The North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition have updated its recommendations for the screening, diagnosis, and treatment of non-alcoholic fatty liver disease in response to a rise in the prevalence of the condition among children.
Following a study of 161 papers by a group of 11 pediatricians and pediatric gastroenterologists, 27 suggestions were issued for medical professionals who care for kids with NAFLD and non-alcoholic steatohepatitis. The Journal of Pediatric Gastroenterology and Nutrition released the recommendations (2017;64:319-334).
The panel's moderator, Miriam Vos, MD, assistant professor of pediatrics and research director of the Strong4Life Clinic at Children's Healthcare of Atlanta, expressed her admiration for the caliber of current studies. "it's a busy and exciting moment for NAFLD," according to Dr. Vos. "One of the things that struck me is how much data there is on NAFLD from so much high-quality research. Due to NAFLD's recent discovery, there is a feeling that we don't understand it very well.
The condition, which is thought to impact 10% of youngsters in the United States, is now untreatable, according to the FDA.
The panel suggests testing for NAFLD in children with risk factors like central adiposity, insulin resistance, prediabetes or diabetes, or a family history of NAFLD or NASH between the ages of 9 and 11. Obese children have a body mass index in the 95th percentile or higher. Overweight children have a body mass index between the 85th and 94th percentiles.
Children are frequently asymptomatic, making it challenging to perform blood-liver biochemistry or abdominal imaging screening to check for NAFLD. The panelists advised against assuming NAFLD when assessing children who are fat or underweight and have chronically increased liver enzymes.
Due to its low invasiveness and widespread accessibility, the committee determined that assessing alanine aminotransferase is the best screening test currently available. With a maximum of 22 U/L for girls and 26 U/L for males, the interpretation of normal ALT levels should be gender-specific. Due to the test's relatively low specificity and sensitivity, they are opposed to routine ultrasonography being used as the exclusive means of screening for fatty liver disease.
Obese boys and children who are Caucasian, Asian, or Hispanic are among the pediatric demographics most at risk. Although they emphasized that the evidence, in this case, is fragile, the panel questioned the prior suggestion not to screen siblings and parents of children with NAFLD who have recognized risk factors such as obesity, Hispanic ethnicity, insulin resistance, prediabetes, diabetes, and dyslipidemia. They also advise annual diabetes screenings for kids with NAFLD, which can be done by assessing hemoglobin A1c or fasting serum glucose levels.
The panelists stressed the importance of proving that NAFLD, and not another hepatic illness that might call for a different course of treatment, was the cause of high liver enzyme levels until a test designed particularly for NAFLD. The panelists observed that there might be severe and dangerous repercussions if another liver illness is missed that requires other treatment, even though the cost-effectiveness of this strategy is unknown. In children with a higher risk of NASH or severe fibrosis, a liver biopsy rather than a CT scan or ultrasonography should be considered for the assessment of NAFLD.
Every two to three years following the initial biopsy, a repeat liver biopsy may be necessary to monitor disease development, particularly fibrosis, particularly in patients with new or persistent risk factors such as type 2 diabetes or NASH. Given the lack of outcomes evidence in adolescents, the panel was against bariatric surgery as a specialized treatment for NAFLD.
Lifestyle modifications are the mainstay of NAFLD management and treatment. The panelists advise a modified diet, staying away from sweetened beverages, increasing moderate- to high-intensity physical activity, and keeping screen time to under two hours per day.
The recommendations suggest that "all children with NAFLD should be offered lifestyle intervention counseling if overweight or obese." Better weight management outcomes in overweight and obese children are associated with offering lifestyle counseling, more frequent visits, and hours of contact with program staff; this link may also help overweight children with NAFLD or NASH.
The panelists also created an algorithm that offers a course of action in clinical settings and is depicted in a chart. According to Dr. Vos, the need to give precise instructions to the clinical workup was a significant factor in developing our algorithm. "One of the reasons we came up with this number is that we know it can be challenging to keep track of the number of kids with NAFLD and know when to repeat them, refer them, and work them up. I frequently hear these inquiries.
According to Joel Lavine, MD, professor of pediatrics and director of gastroenterology, hepatology, and nutrition at Columbia University Medical Center in New York City, conclusions about the diagnosis and treatment of NAFLD have yet to be consistent.
According to Dr. Lavine, the problem with the recommendations is that there is a lot of evidence that needs to be included for youngsters, such as longitudinal follow-up. The panelists cited this area as a top priority for research, identifying risk factors that indicate disease progression rather than regression, noninvasive techniques for detecting NAFLD and NASH, economical screening methods, and carefully planned clinical trials to ascertain the best course of action and medications.
According to Dr. Lavine, who contributed to the 2012 clinical guidelines on NAFLD for the American Association for the Study of Liver Diseases, the American College of Gastroenterology, and the American Gastroenterological Association (Hepatology 2012;55:2005-2023), NAFLD researchers who are interested in evaluating new treatments with patients who have just begun making the suggested lifestyle changes should give their patients about six months to make these changes before testing the results.
— Helina Selemon
