West of Scotland Paediatric Hepatitis Pathway

The referral pathway is summarised in Figure 1. Paediatric Units who identify potential cases should complete the referral proforma (Appendix 1 or link here) and contact the GI Consultant on call at RHC Glasgow for an initial case discussion. After this discussion, confirmed cases should be reported by the referring paediatric unit to their local health protection team (HPT). Please see Appendix 2 for list of HPT contacts by locality/postcode. The most appropriate initial place/team of care will be agreed. Recruitment to the ISARIC study will be undertaken by the local paediatric team if remaining in general paediatric care, or by the GI team at RHC if transferred. Initial and long-term follow-up should be agreed in discussion with the GI team (lead clinician for hepatology Dr Rachel Tayler).

DRAFT West of Scotland Paediatric Hepatitis Pathway Version 1.1 10th May 2022

Figure 1: West of Scotland Referral Pathway for Paediatric Hepatitis

Investigations recommended by Public Health Scotland are listed in Tables 1 and 2. Where sampling is difficult, please prioritise blood tests essential to clinical monitoring, viral and autoimmune hepatitis diagnostics and stool and respiratory samples for virology.

Informing relevant laboratories

It is essential that biochemistry, virology and immunology laboratories are aware that these are samples from patients who are being investigated as part of this public health response. Samples are being processed and excess stored in specific ways for this investigation. Please include “Query non A-E Hepatitis Investigation” in the clinical details of all samples.

Please phone the duty biochemist at your hospital to enable them to store any excess sample appropriately for future investigation.

Please inform virology and immunology laboratories by email of the name and CHI number of each patient and confirm investigation for Non A-E hepatitis ( email west-ssvc2@ggc.scot.nhs.uk and immunology.labs@ggc.scot.nhs.uk).

Table 1: Initial Investigations - All patients

Table 2: Additional tests if clinically indicated

Cases should remain under general paediatric care unless concerns regarding liver synthetic function or complications. Patients should be discussed regularly with on call GI consultant.

If the patient is jaundiced or has a raised bilirubin on bloods, please commence oral ursodeoxycholic acid (10mg/kg twice daily, increased if necessary to three times daily) and oral vitamin K (0.3mg/kg, max 10mg). Cases with prolonged PT >15 should be discussed with GI to consider IV vitamin K and other supportive management.

The on call gastroenterology consultant available ~8-5 Monday to Friday on 85806 or 24 hours a day via switchboard.

LFT, GGT, U&E, Bone profile, magnesium and coagulation studies should be checked daily initially. Blood glucose monitoring should be at least daily, and more frequent if concerns. The most important marker of synthetic liver function is PT. FBC should be monitored at least twice weekly.

Daily venous bloods will be required until bilirubin, PT, ALT and AST are all falling and the child is no longer requiring  intravenous vitamin K.  Step down from daily bloods to less frequent monitoring, and discharge decisions should be discussed with the GI consultant on call.

Following discharge, patients should be followed up by Dr Tayler in the dedicated hepatitis clinic, or locally as agreed with Dr Tayler.

ISARIC-CCP-UK Study

PHS is recommending recruitment of all identified cases to the ISARIC-CCP-UK study. There are 3 “tiers” to the ISARIC study. Tier 0 collects data and allows for use of excess clinical samples, Tier 1 collects research samples only at recruitment and Tier 2 collects serial samples on days 3, 9 and 28. For this outbreak, the most important research samples are the stool and viral throat swabs which should be obtained as soon as possible after consent. Use of excess clinical samples is also a priority, so even if families decline “Tier 1 or 2” sampling, Tier 0 consent should be encouraged.  All other blood tests should be timed to co-incide with clinical sampling where possible to minimise the number of times children are bled. A detailed guide to ISARIC samples is available here. Details of the ISARIC study and all study documents can be found here: https://isaric4c.net/protocols/. See Appendix 3 for a visual guide to samples required for ISARIC. Blood sampling should be co-ordinated with clinical sampling where possible.

Please inform the local ISARIC study team by email as soon as possible when cases are identified (see Appendix 3).

Paediatric Hepatitis Referral Form 2022 (pdf)