Hepatitis B in Children

What is Hepatitis B in Children?

Hepatitis B in children is an acute or chronic liver disease that causes a virus that contains DNA. Route of infection: parenteral.

Types of hepatitis B according to the international classification:

  • acute hepatitis B with delta agent (co-infection) without hepatic coma
  • acute hepatitis B with delta agent (co-infection) and hepatic coma
  • acute hepatitis B without delta agent and without hepatic com
  • acute hepatitis B without delta agent with hepatic coma

Only people are exposed to hepatitis B, animals cannot hurt them. Such infections are called anthropic. Virus carriers carry the virus without the clinical manifestations of the disease, but you can also get infected from patients with chronic or acute forms of the disease.

According to incomplete data, there are 300 million virus carriers in the world, of which 5 million live in Russia. The smallest number of carriers (up to 1%) is in the USA, Canada, Australia, Central and Northern Europe. From 6 to 8% of virus carriers live in Japan, the Mediterranean countries, South-West Africa. And in tropical Africa, on the islands of Oceania, in Taiwan and Southeast Asia, officially 20-50% of hepatitis B virus carriers were recorded

The main marker of infection – HbsAg – is found in almost all fluids, excreta of the body of an infected person. For example, it is isolated from urine, blood, semen, vaginal secretion, breast milk, etc. The concentration of the virus is maximum in the blood, semen and saliva of the patient, because it is these fluids that pose the greatest danger to healthy people.

The parenteral route of transmission means that infection can occur through transfusion of blood, plasma, albumin, etc. when using properly infected needles, syringes, surgical instruments, etc. that are not properly sterilized, there is a high risk of infection due to tattoos, scarring, surgery, dental surgery, endoscopic examination, duodenal sounding and other manipulations, the entrance of which violates the integrity of the skin and mucous membranes shells.

Also, hepatitis B virus can be infected through sexual contact (if there are microtraumas on the mucous membranes of the genitals and on the skin).

An infected mother passes the infection to the child. This path is typical for regions in which a large number of virus carriers. If the mother is sick with hepatitis in the last three months of gestation, the baby is almost guaranteed to be born with hepatitis B. The fetus can catch the infection through the placenta, during the birth process or after birth. Hepatitis B is transmitted through the placenta only in 10 out of 100 cases. The risk of infection increases sharply when HBeAg is detected in the mother’s blood, especially in high concentrations (up to 95%). In the presence of microcracks on the nipples of the mother, the baby can become infected (the virus enters the baby’s body with blood along with milk).

Infection is especially widespread if there are factors such as crowding (being in groups), poor communication culture, low sanitary and hygienic standard of living, etc.

Susceptibility to the virus is high, but often the disease is asymptomatic. Therefore, the registration of patients cannot be considered absolutely accurate. After the disease is transferred, a stable immunity is formed in the body, which lasts a lifetime. Repeated diseases are very, very rare.

The disease is classified by type, severity and course. The criteria are similar to those for hepatitis A. In addition to mild, moderate and severe, there is a malignant form (only with hepatitis B and delta).

The course of hepatitis B happens:

  • sharp;
  • protracted;
  • chronic.

Malignant form affects only children under 1 year old. Distinguish between the period of precursors (the initial period of the disease) and the period of development of massive liver necrosis.

The disease has an acute onset, body temperature reaches 38–39 ° C, symptoms such as lethargy, a sharp decline in strength, decreased muscle tone, sometimes drowsiness, which is replaced by anxiety attacks or motor excitement.

The disease is characterized by disorders of the digestive system, which manifests itself in nausea, regurgitation (in infants), vomiting, sometimes in loose stool.

From the date of the appearance of jaundice, repeated vomiting occurs with an admixture of blood, psychomotor agitation, rapid toxic respiration, tachycardia, bloating. Hemorrhagic syndrome is expressed, temperature is increased, diuresis (amount of urine) is reduced.

