PEDIATRIC NURSING

1. HEPATITIS
Presented by
Ms Arifa T N,
Second year M.Sc Nursing, MIMS CON

2. INTRODUCTION
 Hepatitis is an acute or chronic inflammation of the liver that
can result from infectious or noninfectious reasons
 Viruses such as the hepatitis viruses, Epstein-Barr virus (EBV),
and cytomegalovirus (CMV) are common causes of many
types of hepatitis
 The most frequently diagnosed causative organisms are
 Hepatitis A virus (HAV),
 Hepatitis B virus (HBV), and
 Hepatitis C virus (HCV).
 Hepatitis D virus (HDV).
 Hepatitis E (HEV)

3. DEFINITION
Hepatitis is an inflammation of the liver caused by a viral
infection. Hepatitis may be an acute or chronic disease.
Acute hepatitis is rapid in onset and, if untreated, may develop into
chronic hepatitis.

4. ETIOLOGY
Hepatitis A is highly contagious and traditionally has been called
infectious hepatitis.
 Infection occurs primarily through
 The fecal–oral route.
 Transmission is by direct person-to-person spread or
 through ingestion of contaminated water or food.
 Hepatitis A frequently occurs in children in childcare settings where
hygiene practices are poor.
 Food handlers can spread hepatitis A if not aware of their infection; it is
a common cause of food borne illness.

5.  The virus is transmitted in the early stages of the disease
when individuals are often asymptomatic or only mildly ill, large
numbers of people may be exposed before the diagnosis is
confirmed.
 Most children recover from hepatitis A; however, in rare
instances, acute liver failure may occur.

6. Hepatitis B can result in acute or chronic infection and is
transmitted by the parenteral route through,
 The exchange of blood or any body secretion or fluids,
 sexual activity, and
 transmission from mother to fetus in utero.
 Adolescents who use intravenous drugs and have unprotected
sexual intercourse are at risk for contracting hepatitis B.
 Major sources for the spread of HBV are healthy chronic
carriers

7. Hepatitis C is the most common chronic blood borne infection
 The hepatitis C virus is transmitted primarily through,
 Intravenous drug use,
 Needlestick injury, and
 birth to a mother infected with hepatitis C.
 Blood transfusions,
 Chronic infection occurs in 75% to 85% of those individuals
infected with hepatitis C

8. Hepatitis D (delta virus) is a defective virus that can gain
entry to a human only in connection with hepatitis B
(CDC,2014f).
 It can occur as a coinfection along with hepatitis B or as a
superinfection in someone already infected with hepatitis B
Hepatitis E infection is primarily transmitted through
contaminated water and is most common in developing
countries

10. PATHOPHYSIOLOGY

12.  Initially, invasion of the parenchymal cells by the virus results
in local degeneration and necrosis.
 Subsequent infiltration of the parenchyma by lymphocytes,
macrophages, plasma cells, eosinophils, and neutrophils
causes inflammation that blocks biliary drainage into the
intestine.
 Impaired bile excretion causes a buildup of bile in the blood,
urine, and skin (jaundice).
 Structural changes in the parenchymal cells account for other
altered liver functions

13.  Incubation period of hepatitis A varies from 28 to 42 days. In
case of hepatitis B, it is much longer, i.e. 60 to 150 days. For
hepatitis C, it is 30 to 60 days, for hepatitis D 60 to 80 days
(similar to HBV), and for hepatitis E 25 to 60 days.

