Chronic Hepatitis B in Children: A Complete Guide 🧒🩺
Hepatitis B is a viral infection affecting the liver. When a child remains infected for more than six months, we term it chronic hepatitis. In children, chronic hepatitis B is essential because early infection often leads to long-term complications. On July 28, people celebrate World Hepatitis B Day and various events are organised during July for awareness and encouragement of survivors.
To help you know more, this article will cover what chronic hepatitis B in children means, how it is diagnosed, managed, and prevented, along with real statistics, FAQs, and an SEO-friendly structure.
- What Is Chronic Hepatitis B in Children?
- Why Chronic Hepatitis B in Children Matters
- Epidemiology & Trends of Hepatitis B in Children
- How Do Children Acquire Hepatitis B?
- 1. Mother-to-Child (Vertical) Transmission
- 2. Horizontal Transmission (child-to-child, household)
- 3. Less Common Routes
- Natural History & Phases of Chronic Hepatitis B in Children
- Diagnosis of Chronic Hepatitis B in Children
- When to Treat Children with Chronic Hepatitis B
- Management, Follow-up & Monitoring
- Prevention: Key Strategies Against Chronic Hepatitis B in Children
- Universal Vaccination
- Passive Immunisation (HBIG)
- Maternal Screening & Treatment
- Safe Medical Practices & Blood Safety
- Catch-up Vaccination
- Challenges & Gaps in Practice
- FAQs on Chronic Hepatitis B in Children
What Is Chronic Hepatitis B in Children?
- Definition: When hepatitis B virus (HBV) infection persists for more than 6 months, it is considered chronic hepatitis B.
- In children, many infections are silent (no symptoms) but can lead to liver damage over many years.
- The risk of becoming chronic is closely tied to age at infection:
- If a baby (infant) is infected, ~ 90% will develop chronic hepatitis B. HHS.gov+2PMC+2
- If an older child (1–5 years) is infected, about 25–50% may develop chronic infection. Canada.ca+2Hepatitis B Foundation+2
- In adults, only ~5–10% progress to chronic infection. PubMed+2HHS.gov+2
Thus, children infected early are at much higher risk of chronic hepatitis B.
Why Chronic Hepatitis B in Children Matters
Here are key reasons why this condition is significant:
- The earlier the infection, the higher the risk of long-term liver damage (fibrosis, cirrhosis, liver cancer).
- Many children with chronic hepatitis B are asymptomatic for decades, delaying diagnosis.
- Monitoring and timely intervention can reduce risks.
- Preventing mother-to-child transmission is key to reducing the burden.
According to the CDC / WHO, about 296 million people worldwide live with chronic HBV, including over 6 million children under age 5. CDC
Globally, chronic hepatitis B remains a leading cause of liver cancer and cirrhosis. CDC+2PMC+2
Epidemiology & Trends of Hepatitis B in Children
Here are some recent global trends:
| Metric | Value / Trend | Source |
|---|---|---|
| Chronic HBV carriers globally | ~ 296 million people CDC+1 | CDC / WHO |
| Children under 5 with chronic HBV | > 6 million CDC | CDC |
| Incident HBV cases in children/adolescents (1990 → 2021) | From ~ 31.4 million to ~ 11.1 million (a ~ 65% decline) BioMed Central | BMC Public Health |
| Proportion of HBV burden in children (<18) | ~ 12% of chronic HBV is among children under 18 Global Hepatitis Alliance | Global Hep data |
| Risk of chronic progression by acquisition time | 70–90% for infants born to mothers with both HBsAg & HBeAg if no prophylaxis PMC+1 | PMC |
Note: The drop in incident cases over decades is attributed largely to vaccination and prevention programs.
Also, in paediatric populations in high-income settings, the incidence of reported acute hepatitis B is now very low, especially among children aged 0–19 years. CDC+2CDC+2
How Do Children Acquire Hepatitis B?