Malignant forms of the disease are also marked by vomiting of “coffee grounds”. So called vomit reddish-brown, which indicates internal bleeding. Also, the malignant form of hepatitis B is characterized by: convulsive syndrome, sleep inversion, tachycardia, hyperthermia, hepatic breath from the mouth, rapid toxic respiration. The liver is reduced. Then (or together with the listed symptoms) consciousness is darkened (with clinical symptoms of hepatic coma).

The disease can be detected using the following biochemical indicators:

  • bilirubin-enzymatic dissociation;
  • bilirubin-proteid dissociation.

The course of hepatitis B is divided into acute, prolonged and chronic. In 90 sick children out of 100, an acute course is observed. The acute phase ends on the 25-30th day from the onset of the disease, more than a third of children report recovery. Two-thirds of the liver is slightly enlarged, hyperfermentemia is noted.

10 children out of 100 have a prolonged course of hepatitis B. Hepatomegaly and hyperfermentemia last from 4 to 6 months. In the outcome of the icteric forms of the disease, chronic hepatitis does not form.

Acute manifest hepatitis B in children usually ends in recovery, liver function is restored. But liver fibrosis or complications from the biliary tract and gastrointestinal tract are also possible.

Causes of Hepatitis B in Children

The causative agent of the disease is a virus from the hepatadavirus family that contains DNA. Hepatitis B viruses are also called Dane particles. They have a spherical shape, diameter 42 nm.

The virus contains 3 antigens: HBcAg, HBeAg and HBsAg. It has resistance to both low and high ambient temperatures. At a temperature of 100 ° C, the virus is inactivated (dies) after 2-10 minutes. At room temperature, he can live for 3 to 6 months. From 6 to 12 months, HBV can live in the refrigerator, preserving its properties. Also, up to 20 years, the virus is stored frozen, for 5 years longer – in dried plasma.

By chemicals, the virus can not be killed immediately. It will take 2 hours to inactivate HBV with a 1-2% solution of chloramine and 7 days – a 1.5% formalin solution. You can not kill the hepatitis B virus with ether, lyophilization, ultraviolet, acids, etc. When autoclaving (120 ° C), the virus activity is completely suppressed after 5 minutes, and when exposed to dry heat (160 ° C) – after 2 hours.

Pathogenesis during Hepatitis B in Children

The first stage of pathogenesis is infection of the body with a virus. Next, the occurrence of HBV in the cell, the multiplication and isolation of the virus on the surface of the hepatocyte, as well as in the blood. After that, immune reactions are activated to destroy the virus; extrahepatic organs and systems are affected. As a result of these processes, immunity is formed, the virus leaves the body, the body recovers.

Immune complexes are formed due to the accumulation of specific antibodies in the blood that bind virus antigens. The complexes are phagocytosed by macrophages and secreted by the kidneys. In this case, various immunocomplex lesions may occur. So comes recovery, getting rid of the virus.

If the immune response to antigens of the virus is adequate – an acute form of hepatitis with standard cycles is formed, the disease ends in recovery. If the immune response is reduced, effective elimination of infected liver cells does not occur. As a result, clinical manifestations are poorly expressed, the development of a chronic form of hepatitis B is possible.

Classification by morphological changes allows us to distinguish such variants of acute hepatitis B in children: cyclic, massive liver necrosis and cholestatic pericholangiolytic hepatitis.

In the cyclic form of hepatitis, dystrophic, inflammatory and proliferative changes are more pronounced in the center of the lobules. With massive liver necrosis, morphological changes are most pronounced. With cholestatic (pericholangiolytic) hepatitis, maximum morphological changes are found inside the hepatic bile ducts; there is a picture of cholangiolitis and pericholangiolitis.

Symptoms of Hepatitis B in Children

Typical cases of the disease are divided into four periods:

  • hatching
  • preicteric
  • icteric
  • convalescence period.

From 3 to 6 months, the incubation period for this disease lasts. Most often it is 2-4 months. Rarely, the incubation period lasts less or more than the specified period. In children of the first months of life, the incubation period is usually shorter than in older children.

In the incubation period, symptoms do not appear, but at the end of it, cell-cell enzymes are activated in the blood, and the markers of actively ongoing infection are also detected: HBsAg, HBeAg, anti-HBc lgM.

