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 is 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