Fatty Liver in Children

Nonalcoholic fatty liver disease (NAFLD), is an accumulation of fat in the liver. Over the last decade it has become the most common cause of chronic liver disease in children.
NAFLD is estimated to affect close to 10% of the American population aged 2 to 19 years, and this figure increases to 30-40% among obese children. Insulin resistance is almost a universal finding in pediatric NAFLD, and consequently, several of the clinical features associated with insulin resistance, such as, obesity, diabetes mellitus, dyslipidemia, hypertension, obstructive apnea, and gallstones are common comorbidities in children who suffer from NAFLD.

NAFLD includes a wide spectrum of liver damage ranging from simple, uncomplicated steatosis(fatty liver) to nonalcoholic steatohepatitis (NASH), to advanced fibrosis (scar tissue) that can lead to cirrhosis, which can lead to liver failure and loss of liver function.
The American Academy of Pediatrics has recommended that serum aminotransferases (ALT and AST), should be performed in all overweight children starting at the age of 10, if their BMI is >95% or between 85-95% with risk factors. The ALT and AST are to be checked in addition to fasting glucose and lipid profile.
The diagnosis of NAFLD requires:
1) Confirmation of diffuse fatty infiltration of the liver in imaging studies regardless of the AST and ALT levels, the most common use modality is a liver ultrasound.
2) Average daily ethanol consumption of less than 10 grams in the appropriate age group and social setting.
3) Appropriate exclusion other liver disease, such as viral hepatitis, Wilson’s disease, alpha-1-antitrypsin deficiency, autoimmune hepatitis, and studies to investigate standard metabolic/inborn error panel
4) Verification that medicine intake is not causing liver injury
5) Some patients may require a liver biopsy
Childhood obesity has more than doubled in children and quadrupled in adolescents in the past 30 years. In 2012, more than one third of children and adolescents were overweight or obese. The rising number of obese children explain the recommendation given by the American Academy of Pediatrics.
“The Natural History of Nonalcoholic Fatty Liver disease in Children: A Follow-Up Study for up to 20 Years” is a recent article published where 66 patients were monitored for up to 20 years in order to observe the natural history of NAFLD. The study revealed two important facts. Firstly, NAFLD in children is associated with a significant shorter long-term survival. Secondly, Two out of the 66 children followed developed liver cirrhosis.
The most common presenting symptoms are: abdominal pain, fatigue, hepatomegaly (enlarged liver), splenomegaly (enlarged spleen) and acanthosis nigricans.
Treatment for NAFLD and NASH:
• Lose weight, through a healthy diet, and increased physical activity. In most cases the liver injury is reversible if it is in the early stages and no scarring is present.
• Vitamin E have shown to improve fatty liver in some children. It is no yet clear why, it does not work for everyone, but genes and other risk factors might play a role.
Some useful Tips:
• Encourage your child to follow a healthy, portion-controlled diet, with low amounts of saturated fats and refined sugars.
• Avoid large portion sizes and sweetened drinks, like soda. Limit the amount of meals eaten at fast food restaurants, since this food is usually high in fat.
• See a dietician who will help guide healthy diet choices.
• Increase your child’s physical activity and outdoor play.
• Have the hepatitis A and B Vaccines updated, to avoid potential injury to the liver caused by these viral infections.

Acknowledgements:
I would like to thank Dr. Diana Lopez Garcia in the preparation of the article.