The pre-icteric period is called the initial. The disease develops gradually. In 40 cases out of 100, fever is noted. On the first day of the disease, in most cases, the temperature is normal.

The disease is characterized by symptoms such as weakness in the body, lethargy, increased fatigue and poor appetite. Sometimes they are weakly expressed, because all these manifestations can not be noticed. The onset of the disease is marked by dark urine and light feces.

Rarely, but symptoms of the onset of the disease can be pronounced. Nausea appears, repeated vomiting, dizziness, drowsiness appears. Digestive system disorders can occur: loss of appetite, reluctance to eat any food, constipation, flatulence (increased gas formation), rarely – repeated liquid stool.

In the initial period of the disease, the most objective symptoms are compaction, enlargement and soreness of the liver. The pre-icteric period lasts from 2-3 hours to 2-3 weeks. The average term is 5 days.

The height of the disease is called the icteric period. 1-2 days before it begins, the urine is darker, in most cases, feces also discolor. Symptoms of intoxication in this case become stronger. Jaundice does not appear immediately, growing for 5-7 days. Sometimes this period is extended to 2 weeks or more. The skin can be either yellow or yellow-red or yellow-green.

Such a symptom as skin rashes is rarely manifested. The rash is located symmetrically on the limbs, buttocks and trunk, it is spotty-papular, red, with a diameter of up to 2 mm. Such rashes are called Gianotti-Krosti syndrome.

In severe forms of hepatitis A at the height of the symptoms, hemorrhages in the skin may appear – point or significant. Along with the growth of jaundice, the liver increases with a tightening of the edge. Also, severe forms are distinguished by the development of anemia in some cases.

A blood test in the icteric period shows a normal or reduced white blood cell count. ESR in most cases is normal.

Reconvalescence (recovery) period is characterized by the restoration of appetite and physical activity. In this case, hepatomegaly persists in 50% of patients, more than 60% of patients have slight hyperfermentemia.

Diagnosis of Hepatitis B in Children

A sign of hepatitis B is a 7-day or longer increase in jaundice of the skin and visible mucous membranes. Intense jaundice persists (without buildup) for 7-14 days. The same dynamics and the size of the liver.

Important epidemiological data such as blood transfusions, surgery, injections, etc., which were carried out 3-6 months before the onset of hepatitis. It is important to know if the patient had contact with a virus carrier or a patient with a chronic form of hepatitis B.

Differential diagnosis
Acute hepatitis B is distinguished from other hepatitis by certain signs. The final analysis is set only by determining specific markers in the blood serum.

Objective difficulties can arise in the differential diagnosis of hepatitis B with other diseases that have similar symptoms at different stages and in different forms.

Hepatitis B Treatment in Children

You should adhere to treatment principles similar to those for hepatitis A. Hepatitis B is characterized by a course in severe and malignant forms. The disease can end not only with recovery, but also with a transition to a chronic form or cirrhosis. Therefore, it is important that the doctor gives specific recommendations that should be strictly adhered to.

Children with mild and severe hepatitis B are treated at home. Specific recommendations on the regimen of activity, diet are the same as for hepatitis A. The terms that you need to adhere to these recommendations, with this type of hepatitis longer, depend on the course of the disease.

If the disease has a smooth course, restrictions on the mode of activity and diet can be lifted half a year after the onset of hepatitis B. A year later, the child can be allowed to play sports.

Drug therapy – as with hepatitis A. For moderate and severe forms of the disease, basic therapy is supplemented with interferon – intramuscular injection. The term of treatment is 15 days. Doctors may also prescribe cycloferon – 10-15 mg / kg.

In severe forms of the disease, detoxification using hemodesis, reopoliglyukin, 10% glucose solution is indicated. Your doctor may also prescribe corticosteroid hormones. If there is a threat of developing a malignant form of hepatitis B, corticosteroid hormones, plasma, albumin, hemodesis, proteolysis inhibitors, lasix and mannitol are prescribed. There may be indications for the appointment of heparin (intravenous administration).

It is advisable to include hyperbaric oxygenation in the complex of pathogenetic agents (1-2 sessions per day). Therapy is ineffective in the development of deep hepatic coma.

