What is Hepatitis A in Children?
Hepatitis A is an acute disease with a cyclic course, which is manifested by symptoms of intoxication and impaired liver function, which quickly pass. Hepatitis A, according to the international classification, is of the following types:
- hepatitis A with hepatic coma
- acute hepatitis A
- hepatitis A without hepatic coma.
Hepatitis A is often affected by children. The incidence is manifested in the form of individual periodic cases or small epidemics. Among patients with hepatitis A, more than 60% are children. Children from 3 to 7 years are more susceptible to this disease. Transplacental immunity protects children under 1 year old from the disease.
Only people are affected by hepatitis A. The infection is transmitted and spread by a person, regardless of the form of the disease – explicit or latent, as well as the virus carrier. Epidemics develop mainly due to patients with atypical forms of hepatitis A. They are not diagnosed with the disease, because an infected person continues to lead a normal lifestyle, spreads the infection without knowing it.
The virus in patients “lives” in the feces, blood and urine. In urine, it appears before any symptoms have been identified. Hepatitis A is classified as a typical intestinal infection. Routes of transmission: contact household, through feces, with food and water. Hepatitis A is not transmitted by airborne droplets. You can also get infected by blood transfusion, but the risk is very, very small, since the virus in the blood is unstable. The transplacental route of transmission is excluded.
The human body is very susceptible to this virus. The vast majority of adults develop antibodies. The largest number of hepatitis A diseases is recorded in autumn and winter, and the lowest incidence is in summer. Epidemics happen in kindergartens and schools. After the disease, the body develops immunity, which protects the person from hepatitis A for the rest of his life.
Hepatitis A is classified by type, severity and course.
Typical hepatitis A – all cases of the disease characterized by icteric staining of the skin and visible mucous membranes. By severity, 3 forms are traditionally distinguished: mild, moderate and severe. Atypical cases include anicteric, erased, subclinical hepatitis. Atypical hepatitis A severity is not classified, it refers to a mild form.
Severity is determined by how pronounced manifestations of general intoxication and jaundice are. Also take into account the results of biochemical studies.
Light form. This form is more than about 50% of children. It is characterized by a moderate increase in body temperature (short-term). Intoxication is weak. The liver is enlarged moderately.
The disease is cyclical and benign. The icteric period lasts from a week to 10 days. The liver regains its normal size on the 25th-35th day. A protracted course of the disease is noted in 5% of children.
In 30% of patients there is a moderate form of hepatitis A. Symptoms of intoxication are moderate, jaundice – from moderate to significant. The edge of the liver is dense, the organ itself is painful. The amount of urine is significantly reduced. The spleen is also often enlarged. The disease runs smoothly. Up to 10-14 days of illness, symptoms of intoxication persist. Jaundice does not pass 2-3 weeks. The liver returns to normal only after 40-460 days of illness. A protracted course is noted only in 3% of cases.
A severe form of the disease is rare, it is recorded only in 1-3 cases out of 100. The phenomena of intoxication are very pronounced, like jaundice. Severe and frequent vomiting, lethargy, anorexia, etc. appear. The appearance of jaundice does not weaken the symptoms of general intoxication, rather the opposite. The child becomes lethargic, inhibited. Among the symptoms are also dizziness, nosebleeds, bradycardia, a significant decrease in diuresis, hemorrhagic rashes.
In severe hepatitis A, the liver is sharply enlarged, the spleen also. Palpation causes severe pain.
The anicteric form of the disease passes without ictericity of the skin and sclera. About 20% of patients with hepatitis A are affected by it. Other symptoms are similar to those of the icteric form of hepatitis. The temperature may rise for a while. The appetite disappears, general weakness and lethargy appears. There may be nausea and even vomiting, but not more than 3-5 days.
The main symptom of the anicteric form is an acute enlargement of the liver with its compaction and pain on palpation. There is also an enlargement of the spleen, dark urine and slightly discolored feces.
The subclinical form of the disease is also called inapparent. With it, clinical manifestations are absent. In this case, hepatitis A can be diagnosed using a biochemical examination of children who are in contact with patients. The diagnosis is confirmed by the detection of serum antibodies of the TgM class against hepatitis A in the blood serum. Children with this form of the disease support the epidemic process in groups.
