KidsMD Health Topics

Hepatitis B Virus (HBV)

  • Thanks to widespread (and now universal) childhood vaccination, the number of new cases of hepatitis B in the United States has dropped dramatically in the last two decades. However, there are still about 1.2 million people in the U.S. with the infection. Most new cases in the U.S. now are in people who have immigrated or children adopted from countries in the Far East, Western Africa, or Eastern Europe, where hepatitis B is still widespread.

    And because a person can have hepatitis B for years, even decades, with few or no symptoms, many people with the hepatitis B virus (HBV) do not even realize it. For this reason, it is not uncommon for multiple members of a family to be infected with HBV.

    There are two phases of hepatitis B. Symptoms during the acute phase – which encompasses the first six months after a person is infected with HBV – can vary depending on the age of the patient. Infants infected from their mothers at birth often show no symptoms at all and young children may have only non-specific symptoms. Teenagers and adults can become quite ill with jaundice, loss of appetite, abdominal pain, fatigue and other symptoms.

    Chronic hepatitis B – defined as an HBV infection lasting more than six months – is a serious, long-term infection that can, over the course of decades, damage the liver to the point of cirrhosis, or even cause liver cancer. The risk that a child's infection will progress to the chronic phase depends on how young he or she was infected with HBV: The younger their age at infection, the more likely that the infection will become chronic.

    While acute hepatitis B is treated with rest, fluids, and a healthy diet, treating chronic hepatitis B is more complicated. The decision to treat depends largely on whether the virus is actively causing liver damage, which can take years to arise. For that reason, children and adults with chronic hepatitis B are closely monitored for any signs of harm to the liver.

    How Boston Children's Hospital approaches hepatitis B

    The Center for Childhood Liver Disease at Boston Children's Hospital is one of the leading centers internationally for the care of children with hepatitis B. Because hepatitis B in children often becomes a chronic condition, it requires a long-term approach to treatment and care. Our board-certified pediatric hepatologists understand the nuances of caring for a child with hepatitis B, including when to carefully watch a child’s progress and when to take a more aggressive stance. We work with families and pediatricians to make sure that children with hepatitis B – and their families – receive the long-term care and monitoring they need.

    Boston Children's Hospital
    300 Longwood Avenue
    Fegan 5
    Boston MA 02115

     617-355-5837
     fax: 617-730-0716
  • We understand that you may have a lot of questions when your child is diagnosed with hepatitis B, such as:

    • What exactly is it?
    • What is the cause of hepatitis B?
    • What are potential complications in my child’s case?
    • What are the treatments?
    • What are possible side effects from treatment?
    • How will it affect my child long term?

    We’ve tried to provide some answers to those questions here, and when you meet with our experts, they can explain your child’s condition and treatment options fully.

    What is the liver, and what does it do?

    The liver is the body’s second largest organ, located in the right side of the abdominal cavity below the diaphragm and above the right kidney and intestines. The liver helps the body in hundreds of ways:

    • All of the blood coming from the stomach and intestines passes through the liver through a large vein called the portal vein. The liver turns nutrients from the food we eat and chemicals from the medicines we take into forms that the rest of our bodies can use.

    • The liver helps clean the bloodstream of harmful substances and poisons.

    • The liver makes bile, which contains chemicals to help us digest the food we eat.

    • The liver helps control blood sugar and cholesterol levels.

    • The liver makes the proteins that allow blood to clot normally.

    What is hepatitis B?

    Hepatitis B is a liver disease caused by the hepatitis B virus (HBV), and the most common serious liver infection in the world. It ranges in severity from a mild illness that lasts a few weeks and clears on its own to a serious, long-term illness that requires lifelong care.

    Children and adults who are not able to clear an HBV infection within six months (the infection's acute stage) go on to develop chronic hepatitis B, a serious illness that can cause long-term health problems and requires long-term care. The risk that a child with acute hepatitis B will develop the chronic form goes down with age, so for instance an infant with acute hepatitis B has about a 90 percent chance of having the infection become chronic; the risk in children under five years old is about 30 percent, while that of an adult is between two and six percent.

    Over the course of decades, chronic hepatitis B progresses through four stages – immune tolerance, immune clearance, inactive carrier, and reactivated – based on the behavior of the virus and how your child’s immune system responds against it. The inactive carrier phase, in particular, can last for years, often until well into adulthood.

    What happens to the liver in hepatitis B?