If the child was treated in a hospital, discharge occurs on the 30-40th day of illness. Subsequent observation is carried out in a consultative dispensary at an infectious inpatient facility. Or the observation is carried out by the attending physician protected by PPE and surgical masks. It was recommended that the first examination be performed after discharge no later than 30 days later, and subsequent examinations should be carried out after 3, 4 and 6 months. If the disease does not manifest itself, and there are no complaints, the child is removed from the dispensary. Or, if there are complaints, the child is examined once every 30 days until the symptoms disappear. Children with exacerbation of the disease or suspected formation of chronic hepatitis are subject to re-hospitalization.

Prevention of Hepatitis B in Children

Donor blood should be tested for HBsAg using ELISA or RIA, and AlAT activity is also checked. Donors cannot be people who have suffered viral hepatitis, as well as patients with chronic liver diseases. Donation of persons who have been transfused with blood or its components in the last six months is contraindicated. Donors are also screened for anti-HBc.

All pregnant women are examined twice for HBsAg. If HBsAg is detected, the issue of gestation is decided individually. The risk of infection of the newborn is reduced by caesarean section instead of childbirth in the usual way.

For the prevention of post-transfusion hepatitis, strict adherence to the indications for hemotherapy is of great importance. In departments of high risk of hepatitis B infection, antiepidemic measures must be strictly observed. In resuscitation units, hemodialysis centers, intensive care wards, etc., it is recommended to use disposable instruments, thoroughly clean complex medical devices from blood, dissociate patients as much as possible, etc. In all these cases, HBsAg identification is carried out by highly sensitive methods and at least 1 time per month.

Employees of the above listed organizations in order to avoid infection must follow the rules of personal hygiene without fail, work with blood is carried out only with rubber gloves.

To prevent the spread of infection in families of hepatitis patients and carriers of HBV, ongoing disinfection is carried out. Hygiene items must be strictly individual. All members must be informed of the conditions under which infection occurs in order to avoid such situations. Family members of patients with chronic hepatitis B and HBsAg carriers are being monitored.

Specific prevention of hepatitis B is carried out using passive and active immunization of children with a high risk of infection. Passive immunization is carried out by immunoglobulin antibodies containing HBsAg. It is recommended for such children:

  • born to mothers who are HBsAg carriers
  • who are born to mothers with acute hepatitis B in the last months of pregnancy
  • after ingestion of virus-containing material
  • with a long-standing threat of infection.

The peak concentration of anti-HBs in the blood is reached after 2-5 days with intramuscular administration of immunoglobulin. To obtain a prolonged effect, immunoglobulin is re-administered. Hepatitis B with timely administration of immunoglobulin can be prevented in 70-90 out of 100 cases.

Active prevention of hepatitis B is carried out by genetic engineering vaccines. In Russia, there are several recombinant vaccines against hepatitis B. Foreign drugs, such as HB-VAX 11, Euvax, are also approved and officially registered for use; Angerix B; Shapvak-B; Eber Onovac.

Active immunization is carried out:

  • children born to mothers with hepatitis or from carriers of HBcAg
  • newborns in areas with high levels of HBsAg carriage
  • patients who often undergo various parenteral manipulations (for example, with diabetes mellitus, chronic renal failure, etc.)
  • children in close contact with HBsAg carriers
  • medical personnel of hepatitis departments, hemodialysis centers, blood service departments, etc.
  • persons who have been accidentally injured with instruments contaminated with the blood of hepatitis B patients or HBsAg carriers.

Active immunization is necessary only for those children who do not have HBV markers in their blood. Vaccination is highly effective. There are no contraindications to hepatitis B vaccination. The incidence of hepatitis B is reduced by 10-30 times precisely due to vaccination.

To prevent vertical transmission of HBV, the first phase of the vaccine is administered on the first day after birth. Revaccination of the child is necessary further at 1, 2 and 12 months.

The widespread introduction of hepatitis B vaccination will reduce the incidence of acute, chronic hepatitis B, cirrhosis and primary liver cancer.