Hepatology in Focus
Peds Group Updates NAFLD Guidelines
Faced with a surge in the number of children with non-alcoholic fatty liver disease, the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition have released new recommendations for screening, diagnosis, and treatment of the condition.
A committee of 11 pediatricians and gastroenterologists reviewed 161 papers and made 27 recommendations for practitioners treating children with NAFLD and non-alcoholic steatohepatitis. The guidelines were published in the Journal of Pediatric Gastroenterology and Nutrition (2017;64:319-334).
Miriam Vos, MD, assistant professor of pediatrics and research director of Children’s Healthcare of Atlanta’s Strong4Life Clinic, led the panel. “It’s a busy and exciting time for NAFLD,” Dr. Vos said. “One of the things that stood out to me is how much evidence has accumulated so many high-quality studies on NAFLD. I think there’s a perception that we don’t know very much about NAFLD because it’s a relatively new disease.”
Currently, the FDA has not approved any medications for the disease, estimated to affect roughly 10% of children in the United States.
Weight Key Trigger for Screening, But Not the Only Consideration
The panel recommends screening for NAFLD between 9 and 11 years of age in obese children (those with a body mass index in the 95th percentile or greater) and in overweight children (body mass index between the 85th and 94th percentiles) with risk factors including central adiposity, insulin resistance, prediabetes or diabetes, or a family history of NAFLD or NASH.
Screening children for NAFLD is challenging because they are often asymptomatic and must be screened with blood-liver biochemistry or abdominal imaging. When filtering, practitioners should not assume an obese or underweight child with chronically elevated liver enzymes has NAFLD, the panelists said.
The committee said measuring alanine aminotransferase is the best available screening test because of its minimal invasiveness and broad accessibility. Interpretation of normal ALT levels should be sex-specific, with an upper limit of 22 U/L for girls and 26 U/L for boys. They oppose using routine ultrasonography as the sole screening method for fatty liver disease because of the test’s relatively poor specificity and sensitivity.
Pediatric populations at higher risk
Pediatric populations at higher risk include the obese, boys, and white, Asian, or Hispanic children. The panel challenged the previous recommendation not to screen siblings and parents of children with NAFLD with known risk factors such as obesity, Hispanic ethnicity, insulin resistance, prediabetes, diabetes, and dyslipidemia. However, they noted that the evidence here is relatively weak. They also recommend screening children with NAFLD for diabetes at diagnosis, and on an annual basis, by measuring fasting serum glucose or hemoglobin A1c levels.
Until a test is explicitly developed for NAFLD, the panelists said, it is critical to establish that elevated liver enzyme levels were caused by NAFLD rather than another hepatic condition that may require different treatment. Although the cost-effectiveness of this approach is unknown, the panelists noted that the consequences of missing another liver disease requiring alternate treatment could be significant and severe. Children at risk for NASH or advanced fibrosis should have a liver biopsy, not CT or ultrasonography.
Assessing the progression of the disease, particularly fibrosis, may call for a repeat liver biopsy every two to three years after the first biopsy, especially in patients experiencing new or ongoing risk factors like type 2 diabetes or NASH. The panel opposed bariatric surgery as a specific therapy for NAFLD, given a lack of outcome data in adolescents.
Treatment Guidelines Focus on Diet, Behavior
The primary treatment and management of NAFLD involve lifestyle changes. Panelists recommend a modified diet, avoiding sugary beverages, increasing moderate- to high-intensity physical activity, and limiting screen time activities to less than two hours per day.
“All children with NAFLD should be offered lifestyle intervention counseling if overweight or obese,” the guidelines state. An association between providing lifestyle counseling, more frequent visits, hours of contact with program staff, and better weight management outcomes in overweight and obese children, which may extend benefits to overweight children with NAFLD or NASH.
The panelists also produced an algorithm, outlined in a chart, to provide a course of action in clinical scenarios. “A lot of what drove our algorithm was the need to be very clear in our directions to the clinical workup,” Dr. Vos said. “Part of why we set this figure up was because our understanding is that it is a real challenge to manage the numbers of children with NAFLD, when to repeat them, when to refer, when to work up. Those are the questions I hear.”
Joel Lavine MD’s Opinion
Conclusions on diagnosing and treating NAFLD have not been uniform, said Joel Lavine, MD, professor of pediatrics and chief of gastroenterology, hepatology, and nutrition at Columbia University Medical Center in New York City.
“The trouble with the guidelines is there’s a lot of evidence that’s missing for children, like a longitudinal follow-up,” Dr. Lavine said. The panelists identified this area as a research priority, pinpointing risk factors that signify disease progression over regression, noninvasive methods of detecting NAFLD and NASH, cost-effective strategies for screening, and well-designed clinical trials to determine optimal treatment and medications.
Dr. Lavine, who helped write 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), recommends that NAFLD researchers interested in testing new interventions with patients who have just started making recommended lifestyle changes should give their patients about six months to make these adjustments before trying their further intervention in a clinical trial so that their data more accurately reflect the effect of the intervention being studied.
- Joel Lavine