Algorithm for selection of children for antiviral treatment of chronic HBV

HBV: hepatitis B virus; HBsAg: hepatitis B s antigen; ALT: alanine aminotransferase; ULN: upper limit of normal; HBeAg: hepatitis B e antigen; DNA: deoxyribonucleic acid; IU: international unit; AST: aspartate aminotransferase.
* Here, "persistent" means for at least four months. The upper limit of normal (ULN) for ALT in children is not well-established; it varies with the testing laboratory and the age of the child. For the purposes of making treatment decisions about chronic hepatitis B, a consensus guidance suggests using an ALT threshold of <25 U/L for girls, <35 U//L for boys, for consistency with recommendations in adults.^[1] ALT values should also be interpreted in the context of the patient's prior ALT results.
¶ Patients with normal ALT and intermediate HBV DNA concentrations (HBV DNA 2000-20,000 IU/mL) cannot be immediately categorized; suggest retesting in a few months.
Δ For the rare patient who has persistently elevated ALT but has low viral load (HBV DNA <2000 IU/mL), an evaluation for additional causes of liver disease is appropriate.
◊ For patients in the immune tolerant and inactive chronic HBV phases, we suggest monitoring liver biochemical tests (ALT and AST) every 6 to 12 months, and HBeAg and HBeAb every 12 months. If the ALT becomes elevated, HBV DNA should be measured.
§ Treatment is indicated for most patients in the immune active, HBeAg positive phase. However, if the liver biopsy shows little or no inflammation or fibrosis, it is reasonable to defer treatment with ongoing monitoring.