We were pleased to read Dr Davison's review of the two recently
published guidelines for managing chronic Hepatitis B infection in
children [1]. We have recently audited our practice against both of these
guidelines.
As Dr Davison points out; "The level of Alanine transaminase (ALT) at
which treatment should be considered highlights a fundamental difference
between the guidelines".
NICE suggests that ALT in males above 30 IU/L and in females above 19 IU/L
is considered abnormal [2]. The ESPGHAN guidelines suggest a threshold of
more than 1.5 times the upper limit of normal (or more than 60 IU/L) [3].
In our cohort of 12 children with chronic hepatitis B, all the children
had an abnormal ALT using NICE guidance, but only 7 had abnormal ALT by
ESPHGAN criteria, of which only 4 remain abnormal 6 months later.
The number of children in our audit is small, but suggests that using the
NICE criteria for abnormal ALT could lead to over investigation for
children with chronic hepatitis B. NICE guidance extrapolated adult ALT
values to children. We agree that "further research is needed to review
the appropriateness of these values in children and young people when
making decisions to start treatment".
References
1. Davison S. Management of chronic hepatitis B infection. Arch Dis
Child. 2014 May 8. doi: 10.1136/archdischild-2013-304925. [Epub ahead of
print]
2. National Institute for Health and Care Excellence (NICE).
Diagnosis and management of chronic hepatitis B in children, young people
and adults, 2013. guidance.org.uk/cg165.
3. Sokal EM, Paganelli M, Wirth S, et al. Management of chronic
hepatitis B in childhood: ESPGHAN clinical practice guidelines: consensus
of an expert panel on behalf of the European Society of Pediatric
Gastroenterology, Hepatology and Nutrition. J Hepatol 2013;59:814-29.
Conflict of Interest:
Dr Davison comes to do a Hepatitis clinic with me once a year.
We were pleased to read Dr Davison's review of the two recently published guidelines for managing chronic Hepatitis B infection in children [1]. We have recently audited our practice against both of these guidelines. As Dr Davison points out; "The level of Alanine transaminase (ALT) at which treatment should be considered highlights a fundamental difference between the guidelines". NICE suggests that ALT in males above 30 IU/L and in females above 19 IU/L is considered abnormal [2]. The ESPGHAN guidelines suggest a threshold of more than 1.5 times the upper limit of normal (or more than 60 IU/L) [3]. In our cohort of 12 children with chronic hepatitis B, all the children had an abnormal ALT using NICE guidance, but only 7 had abnormal ALT by ESPHGAN criteria, of which only 4 remain abnormal 6 months later. The number of children in our audit is small, but suggests that using the NICE criteria for abnormal ALT could lead to over investigation for children with chronic hepatitis B. NICE guidance extrapolated adult ALT values to children. We agree that "further research is needed to review the appropriateness of these values in children and young people when making decisions to start treatment".
References
1. Davison S. Management of chronic hepatitis B infection. Arch Dis Child. 2014 May 8. doi: 10.1136/archdischild-2013-304925. [Epub ahead of print]
2. National Institute for Health and Care Excellence (NICE). Diagnosis and management of chronic hepatitis B in children, young people and adults, 2013. guidance.org.uk/cg165.
3. Sokal EM, Paganelli M, Wirth S, et al. Management of chronic hepatitis B in childhood: ESPGHAN clinical practice guidelines: consensus of an expert panel on behalf of the European Society of Pediatric Gastroenterology, Hepatology and Nutrition. J Hepatol 2013;59:814-29.
Conflict of Interest:
Dr Davison comes to do a Hepatitis clinic with me once a year.