    In acute symptomatic hepatitis B, the liver can become swollen and inflamed, but the infection may be silent, particularly in infants. Should the infection become chronic and enter reactivated stage, the virus can cause inflammation that in turn causes the healthy, soft tissues in the liver to harden and scar, typically over the course of decades. If not stopped, this hardening can lead to serious liver diseases such as cirrhosis or liver cancer. This happens in upwards of a quarter of people with chronic hepatitis B.

    Causes

    What causes hepatitis B?

    Hepatitis B is caused by the hepatitis B virus (HBV). The virus is passed from person to person through contact with blood infected with HBV, sexual intercourse, or intravenous drug use. Mothers infected with HBV can pass the virus on to their children during childbirth, though doctors can reduce that risk by giving newborns both the hepatitis B vaccine and a medication called hepatitis B immune globulin (or HBIG) within about 12 hours of birth.

    While the number of new cases of hepatitis B in the United States has dropped dramatically in the last two decades – thanks to widespread (and now universal) childhood vaccination – there are still about 1.2 million people in the U.S. with the infection. Most cases in the U.S. now are in people who have immigrated or children adopted from countries in the Far East, Western Africa, or Eastern Europe, where hepatitis B is still widespread. Because chronic hepatitis B causes few or no symptoms, many do not even realize they are infected.

    Signs and symptoms

    What are the symptoms of hepatitis B?

    The majority of infants with acute hepatitis B have no symptoms; they also have no idea they are infected. Over time, as the virus causes increasing damage to the liver, patients can experience symptoms like fatigue, nausea, dark urine, muscle soreness, vomiting, loss of appetite, stomach pain and jaundice.

    How is hepatitis B diagnosed?

    If your child’s doctor suspects that your child may have been infected with HBV, he or she may test their blood to see if it contains a portion of the virus called the surface antigen. If the test comes back positive, your child’s doctor may run additional tests for the other portions of the virus that can provide more information.

    Children and adults with HBV surface antigen in their blood for more than six months – meaning that they now have chronic hepatitis B – typically undergo periodic tests to monitor their liver function and look for signs of serious liver disease. If such tests show that the virus is starting to damage your child’s liver, then a biopsy may be ordered as well to determine whether the time is right to start treatment.

    Because in the U.S. HBV is most often passed from mother to child, your doctor will also want to know whether there is any history of liver disease, and in particular liver cancer, in your family. It is not uncommon for multiple members within a family to be infected, and knowledge of your family’s history could help your doctor predict how the virus will behave within your child.

    How do you treat hepatitis B?

    Acute and chronic hepatitis B are treated very differently. In prescribing treatment for hepatitis B, doctors in our Center for Childhood Liver Disease aim to inactivate the virus, reduce the amount of virus in the blood, and prevent the progressive liver damage that could lead to cirrhosis or liver cancer.

    If your child has acute hepatitis B, our doctors will recommend rest, healthy eating, and drinking plenty of fluids. If we determine that the infection has lasted more than six months – that is, that your child has chronic hepatitis B – and that the virus is starting to damage the liver, then we may start treatment with one of a variety of medications. Your doctor will discuss pros and cons of each medication with you.

    In additions, new medications have become available over the last few years to treat hepatitis B in adults, and are currently being evaluated for the treatment of children. Your child’s doctor may discuss clinical trials (research studies) of these medications in which your child may be able to participate.

    While the hepatitis B vaccine is not effective in people who are already infected with the virus, we do recommend that all children and adults with hepatitis B receive the vaccine against hepatitis A in order to prevent additional liver inflammation and injury.

    How can hepatitis B affect my child in the long term?

    First off, you should know that children with chronic hepatitis B can lead completely normal lives, and can attend school and play sports without any special arrangements, just like any other child.

    However, if your child has chronic HBV infection he or she could very well be infected with it for life. Over the decades, the virus can cause progressive damage to the liver and lead to such complications as cirrhosis and liver cancer.

    When they become older, children with hepatitis B should avoid drinking alcohol, as it can make the disease progress more quickly. Once they become or if they are sexually active, they should practice safe sex so as to not pass the virus on to others.

  • As noted earlier, it is possible for a mother with hepatitis B to pass HBV on to her newborn. If your doctor suspects that your child may have hepatitis B, he or she may order a blood test to see whether your child’s blood contains a portion of the virus called the surface antigen.

    If the surface antigen test comes back positive, your child’s doctor may run additional tests for other portions of the virus, ones that will tell how the virus is behaving within your child’s body (e.g., is it being cleared by the immune system, entering a latent phase, or rebounding/reactivating).

