Paeds · infectious-diseases
Hepatitis A, B, C and E in children
Also known as Viral hepatitis in children · Hepatitis A infection · Hepatitis B infection and chronic carriage · Hepatitis C infection · Hepatitis E infection · Acute viral hepatitis · Hepatotropic virus infection
Fellowship topic on the four hepatotropic viruses in children — hepatitis A, B, C and E — grouped by transmission route and chronicity. Hepatitis A and E are enteric, faecal-oral, acute and self-limited (with hepatitis E carrying disproportionate mortality in pregnancy); hepatitis B and C are blood-borne and perinatal, and become chronic when acquired at birth. The page covers the acute hepatitis presentation (and its anicteric form in young children), the serology and viral-load panels, the vertically-exposed neonate hepatitis B immunoprophylaxis bundle of birth-dose vaccine plus HBIG and maternal tenofovir suppression, the hepatitis C test-and-treat pathway with direct-acting antivirals, the support-and-survival pathway for hepatitis E, and the acute liver failure bundle where INR — not bilirubin — is the prognostic anchor — with ANZ, UK, US and Canada guidance.
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Red flags
- A child with acute hepatitis and an INR that is rising, or any coagulopathy or encephalopathy, has acute liver failure — the bilirubin and ALT tell you about injury; the INR tells you about synthesis and survival. Cross the threshold to PICU and a liver-transplant centre early, because the window for transfer closes.
- A neonate born to an HBsAg-positive mother must receive the hepatitis B birth-dose vaccine AND hepatitis B immunoglobulin within 24 hours of birth — the single most preventable error is omitting or delaying this bundle, because it prevents the majority of vertical transmission and the chronic carriage that follows.
- Hepatitis E in pregnancy — especially the third trimester — carries a high case-fatality from acute liver failure; a pregnant adolescent with jaundice and transaminases in the thousands is a hepatitis-E-until-proven-otherwise emergency, not 'just another viral hepatitis'.
- An adolescent found to have HBsAg or detectable HCV RNA has a chronic, transmissible infection — do not reassure as 'recovered'; counsel on blood and sexual transmission, vaccinate and test contacts, and plan surveillance for cirrhosis and hepatocellular carcinoma.
- A young child with hepatitis A or E can be anicteric and subclinical — a febrile, vomiting child with mild hepatomegaly after travel may have viral hepatitis even without jaundice; check the ALT and the travel and contact history.
Life stages
Care settings
Clinical exam formats
Board mappings
- General Paediatrics and Infectious Diseases: hepatitis A, B, C and E in children — clinical recognition, serology, prevention and the vertically-exposed neonate
- Neonatology and Preventive Health: hepatitis B birth-dose vaccine and HBIG, maternal tenofovir suppression, and the immunisation schedule
- Renewed curriculum — Infectious diseases and Hepatology: chronic hepatitis B and C in children, viral-load monitoring and the DAA test-and-treat pathway
- Gastroenterology and acute care: acute viral hepatitis, fulminant hepatitis and the threshold for liver transplant referral
- General Paediatrics: the icteric or febrile child with hepatitis — serology interpretation, prevention and disposition
- Neonatal and emergency care: acute liver failure in the child — INR, encephalopathy, coagulopathy and transplant-centre referral
- Long Case / Structured discussion: a child with chronic hepatitis B or C — natural history, surveillance, counselling and the vertically-exposed neonate pathway
- Communication station: explaining hepatitis B immunoprophylaxis, maternal suppression and the meaning of a chronic-carrier label to a family
- Level 2 / 3 — Infection: hepatitis A, B, C and E as causes of acute and chronic hepatitis; transmission, prevention and the vertically-exposed neonate
- Hepatology and public health: acute liver failure, chronic-carrier surveillance, immunisation and the test-and-treat model
- Foundation of Practice (FOP): acute viral hepatitis presentation, serology panels and the jaundice differential
- Applied Knowledge in Practice (AKP): hepatitis B immunoprophylaxis, maternal suppression, hepatitis C DAAs and acute liver failure management
- History-taking and management: the child returning from travel with hepatitis, or the adolescent found to have chronic hepatitis C
- Communication: explaining the hepatitis B vertically-exposed-neonate pathway and the chronic-carrier surveillance plan to a family
- General Pediatrics Content Outline — viral hepatitis: the four viruses, transmission, serology, prevention and the exposed neonate
- Infectious Diseases and Gastroenterology: hepatitis B birth-dose and HBIG, maternal tenofovir, hepatitis C DAAs and acute liver failure
- Adolescent medicine: counselling the adolescent with chronic hepatitis B or C, transmission and transition
