NASPGHAN Clinical Practice Guideline for the Diagnosis and Treatment of Nonalcoholic Fatty Liver Disease in Children: Recommendations from the Expert Committee on NAFLD (ECON) and the North American Society of Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN)

Abstract

Nonalcoholic fatty liver disease (NAFLD) is a highly prevalent chronic liver disease that occurs in the setting of insulin resistance and increased adiposity. It has rapidly evolved into the most common liver disease seen in the pediatric population and is a management challenge for general pediatric practitioners, subspecialists, and for health systems. In this guideline, the expert committee on NAFLD reviewed and summarized the available literature, formulating recommendations to guide screening and clinical care of children with NAFLD.

Conflict of interest statement

POTENTIAL CONFLICT OF INTEREST / FINANCIAL DISCLOSURE STATEMENT

MV has research funding from Resonance Health Inc, serves on a DSMB for Aegerion and as a consultant for Shire, Immuron, Intercept and Target Pharmasolutions. SD serves on a DMC for Novo Nordisk and consults for Sanofi. RK has research funding from Raptor. The remaining authors have no personal or financial conflicts of interest to declare.

Figures

Figure 1

An algorithm proposed by the ECON group. Further research is likely to alter the algorithm. The steps are suggested courses of action and should be interpreted within the clinical scenario of individual patients. Additional testingfor chronic liver diseases to consider:

1. Screening labs: CBC with differential, AST, bilirubin (total, conjugated), alkaline phosphatase, GGT, INR, albumin, total protein, hemoglobin A1c

2. Exclude infections (e.g. hepatitis A IgM, hepatitis B surface antigen, hepatitis C antibody, other chronic viral infections)

3. Exclude endocrine disorders (TSH, free T4)

4. Exclude autoimmune causes of ALT elevation (total IgA, total IgG and tissue transglutaminase antibody, anti-nuclear antibody, anti-smooth muscle antibody, anti-liver kidney microsomal antibody)

5. Exclude genetic causes of ALT (ceruloplasmin and/or 24 hour urine copper, lysosomal acid lipase, alpha-1 antitrypsin phenotype)

6. Imaging: Abdominal ultrasound to rule out anatomical abnormalities or assess features of portal hypertension, magnetic resonance imaging or spectroscopy to measure hepatic fat.

7. Liver biopsy (histology, copper measurement, stain for microvesicular fat, assess fibrosis)

Red flagsfor advanced liver disease – chronic fatigue, GI bleeding, jaundice, splenomegaly, firm liver on exam, enlarged left lobe of the liver, low platelets, low white blood cell count, elevated direct bilirubin, elevated international normalized ratio (INR), long history of elevated liver enzymes (> 2 years).

Figure 2

Treatments for pediatric NAFLD