Pediatric liver specialist Kathleen B. Schwarz, M.D., and experts from other children’s hospitals are calling for more consistent monitoring and referral of children chronically infected with the hepatitis B virus (HBV). The new recommendations — published online October 5, 2009, in Pediatrics— resulted from a meeting of nationally recognized pediatric liver specialists held November 11, 2008, at the Hepatitis B Foundation’s headquarters in Bucks County, PA.

The panel recommends that pediatricians and other primary care practitioners stress the need for routine monitoring of children with chronic HBV infections, and timely consultation with a pediatric liver specialist.

“Most children with chronic HBV infection are asymptomatic, lacking any signs or symptoms of disease,” said Schwarz of Johns Hopkins Children’s Center, panel member and a co-author of the report. Schwarz stressed, however, that “this is a progressive disease, and children infected chronically with HBV have an increased risk of severe complications as teens or adults, including cirrhosis, and even liver cancer. This is why screening and identification of HBV infection in children is essential.”

Chronic HBV infection remains a serious health concern in populations who are not vaccinated against HBV, or are who are exposed prior to being vaccinated. The panel’s report discusses the importance of screening children in high-risk groups, such as those born in countries endemic for HBV. A challenge facing pediatricians is the lack of clear screening, monitoring and treatment guidelines.

"Because the majority of infants born in the U.S. are now vaccinated against HBV, most pediatricians don't encounter chronic HBV infection very frequently," said lead author Barbara A. Haber, MD, of the Children’s Hospital of Philadelphia. "And often times children at risk, including immigrants from endemic areas, are not screened and remain undiagnosed."

The panel's report provides recommendations for primary care providers on the initial management of these children, including what tests to conduct to periodically monitor disease progression, and when, based on the test results, a pediatric liver specialist should be consulted. The report includes a flow chart outlining the recommendations, which cover liver function testing, hepatitis B serology and DNA levels, liver ultrasound, alpha-fetoprotein (AFP) testing, and family history. The panel advocates for referral of any child with elevated serum liver enzyme levels, elevated AFP levels, or a family history of liver disease or liver cancer.

“The decision whether or not to treat needs to be evaluated carefully by a pediatrician or specialist familiar with indications for treatment of chronic HBV,” Dr. Schwarz said. “The right treatment at the right time can enhance quality and length of life. Inappropriate or unnecessary treatment can result in the emergence of drug-resistant strains of the virus, potentially limiting our treatment options for the future.”

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