Author: Shikha S. Sundaram, MD MSCI
Shikha S. Sundaram, MD MSCI is the Assistant Professor of Pediatrics at the University of Colorado School of Medicine and Children’s Hospital Colorado. She is interested in childhood liver disease, Non-alcoholic fatty liver disease and Pediatric liver transplant. She wrote this month’s article on Pediatric Non-Alcoholic Fatty Liver Disease.
What is Pediatric Non-Alcoholic Fatty Liver Disease (NAFLD)?
NAFLD is a spectrum of diseases that all begin with excess fat deposition in the liver. As the disease becomes more severe, inflammation or irritation of the liver occurs and then scar tissue (fibrosis) accumulates. The disease is then referred to as NASH (Non-Alcoholic Steatohepatitis). If the fibrosis is extensive, cirrhosis develops and the liver may function poorly.
How common is Pediatric NAFLD?
NAFLD is the most common liver disease in the United States. It is thought to affect approximately 30 million people, 8.6 million of whom have the more severe form of the disease, NASH. NAFLD affects almost 10% of all children in the United States. Approximately 1% of 2 to 4 year olds, and 17% of 15-19 year olds have NAFLD. In addition, 38% of obese children have NAFLD. Among adults, NAFLD has become the 3rd leading indication for liver transplant. Children, who will have the longest time course of disease, are at particular risk of complications and poor prognosis, including the need for liver transplant in adulthood.
What are the risk factors for developing pediatric NAFLD?
Most children with NAFLD are in their early adolescent years. NAFLD, however, is being increasingly observed in young children. Males are affected twice as often as females and Hispanics are more likely to develop NAFLD than non-Hispanics whites or blacks. Obese children are at the greatest risk for developing NAFLD. In addition, having type 2 diabetes or pre-diabetes, the metabolic syndrome, or hyperlipidemia increases your risk of developing NAFLD.
What are the symptoms of pediatric NAFLD and how will my doctor diagnose it?
Most commonly, children with NAFLD are asymptomatic. In such an instance, a doctor may notice abnormal blood tests during a routine well child check up. Some children experience right sided abdominal pain, fatigue, or constipation. On exam, doctors may find obesity, especially in the waist area, an enlarged liver, signs of insulin resistance called acanthosis nigricans, a dark discoloration on the back of the neck and armpits, or the exam may be completely normal.
In order to diagnose pediatric NAFLD, your doctor will start with blood tests to look for elevations of liver enzymes. They may also test for pre-diabetes and hyperlipidemia, and try to exclude other causes of liver disease, such as viral hepatitis, autoimmune hepatitis and Wilson’s disease. They may check an abdominal ultrasound to look for fat deposition in the liver. The only way to be certain that you have NAFLD, however, is a liver biopsy. This test allows your doctor to determine if you have NAFLD, and how severe the disease is.
What causes NAFLD?
The exact cause(s) of pediatric NAFLD is currently unknown. It is likely a combination of several factors, including a predisposing genetic background along with environmental triggers that allow for insulin resistance and accumulation of specific fats in the liver. Activation of immune cells and oxidative stress then likely can cause ongoing damage to the liver.
What can I do if I have NAFLD?
Currently there is no medication that treats this disease. Many research trials of medications for NAFLD are underway and may yield effective medications in the future. NAFLD must be treated by gradual weight loss, typically about 1 pound per week. Research shows that for many children, losing only 10% of their body weight can help their liver disease. This should occur through a combination of both exercise and dietary changes. A reasonable goal is to exercise 3 to 5 times per week for at least 30 minutes. Exercise not only helps to burn stored calories, but also increases the body’s metabolism. Nutrition should be balanced, including regularly eating breakfast. Sugar sweetened beverages should be limited and lean meats, poultry and fish, along with fresh fruits and vegetables and whole grains emphasized.