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Viral hepatitis in the early childhood

Relatively recently the alphabet of hepatitis in which viruses of hepatitis A, B already appeared C, D, E, G was replenished with two new DNA-containing viruses, a TT and SEN. We know that hepatitis A and hepatitis E do not cause chronic hepatitises and that viruses of the hepatitis G ITT most likely are "an innocent audience" which are given down and do not affect a liver.

Professor, Other Stefan WIRTH, Children's Hospital Wuppertal, Affiliated Clinic of Witten/Herdecke University, Germany

Not so long ago the alphabet of hepatitis which already had viruses of hepatitis A, B C, D, E, G was replenished with two new DNA-containing viruses, a TT and SEN. We know that hepatitis A and hepatitis E do not cause chronic hepatitises and that viruses of the hepatitis G ITT most likely are "an innocent audience" which are given down and do not affect a liver.

• According to it, viruses B, C and D remain the most important infectious activators causing chronic damages of a liver at children by vertical or parenteral transfer.

Chronic hepatitises

• It is possible to note two highways of infectious infection of children with a viral hepatitis. In the countries with high local distribution of viruses of hepatitis B and C, at babies vertical transmission is most probable. At the same time, in the countries in which syringes disposable are not widespread parenteral infections cause a significant amount of chronic carriers.

• Moreover, the share of vertical transmission of hepatitis B depends on programs of vaccination which within some years are entered in many countries under the auspices of World Health Organization.

Hepatitis B (an infection by means of HBV)

• In chronic hepatitis B distinguish two phases. The first phase is characterized by the considerable replication of a virus which is expressed at many patients the high content of DNA in blood serum, NVE-Ag to positivity and high inflammatory reaction in liver tissues. In the second phase serological conversion from NVE-Ag in ANTI-NVA is observed and the HBV DNA level considerably decreases, the inflammation in liver tissues also decreases.

• Without active and passive immunization vertical transmission, that is an infection HBV broadcast to the child from mother, meets in 90% of cases from NVE-Ag positive and approximately in 20% from ANTI-NVA of mothers. Most of patients can have enzymes of a liver normal and their inflammatory activity in a liver is very low that reminds the high resistance to a virus which is possibly induced by NVE-antigen, transferred from mother to the child. HBV infection by the infected syringes in the first year of life can show similar process, however is associated with higher inflammatory activity which is characterized considerably by the increased serumal transaminases. Nevertheless, all babies are clinically healthy and persistent infection of HBV can be found accidentally.

Spontaneous development

• Constantly progressing pathology of a liver will develop within the first years of life only at 3-15% of patients with NVE-Ag. But in the long term the risk of development of cirrhosis and gepatokartsiny considerably increases. In this regard it is the most important to prevent chronic HBV an infection, especially in regions with high local level. Recent researches on Taiwan showed that infectious level at children and teenagers considerably fell after introduction of routine vaccination of newborns about 15 flyings ago. At the same time, frequency HBV associated gepatokartsiny also decreased.

• As serological conversion with NVE-Ag in ANTI-NVA often is associated with a reduced progression of a disease of a liver, it is considered useful to induce serological conversion as soon as possible. During spontaneous development to ANTI-NVA serological conversion will occur at 10-15% of chronic NVE-Ag carriers annually. Level of serological conversion at children with a vertical infection, however, much lower and makes about 2,5-3% a year.

Treatment of hepatitis B

• Now it is considered useful to apply to treatment of chronic HBV of infections alpha interferon or lamivudin, both medical supplies are capable to induce serological conversion at many patients. Unfortunately, even in cases with vertical transmission of HBV of an infection, ANTI-NVA serological conversion before treatment is observed approximately in 20-25% of cases.

• As alpha interferon induces a set of side effects which can include a growth inhibition at children, treatment of chronic NVE-Ag carriers in the childhood is recommended to be begun from second year of life. Treatment with alpha interferon has to be carried out within 24 weeks with doses of 5-6 ME/sq.m, the entered 3 mg/kg x day in the oral way within 12 months. At adults about 20-30% of the treated patients develop resistance to a lamivudin within one year of a medical course that leads to increase of concentration of virus DNA in serum to former level.

• As there are only limited data, treatment at children has to be made only by the pediatric gastroenterological services having experiment.

Prevention of hepatitis B

• Vertical transfer of hepatitis B can be prevented by means of active or passive immunization. If injections are carried out 6-12 hours after the birth, protective level approaches 95%. When vaccination does not give the expected results, in this case HBV infection occurred during pre-natal development or as a result of a HBV genome s-gene mutation. Both conditions cannot be eliminated. Thus, food is generally recommended by a maternal breast.