Cholestatic form. It is characterized primarily by the symptoms of obstructive jaundice. The basis for the development of this form of the disease is a delay in bile at the level of intrahepatic bile ducts. The main symptom is prolonged, pronounced jaundice, which disappears after 30-40 days or later. The skin can have not only yellow, but also a greenish or saffron hue. In such cases, itching predominates. Symptoms of intoxication are not pronounced, there is a slight increase in the liver. The urine is dark, feces discolored. The course of the cholestatic form of hepatitis A is long, but nonetheless favorable. Chronic hepatitis does not occur.
The disease can be acute or prolonged, smooth without exacerbations, with exacerbations. There may also be complications from the biliary tract and the accession of concomitant diseases.
An acute course occurs in 95/100 cases. There are times when the symptoms disappear very quickly – in 2-3 weeks. The liver returns to normal during this time. In children, the total duration of the disease, although it fits into the time frame of acute hepatitis (2-3 months), but for 6-8 weeks after the disappearance of jaundice, certain complaints may remain. These cases can be considered as dragging convalescence.
A protracted course is diagnosed with hepatitis, which lasts 3-6 months or longer. Violation of the cycle of the disease is detected in the period after jaundice. The liver remains enlarged for a long time, sometimes also the spleen. The protracted form of hepatitis A ends in recovery.
Exacerbation. An exacerbation is understood to mean an increase in the clinical signs of hepatitis and a deterioration in functional liver tests against a background of a continuing pathological process in the liver. An exacerbation differs from a relapse of hepatitis A. Relapse refers to the re-occurrence of the disease, which begins after complete recovery (when the visible symptoms disappear). Relapses may not be accompanied by the appearance of jaundice.
In children, the manifestation of a relapse of the disease is accompanied by the addition of another type of hepatitis. Exacerbations occur due to low immunity.
The course with the defeat of the biliary tract usually occurs with a moderate form of the disease. Often the disease in this case proceeds without distinct symptoms and is diagnosed according to the results of a laboratory study. Lesions pass without the use of specific treatment along with the disappearance of the symptoms of hepatitis A.
The course with the addition of intercurrent infections. Joining diseases usually do not increase the severity of symptoms. But they can cause liver enlargement in some cases.
A positive outcome is possible – a full recovery, which is manifested, among other things, by restoration of the liver structure. Recovery can be with anatomical defects, in which case the liver is enlarged for life. There may also be complications. Damage to the biliary tract is considered not so much as an outcome, but as a complication of hepatitis A due to the activation of the microbial flora.
When the biliary tract is affected, patients complain of pain under the ribs on the right, nausea or vomiting. Moreover, complaints begin after a 2-3 month period after recovery.
Causes of Hepatitis A in Children
Hepatitis A virus was discovered in 1970 by S. Feinstone and the team. The virus contains RNA with a diameter of 27 to 30 nm. The virus belongs to enteroviruses. HAV can be “killed” with a solution of formalin, chloramine and ultraviolet rays. Also, the virus dies in the first minute if the temperature reaches 85 ° C. But the CAA is insensitive to ether.
Pathogenesis during Hepatitis A in Children
With hepatitis A, a direct cytopathic effect of the virus on the liver parenchyma is allowed. The virus enters the stomach with saliva or food / water. From the stomach, it descends into the small intestine, in which it is supposedly absorbed into the portal bloodstream and through the related receptor penetrates into hepatocytes and interacts with biological macromolecules involved in detoxification processes.
Due to this process, free radicals are released that initiate the processes of lipid peroxidation of cell membranes. The organization structure of the lipid components of the membranes is changing. Holes appear in the hydrophobic barrier of biological membranes, which ultimately leads to their permeability. There is a central link in the pathogenesis of hepatitis A – cytolysis syndrome.
In the body, protein, fat, carbohydrate, pigment and other types of metabolism are disturbed. Therefore, the ability to synthesize albumin, blood coagulation factors, various vitamins decreases, the use of glucose deteriorates, etc. In the phase of convalescence, the liver is restored.
Pathomorphology. The morphology of hepatitis A was able to be studied thanks to the data of intravital puncture biopsies of the liver. Changes are visible in all its tissue components. With hepatitis A, there is no massive liver necrosis.
Symptoms of Hepatitis A in Children
The disease, which has a typical course, is cyclical, and includes periods: incubation, initial (preicteric), the height of the disease (icteric), postanteric and convalescence periods. There are five of them.
From 10 to 45 days, the incubation period lasts when children are infected with hepatitis A. In most cases, it is 15-30 days. Viral antigen at this time can already be detected in the blood of an infected child. There is also a high activity of hepatocellular enzymes.