14.  Symptoms of acute viral hepatitis infection include
 In the prodromal phase.
 Nausea,
 Vomiting,
 fatigue,
 abdominal pain,
 joint pain,
 pruritus, and
 urticaria
 In the icteric phase, the child develops jaundice, gray- or pale-
colored bowel movements, gastrointestinal symptoms, right upper
quadrant pain, and malaise.
 In the convalescent phase the jaundice resolves and laboratory
values return to normal

16. DIAGNOSIS
 Diagnosis is mainly clinical.
 The following investigations are of value
 Van den Bergh reaction is direct during early days of jaundice. But,
during terminal stage of jaundice, it may be indirect.
 Conjugated serum bilirubin is as high as 10 mg
 Bromosulfan retention test tends to parallel the retention of bilirubin
in blood but remains abnormal for a prolonged period

19.  SCOT and SGPT are remarkably high in the early course of
the disease; alkaline phosphatase and LDH are only slightly
raised
 ESR is increased.
 Electrophoretic analysis shows high gamma globulins.
 Occasionally, monocytosis to the extent of 25% may be
present.

20.  Serologic tests are mandatory for identifying the exact type
of viral hepatitis.
 Diagnosis of HAV depends on demonstration of raised titer of
anti- HAV IgM antibody in serum by such methods as RIA or
ELISA.
 For HBV, demonstration of HBsAg is required. It appears
quite early in the infection (though during a brief “window
period”it may not be detectable) and disappears soon.
 HDV is diagnosed by demonstration of anti-HDV antibodies of
IgM type.

21. TREATMENT
Hepatitis A
 Bed rest (not “absolute”; uncomplicated cases do not need hospitalization)
as long as jaundice is present and ESR remains high.
 Small but frequent feeds of high carbohydrate diet; intravenous glucose (10
to 20%) in case of severe vomiting.
 Fats, in any form, are poorly tolerated and should be avoided
 Adequate vitamin supplements. Role of vitamins is only supportive.
However, vitamin K is of definite value when PTT is prolonged.
 Gamma globulins.
 Neomycin may be given in serious cases for sterilization of the gut.

22.  Lactulose, a nonabsorbable disaccharide, should be given as a syrup, 10
to 50 ml/day (O), or its diluted form as retention enema every 6 hours. It
lowers blood ammonia level by reducing microbial ammonia production
and by trapping ammonia in acidic intestinal contents
 A benzodiazepine antagonist, flumazenil, claims to reverse early hepatic
encephalopathy.
 Steroids must not be given since they increase risk of chronicity and
relapses. Their use just-because they produce temporary sense of well-
being and improvement in liver function is injudicious.
 Hepatotoxic drugs like chloropromazine, paraceta-mol, etc. should be
avoided. Phenobarbital, chloral hydrate or diazepam are good enough for
sedation.

23.  For hepatitis B, no special treatment is required, except in
special situations such as fulminant hepatitis and chronic
hepatitis.
 For hepatitis C (chronic), drug therapy with interferon and
ribaviron is available.
 For hepatitis E, interferon and ribaviron may be of value

24. PREVENTION
Hepatitis A
 improving the food, water and personal hygiene and environmental
sanitation
 Passive immunization can be attained by administering gamma
globulin rich in anti-HAV antibodies (0.1 ml/kg) or specific anti-HAV
gamma globulin (0.05 ml/kg) intramuscularly to close contacts of a
case of hepatitis A (as in a family; not school) or to a child moving to
an endemic area.
 A vaccine (Havrix) for human use is now available. This highly safe
and highly immunogenic vaccine (formaline-killed) has emerged as
a major step in the prophylaxis of hepatitis A. A live attenuated
hepatitis A vaccine too is now available

25. Hepatitis B
 Avoiding contamination by infected blood or its products.
 Screening of blood donors.
 Utmost care needs to be exercised while handling HBsAg-positive
material.
 Passive immunization can be achieved by administering specific anti-
HBs gamma globulins for short term immediate protection in such
situations as accidental needleprick, neonate of a HBsAg-positive
mother.
 Hepatitis B vaccine (Engerix-B, Shanvac-B, Hbvac, Envac, Hepavax)
provides active protection which is long-lasting though not immediate

26.  WHO has now recommended that the hepatitis B vaccine may be
incorporated as the seventh vaccine in all national child immunization
programs
 The dose is 0.5 ml (IM) for children under 10 years and 1 ml for those
over 10 years. There should be a gap of at least 1 month between
the first and the second doses and a gap of 6 months before the third
dose is given.
 Provide immediate and long-lasting protection, it is advisable to
combine specific anti- HBs gamma globulins with vaccine

27. hepatitis C, prevention consists in
 limiting the use of potentially dangerous blood derivatives and
preheating of antihemophilic factor.
Delta hepatitis,
 Preventive measures are on the same lines as for hepatitis B.
Hepatitis E,
 Improving the hygienic and sanitary conditions in the same
way as for hepatitis A.

