Patient Presentation
A 2-week-old male came to clinic with his parents for his health supervision visit. He had surpassed his birth weight by 10%. The parents voiced usual concerns, but the father also asked about anything special he should do because he himself had chronic Hepatitis C. He was an older father and had contracted it through a blood transfusion during a surgery as a teenager. He only knew about it several years later when he was told he could not donate blood. He was being monitored by his physician and his wife was Hepatitis C negative during pregnancy.
The pertinent physical exam showed a healthy newborn with growth parameters in the 50-90% He had some erythema toxicum on his face. The diagnosis of a healthy newborn was made. The pediatrician wasn’t sure if there were specific recommendations for newborns and other children living in a family with a Hepatitic C positive parent. After looking at several articles online including recommendations from two professional groups in different countries, the pediatrician contacted the father. The infant had already had Hepatitis B vaccine and would receive additional doses plus Hepatitis A at the proper time. The father was told to be careful with any blood or body fluids that the child over time could come in contact with. He was also advised to not share toothbrushes or razors with the child as he grew. The pediatrician also recommended continued monitoring by the father and mother’s own physicians.
Discussion
Hepatitis C virus (HCV) is a single-stranded RNA Flavivus that was first identified in 1989 and universal screening in the blood supply was begun in 1992 in the United States. Overall incidence of acute HCV in children under age 19 is 0.1 per 100,000.
In adults, the transmission is mainly from contaminated blood and body fluids, primarily intravenous drug use. It is the most common reason for liver transplantation in adults. Of those that acquire the acute infection, about 70% go on to become chronically infected. Adults have a slow progression of their disease with 20% having cirrhosis within 20 years. Being male, older, increased duration of infection, co-infections (particularly HIV and Hepatitis B), immunosuppression, hepatotoxic drug and alcohol use all increase the risk of cirrhosis. There is a 3-4% chance of hepatocellular carcinoma developing in chronic HCV patients with cirrhosis.
In children the transmission is mainly vertical. Among family members, transmission is uncommon but inapparent or direct percutaneous or mucosal exposure to blood could occur. Of infants born to HCV-positive mothers, about 5-10% will acquire HCV. Of those that are acutely infected, only about 50-60% become chronically infected, and 25-75% of those will spontaneously resolve by 2-3 years of age. Unfortunately school age children and teenagers who acquire the infection have a natural history that is like adults. Most children who were infected at birth have no symptoms and may have normal, or elevated transaminases and viral levels. Long-term studies (10-20 years) show perinatally acquired HCV patients only have a 5-10% chance of significant fibrosis and < 5% develop cirrhosis.
Testing is by specific immunoassays which detect IgG antibodies. Those for IgM are not available. Treatment recommendations are different for children infected through vertical transmission and older children and adults. Because younger children have a high spontaneous resolution rate, treatment may not be necessary particularly since there are side effects to the medications. Recommendations are also changing particularly in the adult populations as new medications are available and are studied more. Factors regarding treatment include: age, presumed transmission method, co-infection, genotype of HCV virus (type 1 is the most common in the US), and actual liver disease. Biomarkers for liver disease are available but are not as thoroughly developed and as useful in the pediatric population.
Learning Point
For families living with a HCV+ family member some general recommendations are advised. All patients should be vaccinated against Hepatitis A and B. HCV patients should also avoid hepatotoxic medications and excessive alcohol. Universal precautions with prompt treatment and clean-up of bloody wounds should be advised. There also should be no sharing of toothbrushes and razors. Breastfeeding is not contraindicated by a HCV+ mother. Patients who are HCV+ can go to a group-based childcare facility. For HCV+ people, changes in sexual practices are not recommended if a steady partner is maintained, but the partner should be informed of the risks and ways to prevent transmission. People with multiple sexual partners are recommended to use condoms and decrease the number of partners.
Questions for Further Discussion
1. When should infants be tested for HCV if their mother is HCV positive?
2. What is the incidence of Hepatitis C in your local area?
Related Cases
- Disease: Hepatitis C
- Symptom/Presentation:Health Maintenance and Disease Prevention
- Specialty: Infectious Diseases
- Age: Newborn
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for this topic: Hepatitis C
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
American Academy of Pediatrics. Hepatitis C, In Pickering LD, Baker CJ, Kimberlin DW, Long SS, eds. Red Book: 2009 Report of the Committee on Infectious Diseases. 28th edit. Elk Grove Village, IL: American Academy of Pediatrics; 2009; Accessed from the Internet on 3/6/13.
Jhaveri R. Diagnosis and management of hepatitis C virus-infected children. Pediatr Infect Dis J. 2011 Nov;30(11):983-5.
Porto AF, Tormey L, Lim JK. Management of chronic hepatitis C infection in children. Curr Opin Pediatr. 2012 Feb;24(1):113-20.
Lagging M, Duberg AS, Wejstal R, Weiland O, Lindh M, Aleman S, Josephson F; Swedish Consensus Group. Treatment of hepatitis C virus infection in adults and children: updated Swedish consensus recommendations. Scand J Infect Dis. 2012 Jul;44(7):502-21.
ACGME Competencies Highlighted by Case
1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients’ is gathered.
3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
4. Patient management plans are developed and carried out.
5. Patients and their families are counseled and educated.
6. Information technology to support patient care decisions and patient education is used.
7. All medical and invasive procedures considered essential for the area of practice are competently performed.
8. Health care services aimed at preventing health problems or maintaining health are provided.
9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.
12. Evidence from scientific studies related to the patients’ health problems is located, appraised and assimilated.
13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
15. Information technology to manage information, access on-line medical information and support the healthcare professional’s own education is used.
18. Using effective nonverbal, explanatory, questioning, and writing skills, the healthcare professional uses effective listening skills and elicits and provides information.
22. Sensitivity and responsiveness to patients’ culture, age, gender, and disabilities are demonstrated.
24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.
Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital
Pediatric Education 