A nurse is caring for a newborn whose mother is positive for the hepatitis B surface antigen

Neonatal hepatitis B virus infection is usually acquired during delivery. It is usually asymptomatic but can cause chronic subclinical disease in later childhood or adulthood. Symptomatic infection causes jaundice, lethargy, failure to thrive, abdominal distention, and clay-colored stools. Diagnosis is by serology. Rarely, severe illness may cause acute liver failure requiring liver transplantation. Less severe illness is treated supportively. Active and passive immunization help prevent vertical transmission.

Mother–infant HBV transmission results primarily from maternofetal microtransfusions during labor or contact with infectious secretions in the birth canal. Transplacental transmission is identified in < 2% of infections. Postpartum transmission occurs rarely through exposure to infectious maternal blood, saliva, stool, urine, or breast milk. Up to 90% of infants infected perinatally will develop chronic infection, and perinatally acquired HBV infection may be an important viral reservoir in certain communities.

• Serologic testing

Family history of liver cancer or liver disease is noted because of the long-term risk of hepatocellular carcinoma. If testing suggests HBV infection, consultation with a pediatric hepatologist is recommended.

Long-term prognosis is not predictable, although chronic HBV infection early in life increases the risk of subsequent liver disease including chronic hepatitis, cirrhosis, end-stage liver disease, and hepatocellular carcinoma.

• Supportive care

Symptomatic care and adequate nutrition are needed. Neither corticosteroids nor hepatitis B immune globulin (HBIG) is helpful for acute infection. No therapy decreases the likelihood of developing chronic, subclinical hepatitis once infection is acquired.

Pregnant women should be tested for HBsAg during an early prenatal visit. Failing that, they should be tested when admitted for delivery. Some women who are HBsAg-positive are treated with lamivudine or telbivudine during the 3rd trimester, which may prevent perinatal transmission of HBV.

Neonates whose mothers have unknown HBsAg status at the time of delivery should also receive their first dose of vaccine within 12 hours of birth. For infants < 2 kg, the first dose is given concurrently with HBIG (0.5 mL IM) at a different site. For infants ≥ 2 kg and whose mothers can be tested for HBsAg and in whom follow up is ensured, HBIG (0.5 mL IM) can be delayed up to 7 days pending a positive maternal test for HBsAg. Testing for HBsAg and anti-HBs at 9 to 15 months is recommended for all infants born to HBsAg-positive mothers.

Neonates whose mothers are known HBsAg–negative should receive their first dose of vaccine within 24 hours of birth if they are medically stable and weigh ≥ 2 kg. For infants < 2 kg, administer 1 dose at age 1 month or before hospital discharge.

Separating a neonate from its HBsAg-positive mother is not recommended, and breastfeeding does not seem to increase the risk of postpartum HBV transmission, particularly if HBIG and HBV vaccine have been given. However, if a mother has cracked nipples, abscesses, or other breast pathology, breastfeeding could potentially transmit HBV.

• Only hepatitis B virus (HBV) is a major cause of viral neonatal hepatitis; it is typically transmitted during delivery.

• Most neonates are asymptomatic but develop chronic, subclinical HBsAg antigenemia and elevated transaminase levels.

• Some infants develop mild hepatitis, and a few have fulminant liver disease.

• Do serologic testing of infant and mother.

• Neonates whose mothers are HBsAg-positive should be given 1 dose of HBIG 0.5 mL IM and HBV vaccine within 12 hours of birth.

• HBV-infected children should be immunized with hepatitis A vaccine; anti-HBV drugs (eg, interferon alfa) may help but should be used only in consultation with a pediatric hepatologist.

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