Pediatric Hepatitis A Treatment & Management

Updated: Apr 14, 2016
  • Author: Nicholas John Bennett, MBBCh, PhD, MA(Cantab), FAAP; Chief Editor: Russell W Steele, MD  more...
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Treatment

Approach Considerations

No specific therapy is available. The investigational antienteroviral drug pleconaril (Disoxaril; ViroPharma) has no activity against hepatitis A virus (HAV). Treatment is therefore supportive.

Hospitalization is indicated for patients with significant dehydration due to vomiting or those with fulminant hepatitis.

Consultation with a subspecialist is generally not required. Fulminant hepatitis warrants care by a pediatric gastroenterologist and, possibly, an intensive care specialist.

Go to Hepatitis A, Pediatric Hepatitis B, Pediatric Hepatitis C, and Viral Hepatitis complete information on these topics.

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Supportive Care

Inpatient care is not needed for most patients with HAV infection. Some patients may require hospitalization for intravenous (IV) rehydration. Once emesis subsides and the patient can tolerate oral fluids, discharge is appropriate. In the rare case of fulminant hepatitis, transfer to a facility with pediatric subspecialty care is indicated.

Follow-up liver enzyme studies should be performed at monthly intervals until levels normalize. If elevations persist for longer than 3 months, complications or additional diagnoses should be considered.

Medications that have known liver toxicity should be avoided.

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Immunization

Pre-exposure prophylaxis with HAV vaccine is recommended for persons aged 1 year or older who are traveling to countries where HAV infection is endemic. If the trip is shorter than 2 weeks, or if the patient is younger than 1 year, IG should be given. If the trip is longer than 3 months, a larger dose of IG (0.06 mL/kg) is needed for those who cannot receive the vaccine. Repeat dosing is recommended if the trip lasts longer than 5 months.

HAV vaccine is currently licensed for use in children aged 12 months or older. [6, 7] One dose of vaccine leads to seroconversion in 88% of adult patients by 15 days and in 99% of adult patients by 1 month. When followed with a second dose 6 months later, the vaccine leads to 100% seroconversion. In those treated with immunosuppressive agents, protective antibody levels appear to be significantly lower, and a single dose does not afford much protection (only 33% after the first dose in one study of patients treated for rheumatoid arthritis). [8] Immunity from the HAV vaccine in healthy people appears to last several decades and is probably life-long. [9]

Others who should receive the vaccine include children aged 12-35 months, patients with chronic liver disease, homosexual or bisexual men, users of injectable illicit drugs, and those with a high occupational risk (those who work with nonhuman primates and HAV laboratory workers). [10]

Vaccination in areas of extremely high incidence of infection may only be cost-effective if prevaccination serology is obtained to target nonimmune individuals. [11]

The Advisory Committee on Immunization Practices (in the United States) (ACIP) has recommended universal immunization in all children older than 1 year (the lower limit of the approved age range) and catchup immunization in those who have not been vaccinated. [12]  A 2016 study by Murphy et al reported that ACIP-recommended childhood HepA vaccination in the United States has eliminated most absolute disparities in HAV disease by age, race/ethnicity, and geographic area with relatively modest ≥1-dose and ≥2-dose vaccine coverage. [13]

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Postexposure Prophylaxis

Postexposure prophylaxis consists of the administration of HAV vaccine (preferred if the patient is >1 y and < 40 y) or immune globulin (IG) to contacts as soon as possible, but no later than 2 weeks after exposure. IG is given as an intramuscular injection of 0.02 mL/kg. It is 80-90% effective in preventing HAV infection by means of passive immunity.

Candidates for postexposure prophylaxis include household and sexual contacts of infected patients, contacts in childcare centers during outbreaks, and, if the patient is a food handler, others who work at the same establishment. Information regarding administration of hepatitis A vaccine after exposure (either alone or in addition to IG) is currently available. [14, 15, 12]

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Diet and Activity

No specific dietary changes are needed. In euvolemic patients with vomiting (but without dehydration that necessitates IV fluid therapy), appropriate intake of oral fluid is recommended, as with other viral illnesses.

Patients should not return to school or work for 1 week after the onset of illness. Hospitalized patients who use diapers or those who are incontinent should have contact isolation for 1 week after the onset of illness. Otherwise, activity can be resumed as tolerated.

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Prevention

General prevention measures consist of good personal hygiene, handwashing, ingestion of safe drinking water, and proper sanitation. Prevention specific to hepatitis A infection includes the use of IG and HAV vaccine [16] (see Postexposure Prophylaxis and Immunization).

The use of contact precautions is recommended for hospitalized patients for 1 week after the onset of symptoms.

People with chronic liver conditions, such as infection with HBV or HCV, should also be vaccinated against hepatitis A virus.

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