The initial period in specialized literature is also called the prodrome period. The disease has an acute onset, the temperature rises to 38–39 ° C, symptoms such as weakness in the body, headaches, loss or loss of appetite, nausea and even vomiting appear. A child may complain of pain on the right under the ribs or without specific localization.
Young children begin to be capricious and annoyed, interest in games disappears, sleep disturbances occur. Often there are transient dyspeptic disorders: flatulence, constipation, in more rare cases – multiple liquefied stools.
After a few days or even after the first day, the temperature returns to normal, the symptoms weaken, but general weakness still persists. The most important objective symptom in this period of the disease is an enlargement of the liver, its sensitivity and tenderness on palpation.
In mild forms of hepatitis A, the disease begins not with the above described symptoms of intoxication, but with changes in the shade of urine and feces. The prodromal period lasts from 3 to 8 days.
The peak period is characterized by the manifestation of jaundice. The general condition is improving. First, sclera yellow, then the skin of the face, torso, palate, and even later – the skin on the limbs. Jaundice manifests itself very quickly.
Jaundice with hepatitis A in children is not always pronounced. It lasts from 1 to 2 weeks, an average of 9 to 13 days. Folds of skin, auricles and sclera remain the longest yellow. In the midst of jaundice, the liver is maximized, pain on palpation. In hepatitis A, the following symptoms can also be observed: lowering blood pressure, weakening heart sounds, impurity of the I tone or a small systolic murmur at the apex, etc.
After the maximum, jaundice begins to subside, it occurs 7-10 days after the start. Symptoms of intoxication disappear, appetite becomes better, diuresis increases. Normal stool color returns. If the course of the disease is cyclical, the clinic subsides after a week (maximum – after 10 days). Then the post-icteric period begins. Despite the well-being, functional liver tests were changed, the liver was enlarged (rarely – also the spleen).
The fifth period is called recovery. It is characterized by the normalization of the size of the liver and the restoration of its functions. The general well-being of the child is good. But often children complain of rapid fatigue during physical exertion, abdominal pain. The fifth period lasts from 2 to 3 months.
Diagnosis of Hepatitis A in Children
Diagnosis of hepatitis A in children is based on clinical, epidemiological and laboratory data. Laboratory methods are crucial. Laboratory indicators are divided into specific and non-specific. Specific ones allow detection of HAV RNA (using PCR) and specific anti-HGA JgM antibodies (using ELISA) in the blood.
Nonspecific laboratory indicators help establish the level of liver damage, assess the severity, course and prognosis of the disease. Among the numerous laboratory biochemical tests, the most effective are the determination of the activity of liver-cell enzymes (ApAT, AsAT, F-1 – FA, etc.), indicators of pigment metabolism and protein-synthesizing liver function.
Hepatitis A Treatment in Children
Treatment in most cases is carried out at home. If the disease is moderate, moderate / minimal physical activity is recommended. The more severe the disease, the less physical activity should be.
If the form of the disease is worn out, mild, a half-bed regimen is recommended from the moment jaundice is detected.
In severe and even moderate form, bed rest should be observed in the first 3-5 days of the icteric period. As soon as symptoms of intoxication begin to manifest less, you can enter the half-bed regimen.
Children are exempted from physical education for 3-6 months, and sports for a period of 6 to 12 months. An increase in physical activity is recommended to be administered depending on individual cases.
Ill children need a complete, high-calorie and, if possible, physiological diet with a ratio of proteins, fats and carbohydrates 1: 1: 4-5.
A child with hepatitis A can consume protein from low-fat dairy products, low-fat meat, low-fat fish, and eggs. Carbohydrates are introduced into the diet in the form of bread, rice, semolina, oatmeal, buckwheat, pasta, sugar, potatoes.
The diet for hepatitis A in children should contain sufficient raw and boiled vegetables, as well as greens, juices and fruits. Extractive consumption should be excluded. Under this concept are hidden organic substances that enter the solution when cooking the product. For example, it is creatine, xanthine, creatinine, tyrosine, urea, leucine, etc.
Also, the child is not recommended refractory fats, which contain fat, margarine, overalls. You can’t eat fatty sausages, canned meat, pork, ham, fatty birds, fatty fish, marinades, hot sauce, legumes, hot cheeses, radishes, garlic, radishes, cakes, chocolate, pastries, sweets, hot spices (including mustard, mayonnaise and pepper), smoked products, g nuts, ribs, horseradish, etc.
