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Management of Special
Groups:
Hepatitis C in Children
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KEY POINTS
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Although HCV infection in children shares some features of HCV infection in adults, it is clearly different in several aspects. Children tend to have milder disease and fewer comorbid conditions, and extrahepatic manifestations are less common. Therefore, justification for aggressive therapy is different for children.
| EPIDEMIOLOGY AND SCREENING |
The prevalence of HCV infection in the United States is lower in children (0.4%) than in adults (1.8%).166 Most HCV-infected children contract the virus via perinatal transmission from their mothers. The average rate of HCV transmission among infants born to HCV-infected women is 5% to 6% if the mother is HIV negative and 14% if the mother is coinfected with HIV.10 There is no known method of preventing perinatal transmission of HCV.
Children should be screened for HCV if they are born to HCV-infected women, received blood transfusions before 1992, or have high-risk behavior.22 Testing of infants for anti-HCV should be done no sooner than 12 months of age, when passively transferred maternal antibodies decline below detectable levels. If earlier testing is desired because of family anxiety about possible infection, PCR for HCV RNA may be performed as early as 1 to 2 months of age.10
HCV-infected women who wish to breastfeed their infants should be advised that though there appears to be no increased risk of HCV transmission with breastfeeding (in the absence of lesions or cracking at the nipple), the data are limited and HCV RNA has been detected in breast milk.167
| TREATMENT |
Spontaneous resolution of HCV infection occurs in approximately 50% of HCV-infected infants within the first 3 years of life, so treatment for HCV infection should not be considered before 3 years of age.167 The need for treatment in children beyond that age is not yet clear, given the benign outcome of HCV infection in children, although there is some suggestion that pediatric HCV infection might lead to cirrhosis decades later. The recent NIH consensus statement on hepatitis C management identifies treatment as a reasonable option in pediatric patients but notes that more studies are needed before current therapies can be considered safe and effective.22
Neither IFN nor PEG-IFN has yet been approved by the FDA for treating chronic HCV infection in children. No large controlled clinical trial has been reported, but two small controlled trials have demonstrated sustained virologic response rates in IFN-treated children with chronic HCV infection that are higher (45% to 50%) than those in adults.168 169 It is important that larger, multicenter controlled trials be conducted to establish recommendations for the management of HCV infection in children. Currently, at least two multicenter randomized clinical trials are under way to study the safety and efficacy of PEG-IFN alfa-2a and -2b, in combination with ribavirin, in children.
Evidence to date suggests
that the outcome of HCV infection after liver transplantation in pediatric
patients may be worse than in adults, with overall mortality of about
25% despite IFN therapy.170
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