagers is in those who share equipment to inject drugs (needles, cookers, cotton, water, etc.)
Transmission of HCV from an HCV-infected mother-to-infant occurs about 6% of the time. It can occur up to 10% of the time if a mother is coinfected with HIV and hepatitis C. Also, a high viral load increases the risk of mother-to-infant transmission. Unfortunately, there are no effective strategies or drugs to prevent the transmission of HCV from mother to child.
When a baby is born to an HCV-infected mother, the child will acquire the mother’s HCV antibodies. For this reason, the child will not be tested for HCV antibodies for 18 months. This is the period that it takes for the baby’s body to clear out the mother’s antibodies.
An HCV RNA or viral load test can be given as early as one month. It might be too early since the HCV RNA, or viral load fluctuates during the acute infection phase. Also, babies have a high rate of natural clearance. Most medical providers prefer to wait out the 18-month period to test for HCV antibodies and the confirmatory HCV RNA (viral load test).
Table 1. Children for whom screening is recommended.
- Children and adolescents with unexplained elevated aminotransferasesChildren at risk for vertically acquired HCV
- Children from regions with high prevalence of HCV (adoptees, refugees, immigrants)
- Children and adolescents with HIV
- Children or adolescents who are victims of sexual assault
- Adolescents with multiple sexual partners
- Adolescents who are or were intravenous drug users, even if only once in the past
- Children or adolescents who have ever been on dialysis
- Sexual partner of HCV-infected person
- Children or adolescent who have received needle stick (needles, piercing or tattooing)*
Source: Mack CL1, Gonzalez-Peralta RP, Gupta N, et al. NASPGHAN practice guidelines:
Diagnosis and management of hepatitis C infection in infants, children, and adolescents Pediatric Gastroenterol, Nutr 2012;54:838-855
Baker R. Viral Hepatitis. In: Pohl JF, editor. Pediatric Gastroenterology. Baton Rougue, FL: CRC Press: 2014. pp 313-327
*I read this recommendation with interest because we know that receiving a tattoo or piercing in a commercial parlor is safe. .
Approximately 75% of infants who are acutely infected with hepatitis C will continue to chronic infection. In children, the rate of disease progression is slow. There is, however, a small percentage (estimated at less than 2%) of children in whom there is a rapid rate of disease progression that could lead to fibrosis and cirrhosis.
Watch, Wait and Protect
A baby born to an HCV-infected mother should receive the hepatitis A and hepatitis B vaccines to protect the child from becoming infected with another liver disease. As well the baby and child should receive other immunizations to protect the health of the child.
Hepatitis C is not spread by casual contact and infected children should not be restricted from attending daycare or school. Children should be taught that they should not share toothbrushes, nail clippers, razors or any other items that have the potential to transmit hepatitis C.
Any drug, herb or supplement that the child is given should be screened to make sure that it is liver safe. When the child is older, a discussion should take place about sex, drugs, and alcohol.
Most importantly, a child should be medically monitored on a regular basis.
When to Tell a Child
Telling a child that they have hepatitis C can be one of the most difficult decisions a parent can ever make. The timing is the most important decision. The best advice is never to lie to a child. We have an excellent fact sheet that can provide plenty of advice to parents. http://hcvadvocate.org/hepatitis/factsheets_pdf/TellChild_HCV.pdf
As stated above most children have a slowly progressive disease. For the small percentage that have severe fibrosis or cirrhosis, immediate treatment may be needed. The decision to treat or not is never easy and in children it is even more difficult. Some questions that are important to consider include:
- Can treatment be postponed until the interferon-free therapies are available?
- Is there an interferon-free clinical trial that your child can enroll in?
- Are you and your child ready to take on interferon treatment and the side effects?
- The new medications are very expensive—there is always the possibility that your insurance company may not cover the new medications.
Current treatment of pegylated interferon plus ribavirin is approved for children who are three years and older with compensated cirrhosis.
Again, most children have slowly progressive disease, and it takes decades before serious liver disease develops. By this time, children will age to adults and be eligible for interferon- and ribavirin-free therapies that approach 100% effectiveness.
Hepatitis C infections are on the rise. The so-called Second Epidemic of hepatitis C is affecting females equally as males. As a result, there will be many women of child-bearing age that will become pregnant and have children who may also have hepatitis C.
For the first time, there is an opportunity to prevent mother-to-child transmission. Direct-acting antiviral medications without ribavirin that are pregnancy category B.
Pregnancy Category B: In humans, there are no well-controlled studies. However, in animal studies, pregnant animals received the medicine, and the babies did not show any problems related to the medicine.
However, there have not been any clinical studies using the interferon- and ribavirin-free medications in pregnant women. As a result, studies are needed to evaluate the safety and effectiveness of these new drugs for the mother and the infant.
1American Liver Foundation
Source: Hepatitis C in Children in Times of Changes, Robert D. Baker and Susan S. Baker Walters Kluwer Health, Inc.