For hepatitis A, honey, marshmallows, preserves, junk cookies, dried fruits (such as prunes, dried apricots, raisins), jellies, mousses, jelly, salads, vinaigrettes, fish, soaked herring can be consumed.
Hepatitis A in children is not treated with medication, but choleretic drugs are prescribed. In the acute period of the disease, it is better to use mainly cholelitic drugs (magnesium sulfate, flamin, berberine, etc.), and in the period of convalescence – cholesterol (allochol, cholenzyme, etc.).
With hepatitis A, doctors prescribe complex B vitamins, vitamins C and PP. In the period of convalescence and especially, but with protracted hepatitis A, phosphogliv, Liv52 K (if the child is older than 2 years), tabletted Liv52 can be prescribed. Or you can conduct a course of treatment with legalon.
The relief of cholestasis with a cholestatic form of the disease is carried out using ursodeoxycholic acid (ursosan). The dose is 10-15 mgDkg / day. If the course of hepatitis A is protracted, the course of ursosan can be extended to 3-6 months. Ursosan is sometimes replaced (on the recommendation of a doctor) with phosphogliv or essentials for 2-4 weeks or with legalon. In severe forms (and in some cases with moderate forms), infusion therapy is prescribed.
A 1.5% reamberin solution is administered intravenously dropwise at the rate of 10 ml / kg body weight reopoliglukin, hemodesis, 10% glucose solution.
When the acute period of the disease passes, the children are under medical supervision. A special office is organized at the hospital. If it’s impossible to organize such an office, a district pediatrician in a children’s clinic conducts a medical examination.
On the 45-60th day after the onset of the disease, the first examination of the sick child is carried out, the second examination is prescribed after 3 months. If there are no clinical manifestations, the child is deregistered.
Regardless of the form and severity of the disease, enterosorption therapy should be prescribed for the entire duration of treatment. Such drugs as enterosgel, enterodesis are used.
If a large child lives in villages or towns, the medical examination is carried out at the infectious departments of the central district children’s hospitals or children’s clinics.
Prevention of Hepatitis A in Children
Measures to prevent the spread of hepatitis A infection suggest an impact on the source of infection, its transmission and susceptibility.
Early diagnosis allows you to isolate a sick person to prevent epidemic outbreaks, especially in children’s organized groups. In children who have had contact with the patient, sclera, skin are examined every day, liver palpation is performed. They can also check the color of urine and feces.
To identify atypical forms in the focus of hepatitis A, a laboratory examination is recommended. The examination is carried out systematically, every 10-15 days, until the outbreak of hepatitis A is over.
Prevention of the spread of infection is carried out by monitoring public catering, the quality of drinking water, and observance of public and personal hygiene. If a patient with hepatitis A is identified in the focal point of infection, current and final disinfection is carried out.
As a prophylaxis, the introduction of normal immunoglobulin is used. This helps stop the flash. Usually immunoglobulin with a high content of antibodies to hepatitis A virus is used – 1:10 000 and higher.
Immunoprophylaxis of the disease is carried out planned and before the season of activity of the disease. Also according to epidemic indications. Planned prophylaxis falls at the beginning of autumn – August or September; it is carried out in regions with a high incidence of hepatitis A, where 12 out of 1000 children are ill.
The most effective prevention of hepatitis A is possible only through universal vaccination. The following vaccines are registered and approved for use:
- hepatitis A vaccine with polyoxidonium GEP-A-in-VAK-PO L, Russia;
- hepatitis A vaccine purified concentrated adsorbed inactivated liquid HEP-A-in-HAC. Russia;
- Hawrix 720 from Glaxo Smith Klein, England;
- Hawrix 1440 of the company Glaxo Smith Klein, England;
- twinrix – a vaccine against hepatitis A and B, Glaxo Smith Klein, England;
- vacca 25 units (and 50 units). Merck Sharp and Dome, USA;
- Avaxim company Sanofi Pasteur, France.
Hepatitis A vaccine is administered intramuscularly to children from 1 year old. The hepatitis A vaccine can be administered simultaneously with the hepatitis B vaccine if the timing of vaccinations in different parts of the body coincides. In 95% of those vaccinated, a protective level of immunity is formed.
Side effects from vaccine administration are virtually uncommon. They can occur in rare cases in the form of pain, hyperemia and edema at the injection site. The temperature may rise, chills, allergic rashes may appear.