Management of chronic hepatitis B infection - will NICE guidance lead to over investigation?

Andrew Riordan, Consultant in Paediatric Infectious Diseases and Immunology,
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Other Contributors:

September 12, 2014

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".


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.

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.

Conflict of Interest

None declared