HCV in children and pregnancy

HCV infections in children and pregnancy are less understood than in adults. Worldwide, the prevalence of hepatitis C virus infection in pregnant women and children has been estimated to 1-8% and 0.05-5% respectively.[1] The vertical transmission rate has been estimated to be 3-5% and there is a high rate of spontaneous clearance (25-50%) in the children. Higher rates have been reported for both vertical transmission (18%, 6-36% and 41%).[2][3] and prevalence in children (15%).[4]

In developed countries, transmission around the time of birth is now the leading cause of HCV infection. In the absence of virus in the mother's blood, transmission seems to be rare.[3] Factors associated with an increased rate of infection include membrane rupture of longer than 6 hours before delivery and procedures exposing the infant to maternal blood.[5] Cesarean sections are not recommended. Breastfeeding is considered safe if the nipples are not damaged. Infection around the time of birth in one child does not increase the risk in a subsequent pregnancy. All genotypes appear to have the same risk of transmission.

HCV infection is frequently found in children who have previously been presumed to have non-A, non-B hepatitis and cryptogenic liver disease.[6] The presentation in childhood may be asymptomatic or with elevated liver function tests.[7] While infection is commonly asymptomatic both cirrhosis with liver failure and hepatocellular carcinoma may occur in childhood.

Diagnosis

Guidelines for the investigation of babies born to hepatitis C positive mothers have been published.[8]

In children born to hepatitis C virus antibody positive but hepatitis C virus RNA negative mothers, the alanine aminotransferase and hepatitis C virus antibodies should be investigated at 18-24 months of life. If both the alanine aminotransferase value is normal and hepatitis C virus antibody is not found, follow up should be interrupted.
In children born to hepatitis C virus RNA positive mothers, alanine aminotransferase and hepatitis C virus RNA should be investigated at 3 months of age. Of these
(1) hepatitis C virus RNA positive children should be considered infected if viremia is confirmed by a second assay performed by the 12th month of age
(2) hepatitis C virus RNA negative children with abnormal alanine aminotransferase should be tested again for viremia at 6-12 months and for antibodies to the hepatitis C virus at 18 months
(3) hepatitis C virus RNA negative children with normal alanine aminotransferase should be tested for antibodies to the hepatitis C virus and have their alanine aminotransferase reestimated at 18-24 months. They should be considered non infected if both the alanine aminotransferase is normal and the antibody levels to the hepatitis C virus are undetectable.
The presence of anti hepatitis C virus antibody beyond the 18th month of age in a never viremic child with normal alanine aminotransferase is likely consistent with past hepatitis C virus infection.

Treatment

Treatment of children has been with interferon and ribavirin.[9] The response to treatment is similar to that in adults.[10] It shows a similar dependence on the genotype. Recurrence after transplant is universal and the outcomes after transplant are usually poor.[11]

In children treatment should be initiated within 12 weeks of the detection of the viral RNA if viral clearance has not occurred within this time.[12] Given the difficulties with establishing a diagnosis of hepatitis C infection in infancy, this recommendation does not apply to infants.

Both pegylated interferon and ribavirin are unsuitable for use in pregnancy and infancy: newer methods of treatment are urgently required.

References
  1. Arshad M, El-Kamary SS, Jhaveri R (2011). "Hepatitis C virus infection during pregnancy and the newborn period--are they opportunities for treatment?". J Viral Hepat. 18 (4): 229–236. doi:10.1111/j.1365-2893.2010.01413.x. PMID 21392169.
  2. Hunt CM, Carson KL, Sharara AI (1997). "Hepatitis C in pregnancy". Obstet Gynecol. 89 (5 Pt 2): 883–890.
  3. Thomas SL, Newell ML, Peckham CS, Ades AE, Hall AJ (1998). "A review of hepatitis C virus (HCV) vertical transmission: risks of transmission to infants born to mothers with and without HCV viraemia or human immunodeficiency virus infection". Int J Epidemiol. 27 (1): 108–117. doi:10.1093/ije/27.1.108. PMID 9563703.
  4. Fischler B (2007). "Hepatitis C virus infection". Semin Fetal Neonatal Med. 12 (3): 168–173. doi:10.1016/j.siny.2007.01.008. PMID 17320495.
  5. Indolfi G, Resti M (2009). "Perinatal transmission of hepatitis C virus infection". J Med Virol. 81 (5): 836–843. doi:10.1002/jmv.21437. PMID 19319981.
  6. González-Peralta RP (1997). "Hepatitis C virus infection in pediatric patients". Clin Liver Dis. 1 (3): 691–705. doi:10.1016/s1089-3261(05)70329-9. PMID 15560066.
  7. Suskind DL, Rosenthal P. "Chronic viral hepatitis". Adolesc Med Clin. 15 (1): 145–58, x–xi. doi:10.1016/j.admecli.2003.11.001. PMID 15272262.
  8. Resti M, Bortolotti F, Vajro P, Maggiore G, Committee of Hepatology of the Italian Society of Pediatric Gastroenterology and Hepatology (2003). "Guidelines for the screening and follow-up of infants born to anti-HCV positive mothers". Dig Liver Dis. 35 (7): 453–457. doi:10.1016/s1590-8658(03)00217-2.CS1 maint: multiple names: authors list (link)
  9. Hu J, Doucette K, Hartling L, Tjosvold L, Robinson J (Jul 13, 2010). "Treatment of hepatitis C in children: a systematic review". PLoS ONE. 5 (7): e11542. doi:10.1371/journal.pone.0011542. PMC 2903479.
  10. Serranti D, Buonsenso D, Ceccarelli M, Gargiullo L, Ranno O, Valentini P (2011). "Pediatric hepatitis C infection: to treat or not to treat...what's the best for the child?". Eur Rev Med Pharmacol Sci. 15 (9): 1057–1067.
  11. Rumbo C, Fawaz RL, Emre SH, Suchy FJ, Kerkar N, Morotti RA, Shneider BL (2006). "Hepatitis C in children: a quaternary referral center perspective". J Pediatr Gastroenterol Nutr. 43 (2): 209–216. doi:10.1097/01.mpg.0000228117.52229.32.
  12. Lagging M, Duberg AS, Wejstål R, Weiland O, Lindh M, Aleman S, Josephson F, Swedish Consensus Group (2012). "Treatment of hepatitis C virus infection in adults and children: updated Swedish consensus recommendations". Scand J Infect Dis. 44 (7): 502–521. doi:10.3109/00365548.2012.669045. PMC 4732459.
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