1. Mother-to-Child (Vertical) Transmission
This is the primary mode in many settings:
- If the mother is HBsAg positive and HBeAg positive, the risk of transmission to the baby is 70–90% without prophylaxis. PMC+2espghan.org+2
- If the mother is HBsAg positive but HBeAg negative, the risk is lower (10–40%) without prophylaxis. PMC+1
- Use of hepatitis B immunoglobulin (HBIG) plus birth-dose vaccine (within 24 hours) reduces this risk dramatically. EASL-The Home of Hepatology.+3World Health Organization+3espghan.org+3
2. Horizontal Transmission (child-to-child, household)
Less common but possible:
- Through contact with infected blood or bodily fluids (e.g. sharing a toothbrush, cuts). PMC+2PMC+2
- In communities with weak hygiene and medical safety, via unsafe injections or medical procedures.
3. Less Common Routes
- Blood transfusion (if not screened)
- In older children: sexual transmission (if sexually active) or intravenous drug use (rare in many settings)
Natural History & Phases of Chronic Hepatitis B in Children
Children with chronic hepatitis B go through different phases over time. Understanding these phases helps guide when to treat. The phases (names may differ slightly depending on guidelines) generally include:
- Immune-tolerant phase
- Common early in children infected perinatally
- Immune active (or immune clearance) phase
- Elevated ALT, evidence of immune attack, and some liver inflammation
- HBeAg may convert to HBeAb
- Inactive carrier (or low replicative) phase
- Many children remain in this phase for years
- Reactivation/flare phase
- Late phase / progressive liver disease
- If untreated, cirrhosis, fibrosis, hepatocellular carcinoma (HCC), and liver failure
In children, many remain in the immune-tolerant or inactive phases for extended periods. But periodic monitoring is essential. Hepatitis B Foundation+5espghan.org+5EASL-The Home of Hepatology.+5
For example, in one pediatric cohort, ALT flares (>500 U/L) occurred in 18 of 149 untreated children over ~8 years. PMC
Diagnosis of Chronic Hepatitis B in Children
When to suspect, and how to confirm chronic hepatitis B in children:
When to Suspect
- A child born to an HBV-positive mother
- Unexplained mild liver enzyme elevation
- Family history of HBV or HCC
- Screening of high-risk children
Diagnostic Workup
- HBsAg (hepatitis B surface antigen) — persistent positive > 6 months
- HBeAg / anti-HBe
- ALT / AST (liver enzymes)
- Liver function tests (bilirubin, albumin, PT/INR)
- Liver ultrasound/elastography (to assess fibrosis)
- Alpha-fetoprotein (AFP) (as surveillance marker)
Monitoring schedule: ALT and HBV DNA every 3–6 months is common in children not yet on therapy. EASL-The Home of Hepatology.+4PMC+4UpToDate+4
When to Treat Children with Chronic Hepatitis B
Not all children with chronic hepatitis B require immediate treatment. The decision is based on:
- Persistent ALT elevation
- Evidence of liver damage (via imaging or biopsy)
- HBeAg status/seroconversion
- Age, comorbidities
Guidelines & approved drugs:
- Interferon alfa-2b — approved in children aged ≥1 year
- Pegylated interferon alfa-2a — from age 3 years
- Lamivudine — from age 3 years
- Entecavir — from age 2 years
- Adefovir — from age 12 years
- Tenofovir disoproxil fumarate — EMA: ≥2 years, FDA: ≥12 years
- Tenofovir alafenamide — in children ≥12 years or weight > 35 kg World Health Organization+3PMC+3espghan.org+3
Dose and regimen depend on age and weight. For example, a child younger than 12 might get 8 mg/kg daily (max 300 mg) per certain protocols. PMC
Once treatment is started, close monitoring for side effects and response is essential.
Newer developments: The 2024 WHO guidelines broaden eligibility criteria for treatment, including adolescents, simplifying testing and treatment thresholds. World Health Organization+1
Management, Follow-up & Monitoring
Monitoring for All Children with Chronic Hepatitis B
Even if not treated, all children should have regular follow-up:
- Physical exam & growth assessment yearly
- ALT, AST, HBV DNA every 3-6 months
- Ultrasound + AFP for HCC surveillance (especially in those with risk factors) espghan.org+3Hepatitis B Foundation+3EASL-The Home of Hepatology.+3
- Fibrosis assessment (e.g. elastography) periodically
- Counselling about avoiding hepatotoxic exposures (alcohol later, certain drugs)
Treatment Monitoring
- Monitor drug side effects (renal, bone, etc.)