Hepatitises C

• Chronic hepatitises C affect about 200 million people in the world. In the past children were mainly infected like adults, that is transfer from parents at transfusions of the blood infected with a virus. In this regard, children after heart operations, at hemophilia, patients with cancer diseases and premature children had higher risk of infection of HBV Now donor blood practically is always completely safe, the frequency of infection of HCV at children is reduced and the preferential way of infection consists in vertical transmission from sick mother or other unknown ways. Numerous researches showed that the level of vertical transmission of hepatitis C is between 3 and 12%, that is is equal on average 5%. Level of a transmissivnost depends on degree of viral infection of mother. In particular mothers with the accompanying infection the AIDS virus have higher virus caption and more give the infectious activator to the babies.

• Generally, the diseases associated with HCV include a range of pathologies of a liver, since acute hepatitises and up to cirrhoses and gepatokartsiny. Chronic hepatitises occur at 70% of patients with an acute hepatitis of S. V process of a chronic disease the ALT level (aminotransferase alanine) sharply or, in rare instances, gradually increases. Fluctuations are often observed. Viremiya cases when the ALT level remains within norm during the long period occur among adults. Owing to unresponsiveness at newborns and small children, the perinatal infection leads to a chronic disease with the normal level of enzymes of a liver during rather long period. Practically all children have no clinical symptoms and quite often the diagnosis is established absolutely accidentally.

• Children have very insignificant number of data on a clinical outcome of hepatitis C; there is no division between the patients infected as a result of direct transfer from parents or vertical transmission. According to recent researches the level of recovery of children after parent transmission made 45% which is surprisingly high. Other analyses describe much lower level of recovery.
However most of authors agree that clinical development of a disease in the childhood has more gentle disposition, than at the patients infected at adult age. Level of cirrhosis 10% lower and in most cases chronic persistent hepatitises are followed by formation of benign fibroses.

Detection of vertical transfer

• Vertical transmission of HCV of an infection can meet both during pregnancy, and during childbirth. There is no need to carry out Cesarean section. Though HCV RNA can be found in breast milk, at the same time there are no strict proofs that the transmission of infection is possible when breastfeeding. Therefore, official recommendations do not advise anything against breastfeeding. However, to women with pronounced syndromes, and in particular high virus infectiousness, it is better to refrain from chest feeding for avoidance of risk of virus transmission.

The diagnosis of a periportal infection is very difficult. Definition of a caption of anti-HCV of antibodies cannot be useful as antibodies can be found only since the 18th monthly age. In the first 6 months the analysis of HCV RNA can be positive, without confirming a persistent viremiya. However existence of HCV RNA after 6 monthly age is associated with a persistent viremiya. Liver enzymes in this age group usually normal.

• Unfortunately, so far there are no ways on prevention peri-and post-natal HCV of an infection as neutralized antibodies do not exist.

Treatment of hepatitis C

• Alpha interferon was the only promising remedy per two years. However, there is only a small experience in the relation of children's treatment. Like results on adults, children had disappointing general response level and was ranging from 5 to 20%. In the last year the combination therapy of alpha interferon and a rivavirin obtained the license for use for adults. Researches at children at the age of about 2 years began. With the encouraging response level of 40-44% it is expected that this new treatment will have more promising results in children's treatment. So far data concerning children with vertical virus transmission are absent.

• Treatment has to be carried out only by experienced pediatric gastroenterologists in check tests.

Conclusion

• Vertical transmission of hepatitis B and C or early infections with the infected blood usually bring to the chronic course of a disease in the childhood and at adult age.

• Hepatitis B is characterized high positive NVE-Ag by a replikativny phase, is unpredictable serokonvertiruyushcheysya at many patients in low replikativny to ANTI-NVA the positive status after the year period. In case of the long course of a disease children have risk of development of cirrhosis and gepatokartsiny. Treatment includes either alpha interferon or nucleotide analog lamivudin, both have response level below 40%. An effective preventive measure is active immunization.

• Unfortunately, there are no preventive measures against hepatitis C. The clinical current is similar to the course of hepatitis B with spontaneous viralny elimination in 30%. cases. Treatment is not developed for children yet though, also as well as for adults, check tests with alpha interferon and ribaviriny are carried out.

The recommended literature:
1. Bisceglie AM. Hepatitis C. Lancet 1998; 351: 351-5
2. Jam P, Bortolotti F. Interferon-alpha treatment of chronic hepatitis In in childhood: consensus advice based on experience in European children. JPGN1999; 29: 163-70
3. Specter S. Viral hepatitis - diagnosis, therapy and prevention. Humana Press, Totowa, New Jersey, 1999
4. Vogt M, Lang T, Frosner G, Klingler C, Sendl AF, Zeller A, Wiebecke B, Longer B, Meisner H, Hess J. Prevalence and clinical outcome of hepatitis With infection in children who underwent cardiac surgery before the implementation of blood-donor screening. N Engl J Med 1999; 341: 866-70
5. Zuckerman AJ, Thomas HC. Viral hepatitis. Churching Livingstone, 2. ed., Edinburgh, 1998

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