The North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition have issued new guidelines for the screening, diagnosis, and treatment of nonalcoholic fatty liver disease in children. This was done in response to an increase in young people diagnosed with this condition.
Following the review of 161 papers, a committee consisting of 11 pediatricians and gastroenterologists came up with 27 recommendations for practitioners treating children with NAFLD and nonalcoholic steatohepatitis. Journal of Pediatric Gastroenterology and Nutrition is where you can find the recommendations written up and published (2017;64:319-334). According to Miriam Vos, MD, research director of the Strong4Life Clinic at Children's Healthcare of Atlanta and assistant professor of pediatrics at Children's Healthcare of Atlanta, who served as the moderator of the panel, she was impressed by the quality of the research that has emerged in recent years. Dr. Vos commented, "It is both a busy and exciting time for NAFLD." "One of the things that stood out to me was how much evidence has accumulated and the number of high-quality studies done on NAFLD. Because NAFLD is still a relatively new disease, there is a common misconception that we do not know much about it. Currently, the Food and Drug Administration (FDA) has not approved any medications to treat the disease, which is thought to affect approximately 10% of children in the United States. The panel recommends that children be screened for NAFLD between the ages of 9 and 11 years old if they are obese (defined as having a body mass index that is at or above the 95th percentile) or overweight (defined as having a body mass index that is between the 85th and 94th percentiles) and have risk factors such as central adiposity, insulin resistance, prediabetes or diabetes, or a history of NAFLD or NASH in their families. It can be challenging to diagnose NAFLD in children because they frequently do not exhibit any symptoms. As a result, screening for this condition is typically performed through blood-liver biochemistry or abdominal imaging. The panelists agreed that medical professionals conducting screenings should not automatically diagnose NAFLD in children who are overweight or underweight and who have persistently elevated levels of liver enzymes. The committee determined that measuring alanine aminotransferase is the most effective screening test currently available because it is not overly invasive and can be performed by virtually anyone. The interpretation of normal ALT levels must consider gender differences, with an upper limit of 22 U/L for girls and 26 U/L for boys. Because of the test's relatively low specificity and sensitivity, they are against using routine ultrasonography as the only screening method for fatty liver disease. Children who are white, Asian, or Hispanic, as well as those who are obese, are at a higher risk than other children's populations. The panel disagreed with the earlier recommendation that siblings and parents of children with NAFLD should not be screened for known risk factors such as obesity, Hispanic ethnicity, insulin resistance, prediabetes, diabetes, and dyslipidemia. However, they did note that the evidence in this area is relatively weak. They also recommend screening children with NAFLD for diabetes at the time of diagnosis and annually. This screening can be done by measuring fasting serum glucose or hemoglobin A1c. The panelists agreed that until a test specific to NAFLD is developed, it is essential to determine whether or not elevated liver enzyme levels were caused by NAFLD rather than another hepatic condition that may require a different treatment. Even though it is not known whether or not this strategy is cost-effective, the panelists pointed out that the consequences of missing another liver disease that requires an alternative treatment could be significant and even life-threatening. When evaluating NAFLD in children with an increased risk for developing NASH or advanced fibrosis, a liver biopsy should be considered rather than CT or ultrasonography as the diagnostic method of choice. Suppose the patient is experiencing new or ongoing risk factors like type 2 diabetes or NASH. In that case, a repeat liver biopsy may be required every two to three years after the initial biopsy to assess the progression of the disease, particularly fibrosis. This is especially true in patients who have already undergone the first biopsy. In light of the lack of outcome data in adolescents, the panel was against bariatric surgery as a specific treatment for NAFLD. Lifestyle changes are the primary component of treatment and management for nonalcoholic fatty liver disease (NAFLD). A modified diet, avoiding sugary beverages, increasing moderate- to high-intensity physical activity, and reducing the amount of time spent in front of screens to less than two hours per day are all recommendations made by the panelists. According to the recommendations, counseling on lifestyle changes should be provided to all children diagnosed with NAFLD who are overweight or obese. There is a correlation between children who are overweight or obese receiving lifestyle counseling, having more frequent visits, and spending more time in contact with program staff, all of which are associated with better weight management outcomes. These benefits may be extended to overweight children who suffer from NAFLD or NASH. In addition, the panelists came up with an algorithm outlined in a chart and designed to provide a course of action for various clinical scenarios. According to Dr. Vos, "the need to be very clear in our directions to the clinical workup" was a large part of the algorithm's development. "One of the reasons we came up with this number was because we know it can be challenging to keep track of the number of children who have NAFLD, as well as when to repeat tests, when to refer patients, and when to work up the severity of their symptoms. These are the inquiries that have been brought to my attention. According to Joel Lavine, MD, professor of pediatrics and chief of gastroenterology, hepatology, and nutrition at Columbia University Medical Center in New York City, there has yet to be a consensus reached regarding the diagnosis or treatment of NAFLD. According to Dr. Lavine, "the challenge with the guidelines is that there is a significant amount of evidence that is missing for children, such as longitudinal follow-up." In addition to identifying risk factors that indicate disease progression rather than regression, noninvasive methods of detecting NAFLD and NASH, cost-effective strategies for screening, and well-designed clinical trials to determine optimal treatment and medications were also identified as research priorities by the panelists. NAFLD researchers who are 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 testing new interventions, according to Dr. Lavine, who was involved in the writing of 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). Dr. Lavine made this recommendation, —Helina Selemon
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