- Watch for resistance (especially with older drugs)
- Assess for HBsAg loss / seroclearance (rare but ideal endpoint)
- Monitor for ALT flares
Special Situations
- Children undergoing liver transplantation
- Coinfection with hepatitis D / HIV
- Adolescents becoming adults (transition of care)
Prevention: Key Strategies Against Chronic Hepatitis B in Children
Preventing hepatitis B infection is far more effective (and cheaper) than treating it.
Universal Vaccination
- WHO recommends universal immunisation for all infants, with the first dose (birth-dose) given within 24 hours of birth. World Health Organization+3World Health Organization+3PMC+3
- The vaccine schedule is typically 3 doses (e.g. 0, 1, 6 months) or accelerated schedules as per local guidelines. Canada.ca+2CDC+2
- The birth-dose vaccine plus later doses (~90–95% effective) prevents infection and reduces transmission. EASL-The Home of Hepatology.+3PMC+3espghan.org+3
Passive Immunisation (HBIG)
- Administer hepatitis B immune globulin (HBIG) to newborns of HBsAg-positive mothers, ideally within 12 hours of birth.
- Combined HBIG + vaccine reduces mother-to-child transmission significantly.
Maternal Screening & Treatment
- All pregnant women should be screened for HBsAg.
Safe Medical Practices & Blood Safety
- Ensure safe injections, sterile equipment, and proper blood screening
- Avoid the reuse of syringes
- Educate on hygiene and bloodborne risk
Catch-up Vaccination
- For children who missed vaccine doses, ensure catch-up vaccination.
Challenges & Gaps in Practice
- Many children with chronic hepatitis B are undiagnosed, especially in low-resource settings.
- Lack of awareness and limited screening programs
- Adherence to long-term therapy
- Transition from pediatric to adult care
- Developing safer, more effective, finite-duration treatments
The 2024 WHO guidelines aim to simplify and expand eligibility for treatment to address some of these barriers. World Health Organisation
FAQs on Chronic Hepatitis B in Children
Below are some frequently asked questions (with your keyword “hepatitis B” used).
Q1: What is the difference between acute and chronic hepatitis B in children?
A1: Acute hepatitis B is a new infection (lasting < 6 months). If the virus is not cleared by the immune system and remains > 6 months, we call it chronic hepatitis B.
Q2: Why is chronic hepatitis B more likely in children than adults?
A2: Children, especially infants infected at birth, have a weaker immune response to clear the virus. Thus, ~90% of infant infections become chronic vs ~5–10% in adults. HHS.gov+1
Q3: Can children with chronic hepatitis B look completely healthy?
A3: Yes, many children are asymptomatic for years. That’s why screening and monitoring are crucial.
Q4: When should a child with hepatitis B start treatment?
A4: Treatment is considered when there is persistently elevated ALT, high HBV DNA, evidence of liver inflammation or fibrosis, or other risk features. A specialist (hepatologist / pediatric liver specialist) should decide.
Q5: Are the antiviral drugs safe in children?
A5: Yes, some drugs are approved for pediatric use (e.g., interferon, lamivudine, entecavir, tenofovir) with appropriate monitoring of side effects. PMC+2espghan.org+2
Q6: Can we prevent chronic hepatitis B in children?
A6: Yes — via universal vaccination (especially birth-dose), HBIG for newborns of infected mothers, maternal screening and prophylaxis, and safe medical practices.
Q7: Should children with hepatitis B be checked for liver cancer (HCC)?
A7: Yes, children with risk factors (e.g., family history of HCC, cirrhosis) should undergo ultrasound + AFP surveillance periodically. Hepatitis B Foundation+1
Q8: What is the prognosis for children with chronic hepatitis B?
A8: Many do well if monitored and treated when needed. However, untreated cases may develop cirrhosis or liver cancer later in life.
