Dr. Ponder

The most common type of liver disease in kids is an epidemic you rarely hear about. It’s usually not infectious and affects over 30 million Americans. The common disorder is called non-alcoholic fatty liver disease (NAFLD), which affects about 1 in 10 children. I’ve seen over 1,000 children with this condition in my practice over the last 15 years.

The disease begins with excess fat deposited into the liver. This fat triggers a cascade of events that causes irritation, inflammation and eventual destruction of liver cells. If it’s not stopped, NAFLD scars the liver and becomes non-alcoholic steatohepatitis (NASH). If left untreated, NASH evolves into cirrhosis and eventually liver failure. Fortunately, at least in children, cirrhosis is still rare.

NAFLD affects about 1 percent of toddlers and 17 percent of older teens. Its final stage, cirrhosis and ultimately organ failure, has become the third most common reason for liver transplants in adults. This condition is more worrisome for children because the longer they live with it, the greater the chances for serious problems happening earlier in their adult lives. Boys are twice as likely to have NAFLD as girls. Hispanics are at greater risk than blacks and whites. Children who are obese, who have metabolic syndrome or who have high triglyceride levels are more likely to have fatty livers.

On exam, many NAFLD kids and teens are overweight or obese. They may have an enlarged liver or dark, thickened skin on the neck and in other body creases. This is called acanthosis nigricans, a skin marker suggesting insulin resistance often associated with NAFLD and NASH.

Diagnosis is challenging, because sufferers are asymptomatic in the early stages. If there are symptoms, they’re usually non-specific, such as fatigue, constipation or mild right-side belly pain. NAFLD often is discovered accidently by a doctor ordering blood tests for other reasons. Two blood tests, the aspartate aminotransferase test (AST) and alanine aminotransferase test (ALT), are part of routine screening tests ordered by doctors. If one or both of these markers are abnormally high, it suggests ongoing injury to your child’s liver.

Because there are other possible reasons for liver ALT and AST elevations, it is important to rule out viral hepatitis, autoimmune hepatitis and Wilson’s disease. In some cases, an ultrasound may be needed to estimate the size of the liver and amount of fat. The only way the doctor can formally diagnose NAFLD is by performing a liver biopsy. The biopsy also will reveal its severity.

There is no medicine to treat NAFLD. The only proven method to improve the condition is gradual weight loss, no more than one pound per week. Even a weight reduction of 8 to 10 percent of total body weight can improve NAFLD in children and teens. Making an appointment to see an experienced children’s dietitian is vital. But making changes to eating habits alone is not enough. Increasing the child’s physical activity to three to five times per week for at least 30 minutes is the recommended minimum, but more is better.

One proven strategy is the S.A.F.E. method. First, slow down or “stop” consuming sugary soft drinks. The sugar in these products can worsen NAFLD and NASH. Second, “alter” snack habits (reduce them), because they contain unnecessary calories that increase liver fatty deposits. Third, reduce processed and “fast” food intake. These products often are packed with processed sugars and high fructose corn syrup, which has been associated with fatty liver disease. Finally, regular “exercise” is a natural method to lower liver fat levels.

Dr. Stephen Ponder is a pediatric endocrinologist at Baylor Scott & White McLane Children’s Medical Center.