    Children with chronic hepatitis B should be checked every six months to see how well their livers are functioning. If it appears that the virus is beginning to damage the liver, your doctor may recommend that your child have a liver biopsy to check the extent of the damage. The results of the biopsy will help determine whether the time is right to start treatment.

    It is not uncommon for many members of a single family to be infected with HBV without knowing it. But because in the U.S. HBV is most often passed from mother to child, your doctor will also want to know whether there is any history of liver disease, and in particular liver cancer, in your family; this knowledge could help your doctor predict how the virus will behave within your child.

    Also, you should talk with your doctor about having all members of your family tested for HBV, and about vaccinating all those whose test results come back negative (that is, who are not infected with the virus).

  •  At Boston Children's Hospital, we take a multidisciplinary approach to the care of children with hepatitis B. Our Center for Childhood Liver Disease is one of the few centers with a dedicated team of specialists who are board-certified in pediatric hepatology.

    Acute and chronic hepatitis B are treated differently, but in either case, our goals in treating your child are to control the virus and prevent the progressive liver damage that could lead to cirrhosis or liver cancer.

    There is a very effective vaccine for hepatitis B that is now given to everyone in infancy. However, the vaccine can only protect one from an HBV infection, not treat existing infections. As a preventive measure, though, all children and adults with hepatitis B should be vaccinated against hepatitis A.

    While the hepatitis B vaccine is extremely safe and has never been associated with any serious complications, some families choose not to have their children vaccinated, so there may still be children and young adults who are at risk for acquiring this serious infection.

    Acute hepatitis B

    The usual treatment for acute hepatitis B is no treatment. Rather, our doctors recommend rest, healthy eating, and drinking plenty of fluids to help the body clear the virus on its own. Your child will be tested periodically to see if the infection goes away on its own.

    Chronic hepatitis B

    Should your child have chronic hepatitis B and tests show that the virus is starting to damage the liver, your child's doctor will start treatment. Historically, this would consist of one of two drugs, interferon and lamivudine, though more often the specialists in the Center for Childhood Liver Disease would recommend enrolling your child in a clinical trial of new, potentially more effective drugs.

    In the long term, children and adults with chronic hepatitis B should avoid alcohol, as it can speed the progression of liver disease, and should also be careful about which prescription or over-the-counter medications or supplements they take. In addition, it is important to maintain a healthy weight, since being overweight can make the liver disease progress faster and the treatment less effective, and if sexually active to practice safe sex so as to not pass the virus on to others.

    He or she should have liver blood tests checked regularly to look for signs of advanced liver disease. People with chronic hepatitis B should also have periodic blood tests and ultrasound exams to look for any signs of liver cancer, even if laboratory test indicate that their viral infection is inactive. This is especially important after age 40, but doctors often begin surveillance earlier to detect the rare advanced cases in younger patients.

    Care in school and other group settings

    The doctors and nurses in the Center for Childhood Liver Disease are often asked whether schools, sports teams, and other group settings need to have special precautions in place for children with hepatitis B. Beyond the universal precautions that all schools, etc. should have in place to deal with contact and disposal of items with blood on them, the answer is no.

    Care within the family

    You can prevent the spread of the virus within the household by not sharing any items that may be exposed to blood, such as toothbrushes, razors, pierced earrings, nail clippers, etc.; all other family activities are fine.

    Because it is not uncommon for many members of a single family to be infected with HBV without knowing it, you should talk with your doctor about having all members of your family tested for HBV, and about vaccinating all those whose test results come back negative (that is, who are not infected with the virus).

  • Historically, children with chronic hepatitis B would be treated with one of two drugs, interferon and lamivudine. There are other medications – adefovir, entecavir, and peginterferon – that the Food and Drug Administration has approved for treating chronic hepatitis B in adolescents and adults. Maureen Jonas, MD, director of the Center for Childhood Liver Disease at Boston Children's Hospital, is studying these medications in children, with the goal of encouraging the FDA to approve their use more broadly in children with chronic hepatitis B.

    Liver biopsies provide a great deal of information about how much hepatitis B and/or other conditions have damaged a child’s liver. But the process of taking a biopsy is invasive, can be painful, and is not without risk. Dr. Jonas and colleagues are also investigating an ultrasound-based imaging technology called Fibroscan, which may be able to help doctors assess a child’s liver scarring through a virtual biopsy.

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