Hepatitis C virus (HCV) is an enveloped, single-stranded RNA virus that chronically infects an estimated 71 million people worldwide. Children typically experience mild or no symptoms during acute infection, but 60–80 percent progress to chronic disease, risking cirrhosis, hepatocellular carcinoma, and portal hypertension later in life.
Six major HCV genotypes (1–6) circulate globally. Genotype 1 predominates in the United States, while genotypes 2 and 3 historically achieved higher cure rates with interferon-based therapies. The advent of direct-acting antivirals (DAAs) has yielded sustained virologic response rates over 95 percent across all genotypes.
HCV is transmitted via exposure to infected blood or body fluids. In pediatrics, key routes include:
Acute HCV in children is often asymptomatic. When present, symptoms resemble adult hepatitis: jaundice, anorexia, nausea, abdominal pain, and elevated aminotransferases. Approximately 20–40 percent of children spontaneously clear the virus within three years; genotype 3 has the highest spontaneous clearance rate.
Chronic infection develops in 60–80 percent of exposed children. Risk factors for rapid progression include obesity, immunosuppression, and coinfection with HBV or HIV. HCV is also linked to extrahepatic conditions such as cryoglobulinemia, membranoproliferative glomerulonephritis, and autoimmune phenomena.
Diagnostic evaluation balances maternal antibody persistence with the need for early detection:
No antiviral therapy is approved for acute HCV in children. Management focuses on supportive care and monitoring for spontaneous clearance:
If HCV RNA remains detectable beyond 12–16 weeks—indicating chronic infection—initiate DAA therapy per chronic HCV guidelines.
Current guidelines recommend DAA therapy for all children aged ≥3 years. Early treatment prevents progression to fibrosis and cirrhosis.
| Regimen | Genotype Coverage | Age/Weight Criteria | Duration |
|---|---|---|---|
| Sofosbuvir–Velpatasvir | Pan-genotypic | ≥6 years or ≥17 kg | 12 weeks |
| Glecaprevir–Pibrentasvir | Pan-genotypic | ≥12 years or ≥30 kg | 8 weeks |
| Ledipasvir–Sofosbuvir | Genotypes 1, 4–6 | ≥3 years or ≥17 kg | 12 weeks |
Pegylated interferon-α plus ribavirin was the former standard: 48 weeks for genotypes 1 and 4, 24 weeks for genotypes 2 and 3, in children >3 years. Cure rates ranged 50–80 percent. Adverse effects and the availability of DAAs have relegated interferon regimens to historical status.
When biopsy is performed, chronic HCV shows portal lymphoid aggregates, periportal necroinflammation, sinusoidal lymphocytes, and steatosis. Noninvasive fibrosis assessment is preferred in children.
Liver transplantation in HCV-infected children often leads to graft reinfection. Whenever feasible, pretransplant DAA therapy is recommended. Posttransplant DAA treatment achieves SVR12 in over 95 percent of pediatric recipients.
No vaccine or immune globulin is available for HCV. Prevention relies on universal precautions:
Universal HCV screening for all pregnant individuals is recommended at the first prenatal visit. If screening is positive, confirm active infection with HCV RNA testing. Currently, DAAs are not approved during pregnancy, and treatment is deferred until after delivery and breastfeeding.
To minimize perinatal transmission, avoid invasive obstetric procedures when possible (chorionic villus sampling, internal fetal monitoring), prevent prolonged rupture of membranes, and limit routine episiotomy. Mode of delivery should be based on obstetric indications alone.
Breastfeeding is not contraindicated for HCV-infected mothers unless there is overt nipple bleeding or maternal HIV coinfection.
No postexposure prophylaxis exists. Exposed infants should undergo HCV RNA testing by two months of age to confirm infection. Alternatively, anti-HCV antibody testing after 18 months distinguishes maternal antibodies from true infant seropositivity.
The advent of direct-acting antivirals has revolutionized pediatric HCV care, enabling all-oral, well-tolerated regimens with cure rates exceeding 95 percent. A unified approach—early diagnosis, genotype-guided therapy, and appropriate perinatal management—supports the global goal of HCV elimination and prevents lifelong complications.