for starters, don't be overly concerned with the mode of delivery; it doesn't influence the rate of transmission of hepatitis C virus (HCV), except in women who are also infected with human immunodeficiency virus (HIV) (strength of recommendation [SOR]: B, consistent retrospective cohort studies)

Bailey, Justin

Maggio, Lauren

Powell, Matthew

University of Missouri: MOspace

Evidence-based answers from the  Family Physicians Inquiries Network289jFPoNlINE.com Vol 59, No 5  |  mAY 2010  |  ThE jourNAl oF FAmIlY PrAcTIcEPerinatal transmission of HCV is rare, occurring only when serum HCV RNA is detectable.Matthew Powell, MD;  Justin Bailey, MDDavid Grant Medical Center, United States Air Force,  Travis Air Force Base, CalifLauren A. Maggio,  MS(LIS), MA, AHIPLane Library, Stanford  University, Palo Alto, CalifTK	 How	should	you	manage		children	born	to	hepatitis	C-	positive	women?	EvidEncE-basEd answErA	 for starters, don’t	 be	 overly		 concerned	 with	 the	 mode	 of	 deliv-ery;	it	doesn’t	influence	the	rate	of	transmis-sion	 of	 hepatitis	 C	 virus	 (HCV),	 except	 in	women	who	are	also	 infected	with	human	immunodeficiency	virus	(HIV)	(strength	of	recommendation	 [SOR]:	B,	 consistent	 ret-rospective	cohort	studies).	Avoid	 internal	 fetal	 monitoring	 and	prolonged	rupture	of	membranes	(SOR:	B,	single	retrospective	cohort	study).	Advise	 patients	 that	 it’s	 OK	 to	 breast-feed.	Breastfeeding	doesn’t	 affect	 transmis-sion	(SOR:	B,	consistent	prospective	cohort	studies).	Check	 HCV	 RNA	 and	 serum	 anti-HCV	 on	 2	 occasions	 between	 2	 and	 6	months	 of	 age	 and	 18	 and	 24	 months	 of	age	(SOR:	B,	consistent	prospective	cohort	studies).	Evidence summaryPerinatal	 transmission	 of	 HCV	 is	 rare.	 It	 oc-curs	only	when	serum	HCV	RNA	is	detectable;	transmission	 rates	 may	 be	 related	 to	 higher	levels	 (>106	 copies/mL).1	 HCV	 is	 transmit-ted	 to	2%	of	 infants	of	anti-HCV	seropositive	women	and	4%	to	7%	of	infants	born	to	moth-ers	who	are	HCV	RNA-positive	at	delivery.1	Spontaneous	 clearance	 of	 the	 virus	 oc-curs	in	approximately	20%	of	infants.	Most	re-main	asymptomatic	if	HCV	persists,	but	have	mild	elevation	of	liver	function	tests.2	Routine	screening	 for	HCV	in	mothers	 is	not	 recommended,	 but	 pregnant	 women	 at	high	risk	for	HCV	infection	should	be	screened	for	anti-HCV.	Route of delivery:  Only a concern for HIV-positive mothersThe	 mode	 of	 delivery	 doesn’t	 influence	 the	rate	 of	 HCV	 transmission,	 except	 in	 moth-ers	 with	 HIV.	 Retrospective	 analysis	 of	 503	HCV-positive	 mothers	 coinfected	 with	 HIV	showed	a	decreased	risk	of	transmission	dur-ing	 cesarean	 delivery	 (odds	 ratio	 [OR]=0.36;	P=.01;	 number	 needed	 to	 treat	 [NNT]=10).3One	 study	 suggested	 an	 increased	 rate	 of	vertical	 HCV	 transmission	 during	 vaginal	 de-livery	compared	with	cesarean	delivery	(32%	vs	6%;	P<.05).	The	study	didn’t	account	for	the	per-cent	of	mothers	coinfected	with	HIV,	however.4	A	 meta-analysis	 of	 11	 studies	 showed	similar	 rates	 of	 transmission	 for	 vaginal	 and	cesarean	 delivery:	 adjusted	 rates	 were	 4.3%	and	3%,	respectively.1	Internal monitoring is an issueAvoid	 internal	 fetal	 monitoring	 to	 minimize	HCV	 transmission,	 based	 on	 a	 single	 retro-spective	 cohort	 of	 244	 infants	 born	 to	 HCV-positive	mothers	 (relative	risk	 [RR]=	7.7;	95%	confidence	 interval	 [CI],	 1.9-31.6;	 number	needed	 to	 harm	 [NNH]=6).7	The	 same	 study	showed	 an	 increased	 risk	 with	 membrane	rupture	longer	than	6	hours	(RR=9.9;	95%	CI,	1.2-81;	NNH=13).5	Breastfeeding	doesn’t	 significantly	 affect	HCV	 transmission.	 Transmission	 rates	 for	breastfed	 and	 nonbreastfed	 infants	 are	 3.7%	and	3.9%,	respectively.1coNTINuEd290 ThE jourNAl oF FAmIlY PrAcTIcE  |   mAY 2010  |   Vol 59, No 5Routine screening for HCV isn’t recommended, but screen pregnant women at high risk of HCV infection for anti-HCV.Defer postpartum lab testingBecause	about	20%	of	infants	exposed	to	HCV	clear	 the	 virus	 spontaneously,	 and	 maternal	antibodies	 can	 confound	 laboratory	 results,	deferring	postpartum	diagnostic	 testing	 is	ap-propriate.	 