•  Measure and monitor liver span- A soft enlarged liver is the most common clinical finding, but non-palpable liver or progressive reduction in liver span is an ominous sign suggestive of acute liver failure.


  • Monitor Sensorium- An agitated /drowsy child or with altered sleep wake pattern suggests early stages of hepatic encephalopathy and warrants immediate management.


  • Monitor Prothrombin time: Always get a prothrombin time(INR) along with liver function test. If INR>1.5-2 despite correction with Vitamin K, then manage as acute liver failure.


  • Watch for possibility of intravenous hemolysis if fall in hemoglobin(Hb) is noted with sudden deep conjugated jaundice and cola colored urine. Very high bilirubin in a setting of acute viral hepatitis with normal Hb is suggestive of cholestasis .


  • Fever is almost always a prodromal feature in a case of acute viral hepatitis, however in case persisting high grade fever rule out cholangitis and other infectious illnesses(e.g. leptospirosis, malaria, enteric fever, dengue).


  •  Look out for underlying chronic liver disease (CLD) features clinically e.g firm/hard liver, significant splenomegaly and/or ascites. Mild splenomegaly or mid ascites may be seen in acute viral hepatitis.


  •  Indications for abdominal ultrasound imaging in acute viral hepatitis are prolonged or relapsing jaundice, cholestatic Jaundice. Pericholecystic edema is the most common finding in a case of acute viral hepatitis. If a patient has atypical features like Jaundice with prolonged fever, splenomegaly abdominal lump, imaging is advisable. At times ultrasound can also unravel features of underlying chronic liver disease like nodular liver, significant splenomegaly and/or ascites. Computed tomography (CT) abdomen is routinely not needed unless specifically indicated in a given case.


  •  Recurrent jaundice or hepatitis- If there are more than 2 distinct episodesof conjugated jaundice with normal LFT in between and negative viral markers, refer to pediatric gastroenterologist for further evaluation. Relapse in hepatitis A (HAV) is seen in a subset of patients and management remains the same. The mean time to relapse is within a range of 2–6 weeks.



  • Frequent tracking of SGOT/SGPT values should not be done. Their falling values may not be a true indicator of improvement in a sick child. PT(INR) is the earliest and most important prognostic marker for monitoring liver functions.


  • 2.If the child is on any herbal or alternative medications, stop them immediately as they may be hepatotoxic.There is no role of medications like Liv52, Silymarin etc.


  • Dont advise any diet restriction(protein/fat). Excess intake of fruit juices or glucose water is known to cause emesis due to their hyperosmotic nature. Promote a healthy normal diet.


  • Hepatitis C (HCV) testing should not be done in acute hepatitis as it rarely causes acute hepatitis .


  •  Prophylactic FFP to improve coagulopathy in acute viral hepatitis is notrecommended. Don’t transfuse Fresh frozen plasma(FFP) unless overtbleeding or INR>7.Prophylactic FFP does not reduce the risk of significant bleeding, nevertheless obscures the trend of PT as a prognostic marker, and also risks volume overload.


  •  Don’t chase alkaline phosphatase (ALP) value as an indicator for obstructive jaundice in a child. Gamma glutamyl transpeptidase (GGT) is the preferred surrogate marker for biliary obstruction in children. Isolated higher ALP values in children may be high due to ongoing growth process of bones.


  •  The role of steroids in the management of cholestasis in acute viral hepatitis is controversial. Since prolonged excretion of hepatitis A virus in stools has been documented in relapsing hepatitis cases, use of steroids early in the course of illness is always fraught with danger.