28. NURSING MANAGEMENT
Assessment
 Observing the child for characteristic signs of hepatitis
(jaundiced skin and sclera),
 Assess for abdominal pain, anorexia, nausea and vomiting,
malaise, and arthralgia.
 A history of the child’s contacts in the past several weeks is
also obtained.
 For an infant, the hepatitis history of the mother and other
family members is important.

29. Nursing diagnosis
 Imbalanced Nutrition, :Less than Body Requirements, related
to chronic illness
 Fatigue related to disease state
 Disturbed (Older Child) Body Image related to jaundice
 Anxiety (Parent and Child) related to threat to health status

30. Intervention
 Home and community considerations because children with
hepatitis are seldom admitted to the hospital
 The hospitalized child is placed in isolation
 Prevention of the disease is integrated through immunization
and standard precautions
 Maintain adequate nutrition, promote rest and comfort, and
provide diversional activities.

31. PREVENTION OF SPREAD OF INFECTION
 Teach the parents and the child infection control measures to
help prevent transmission of the virus.
 For parents,
 Reinforce good hygiene practices, such as washing hands before
and after toileting and proper disposal of soiled diapers.
 Vaccination for those exposed to hepatitis A or B
 All healthcare providers should receive the hepatitis B
immunization series and use standard precautions at all times

32. PREVENTION OF SPREAD OF INFECTION

33. MAINTAIN ADEQUATE NUTRITION
 Initially, the child is encouraged to eat favorite foods.
 Once the anorexia and nausea have resolved, a high-protein, high
carbohydrate, low-fat diet is recommended.
 Increased protein helps maintain protein stores and prevent muscle
wasting.
 Increased carbohydrates ensure adequate caloric intake and prevent
protein depletion.
 The use of low-fat foods lessens stomach distention.
 Offer the child small, frequent feedings.

34. PROMOTE REST AND COMFORT
 Bed rest is necessary only if the child has severe fatigue and
malaise.
 Most children voluntarily limit their activities during the initial
phase of the disease.
 Keep the child quiet and comfortable.
 Offer comfort items such as favorite toys, blankets, and
pillows.

35. ADMINISTER MEDICATIONS
 Drug metabolism is altered during hepatitis since the liver
cannot detoxify medications readily.
 As with all liver disorders, medications need to be
administered carefully, and the child’s condition must be
monitored for possible drug side effects, especially since so
many drugs are metabolized by the liver.
 Caution parents to check with healthcare providers before
giving any nonprescription medication.
 For example, acetaminophen is metabolized in the liver, and liver
disease can interfere with its breakdown

36. PROVIDE DIVERSIONAL ACTIVITIES
 Hospitalized children with hepatitis are kept in isolation.
 Non- hospitalized should be kept at home for 2 weeks following the
onset of symptoms.
 Arrange home sitters to stay with the child if parents are working .
 Offer suggestions for diversional activities during this period.
 Young children can be given a new toy or favorite activities.
 Older children and adolescents can be given board games, puzzles, books
or magazines, movies, or video games.
 Phone calls and short visits from friends help school-age children
and adolescents maintain contact with peers.

37. EVALUATION
 The child demonstrates adequate nutritional intake to meet growth
and development needs.
 The child participates in quiet, nonfatiguing activities and self-care.
 Positive body image is achieved.
 Parents demonstrate effective coping with the stress of the child’s
condition.
 Hepatitis is not spread to the child’s contacts