A	 study	 of	 1104	 children	 in	 whom	vertical	 transmission	 didn’t	 occur	 after	 ex-posure	 to	 HCV	 showed	 that	 95%	 of	 the	 chil-dren	 were	 anti-HCV	 antibody	 negative	 by	12	months	age.6	A	prospective	 study	of	23	 in-fants	 documented	 spontaneous	 clearance	 of	HCV	RNA	by	6	months	in	all	patients.7Recommendations The	 National	 Institutes	 of	 Health	 2002	 Con-sensus	Statement	recommends:8	 •	 	avoiding	 fetal	 scalp	 electrodes	 and	 pro-longed	rupture	of	membranes	 •	 	serum	testing	 for	HCV	RNA	at	2	months	and	6	months	of	age	 •	 	anti-HCV	 antibody	 testing	 after	 15	months	of	age.The	 American	 College	 of	 Obstetricians	and	 Gynecologists	 supports	 breastfeeding,	recommends	against	routine	HCV	screening,	and	 recommends	 that	 cesarean	 delivery	 be	reserved	for	obstetric	indications.9	The	 American	 Association	 for	 the	 Study	of	 Liver	 Diseases	 recommends	 serum	 testing	and	liver	biopsy	on	the	same	schedule	as	adult	patients	 and	 endorses	 considering	 treatment	after	3	years	of	age.6	The	US	Food	and	Drug	Administration	has	approved	treatment	after	3	years	of	age	for	chil-dren	 with	 detectable	 HCV	 RNA	 levels	 higher	than	50	IU/mL	and	who	have	had	a	liver	biop-sy	with	portal	or	bridging	fibrosis	and	at	 least	moderate	inflammation	and	necrosis.The	American	Gastroenterological	Asso-ciation	 recommends	 considering	 treatment	with	PEG-interferon	and	ribavirin	after	3	years	of	age.10				 	 	 															JFPACKNOwLEDgEMENTSThe opinions and assertions contained herein are the private view of the authors and not to be construed as official, or as reflecting the view of the uS Air Force medical Service or the uS Air Force at large.	references	 1.	 	Yeung	LT,	King	SM,	Roberts	EA,	Mother-to-infant	transmission	of	hepatitis	C	virus.	Hepatology.	2001;34:223-229.	 2.	 	European	 Paediatric	 Hepatitis	 C	 Virus	 Network.	 Three	 broad	modalities	in	the	natural	history	of	vertically	acquired	hepatitis	C	virus	infection.	Clin Infect Dis. 2005;41:45-51.	 3.	 	European	Paediatric	Hepatitis	C	Virus	Network.	Effects	of	mode	of	delivery	and	infant	feeding	on	the	risk	of	mother-to-child	trans-mission	of	hepatitis	C	virus.	BJOG.	2001;108:371-377.		 4.	 	Paccagnini	S,	Principi	N,	Massironi	E,	et	al.	Perinatal	 transmis-sion	and	manifestation	of	hepatitis	C	virus	infection	in	a	high	risk	population.	Pediatr Infect Dis J.1995;14:195-199.		 5.	 	Mast	 EE,	 Hwang	 LY,	 Seto	 DS,	 et	 al.	 Risk	 factors	 for	 perinatal	transmission	 of	 hepatitis	 C	 virus	 (HCV)	 and	 the	 natural	 his-tory	of	HCV	infection	acquired	in	infancy.	J Infect Dis.	2005;192:1880-1889.		 6.	 	England	K,	Pembrey	L,	Tovo	P,	et	al.	European	Paediatric	Hepa-titis	C	Virus	Network.	 Excluding	hepatitis	C	 virus	 (HCV)	 infec-tion	by	serology	in	young	infants	of	HCV-infected	mothers.	Acta Paediatr.	2005;94:444-450.		 7.	 	Ketzinel-Gilad	M,	Colodner	SL,	Hadary	R,	et	al.	Transient	trans-mission	of	hepatitis	C	virus	from	mothers	to	newborns.	Eur J Clin Microbiol Infect Dis.	2000;19:267-274.	 8.	 	Management	of	Hepatitis	C:	2002.	National	 Institutes	of	Health	Consensus	 Conference	 Statement,	 June	 10-12,	 2002.	 Available	at:	 http://consensus.nih.gov/2002/2002HepatitisC2002116html.htm.	Accessed	August	23,	2009.		 9.	 	American	 College	 of	 Obstetricians	 and	 Gynecologists.	 ACOG	Practice	 Bulletin	 No.	 86.	 Viral	 hepatitis	 in	 pregnancy.	 Obstet Gynecol.	2007;110:941-956.		 10.	 	Dienstag	 JL,	 McHutchison	 JG.	 American	 Gastroenterological	Association	medical	position	 statement	on	 the	management	of	hepatitis	 C.	 Gastroenterology.	 2006;130:225-230.	 Available	 at:	www.gastrojournal.org/article/PIIS0016508505022717/fulltext.	Accessed	on	August	23,	2009.Online at jfponline.comget answers to these Clinical Inquiries by going to jfponline.com and  clicking on “Online Exclusives” in the left-hand navigation bar.•	 	How	can	nursing	moms	get	relief	from	nipple	pain?	•	 	What’s	the	best	way	to	monitor	low-risk	patients	with	a	history	of	differentiated	thyroid	cancer?

How should you manage children born to hepatitis C-positive women?

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