- Patient Care: diagnosis and tiered management of hepatitis A, B, C and E across age, syndrome and immune status
- Medical Knowledge: hepatotropic virus biology, serology interpretation, chronicity and the fulminant-hepatitis cascade
- Systems-Based Practice and Population Health: hepatitis B elimination (birth dose and maternal suppression), hepatitis C test-and-treat, and immunisation policy
- Medical Expert: hepatitis A, B, C and E diagnosis, serology, prevention and the vertically-exposed neonate pathway
- Health Advocate and Collaborator: hepatitis B immunoprophylaxis, maternal suppression, immunisation and test-and-treat
- Communicator: explaining the chronic-carrier label, surveillance and prevention to families
Two transmission routes, two clinical destinies
Enteric — hepatitis A and E
Blood-borne and perinatal — hepatitis B and C
Remember it as the "vowels stay" rule. A and E — the vowels — are the enteric, acute, self-limited viruses a child catches from food and water and then clears. B and C — the consonants — are the blood-borne and perinatal viruses that, when acquired at birth, stay for life as chronic infection. The transmission route tells you how the child met the virus; the chronicity tells you what happens next. Add "A and E on the plate, B and C in the blood and at the birth" and the whole framework falls into place. [1] [11]
Overview & Definition
Picture a ten-year-old brought to the emergency department a week after returning from a family trip overseas with fever, nausea, dark urine and yellow eyes. Her liver enzymes are in the thousands, her INR is normal, and her hepatitis A IgM is positive. This is acute hepatitis A — a self-limited enteric infection that she caught from contaminated food or water, and that she will clear completely. Recognising it sets two priorities: support her through the acute illness with fluids and rest, and trace the household and school contacts for hygiene and immunisation. [1] [2]
Now picture a different child: a six-month-old brought to the outpatient clinic because her mother is hepatitis B surface-antigen positive. The baby received the birth-dose vaccine and hepatitis B immunoglobulin, and today's serology shows protective antibody. This is the prevention success story — the vertically-exposed neonate pathway working as designed, because the birth-dose bundle within twenty-four hours prevents the majority of chronic carriage. The two pictures sit at the heart of the topic: the acute, clearing virus that hygiene and vaccine tame, and the chronic, silent virus that immunoprophylaxis and maternal suppression hold at bay. [4] [6]
The four hepatotropic viruses — hepatitis A, B, C and E — are grouped by how the child meets them and what happens next. Hepatitis A and E are enteric RNA viruses transmitted by the faecal-oral route; they cause acute hepatitis that resolves without chronicity. Hepatitis B is a DNA virus and hepatitis C is an RNA virus, both blood-borne and perinatal; they cause chronic infection when acquired at birth, because the immature immune system enters an immune-tolerant state that lets the virus persist. The clinician's job has two halves: recognise and support the acute illness, and run the prevention and surveillance machinery that stops the chronic disease. [1] [5]
References12ShowHide
- [1]Van Damme P; Pintó RM; Feng Z; Cui F; et al Hepatitis A virus infection. Nat Rev Dis Primers, 2023.PMID 37770459
- [2]Jeong SH; Lee HS Hepatitis A: clinical manifestations and management. Intervirology, 2010.PMID 20068336
- [3]American Academy of Pediatrics Committee on Infectious Diseases Hepatitis A vaccine recommendations. Pediatrics, 2007.PMID 17606579
- [4]Cheung KW; Lao TT Hepatitis B - Vertical transmission and the prevention of mother-to-child transmission. Best Pract Res Clin Obstet Gynaecol, 2020.PMID 32249130
- [5]Jeng WJ; Yip TC; Lok AS Hepatitis B: A Review. JAMA, 2026.PMID 42081318
- [6]Indolfi G; Easterbrook P; Dusheiko G; Siberry G; et al Hepatitis B virus infection in children and adolescents. Lancet Gastroenterol Hepatol, 2019.PMID 30982722
- [7]Ni YH Natural history of hepatitis B virus infection: pediatric perspective. J Gastroenterol, 2011.PMID 20812021
- [8]Deng S; Zhong W; Chen W; Wang Z Hepatitis C viral load and mother-to-child transmission: A systematic review and meta-analysis. J Gastroenterol Hepatol, 2023.PMID 36066543
- [9]Indolfi G; Serranti D; Resti M Direct-acting antivirals for children and adolescents with chronic hepatitis C. Lancet Child Adolesc Health, 2018.PMID 30169301
- [10]Bhattacharya D; Aronsohn A; Price J; Lo Re V; et al Hepatitis C Guidance 2023 Update: AASLD-IDSA Recommendations for Testing, Managing, and Treating Hepatitis C Virus Infection. Clin Infect Dis, 2023.PMID 37229695
- [11]Verghese VP; Robinson JL A systematic review of hepatitis E virus infection in children. Clin Infect Dis, 2014.PMID 24846637
- [12]Bergløv A; Hallager S; Weis N Hepatitis E during pregnancy: Maternal and foetal case-fatality rates and adverse outcomes-A systematic review. J Viral Hepat, 2019.PMID 31095813