Treatment for Chronic Hepatitis in Pediatric Cases Remains Suboptimal

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Findings from this new study are the result of an investigation into over 360 children, many with active hepatitis, elevated alanine aminotransferase levels, and an immune active phenotype.

There is a need for improved treatment for children with hepatitis B virus (HBV) infection, say researchers, who recently published their findings showing that many of these children are at risk for liver disease but remain untreated.

The findings, appearing in The Journal of Pediatrics, come from over 360 children across North American with HBV infection, many of whom had active hepatitis throughout the study period, with elevated alanine aminotransferase (ALT) levels and an immune active phenotype. This included 50 patients who were originally hepatitis B e antigen (HBeAg) positive but subsequently achieved HBeAg-negative status during the study.

“Many children thus appeared to remain at risk for advancing severity of fibrotic liver disease and fulfilled recommended treatment criteria, although clinicians seldom provided anti-HBV treatment,” wrote the researchers. “A low incidence of cirrhosis and no other major clinical outcomes occurred during these childhood years, such as cirrhotic decompensation events, hepatocellular carcinoma, or death related to liver disease.”


The low chance of receiving anti-HBV treatment has been recognized globally, according to the researchers. For example, there are several known barriers to accessing such treatment among immigrant populations due to unawareness, language and cultural barriers, and the potential costs of treatment.

In the current study, nearly one-third of patients fulfilled American Association for the Study of Liver Diseases (AASLD) criteria for anti-HBV treatment during the median 4.2 years of follow-up; however, just 25 of these patients received cirrhotic treatment.

“We speculate that low treatment rates reflect clinicians’ perception of unsatisfactory outcomes of therapy, including the rare achievement of clearance of hepatitis B surface antigen; concerns about the need for long-term therapy with nucleotide analogues; the possibility of antiviral resistance; the known, common adverse effect profile of interferon-based therapies; and awareness of the rarity of significant adverse outcomes of HBV infection during childhood.”

Among the 129 patients who fulfilled the AASLD criteria, the probability of receiving anti-HBV treatment was higher in earlier years of the study (2011-2015) compared with later years (2016-2018).

Patients with higher ALT levels were more likely to receive treatment, indicating that abnormal aminotransferase levels may be a primary driver for clinicians to prescribe treatment. However, the researchers note that while clinicians may have seen these higher ALT levels as an indicator of a need for treatment, they did not collect data on reasons behind the clinicians’ prescribing patterns.

“To enable improved treatment guidelines to be developed, future studies should identify barriers to anti-HBV treatment in childhood and quantify the potential long-term benefits of treatment,” they concluded, “such as prevention of progression of fibrosis during childhood, or the development of cirrhosis and HCC arising as major clinical outcomes during young adult life.”


Ling SC, Lin H-HS, Murray KF, et al; Hepatitis B Research Network. Chronic hepatitis is common and often untreated among children with hepatitis B infection in the United States and Canada. J Pediatr. 2021;237:24-33.e12. doi:10.1016/j.jpeds.2021.05.035