Fatty Liver (NAFLD)
We understand that you may have a lot of questions when your child is diagnosed with non-alcoholic fatty liver disease (NAFLD).
- What exactly is it?
- What are the causes of NAFLD?
- What are potential complications in my child’s case?
- What are the treatments?
- What are possible side effects from treatment?
- How will it affect my child long term?
We’ve tried to provide some answers to those questions here, and when you meet with our experts, they can explain your child’s condition and treatment options fully.
What is the liver, and what does it do?
The liver is the body’s second largest organ, located in the right side of the abdominal cavity below the diaphragm and above the right kidney and intestines. The liver helps the body in hundreds of ways:
- All of the blood coming from the stomach and intestines passes through the liver through a large vein called the portal vein. The liver turns nutrients from the food we eat and chemicals from the medicines we take into forms that the rest of our bodies can use.
- The liver helps clean the bloodstream of harmful substances and poisons.
- The liver makes bile, which contains chemicals to help us digest the food we eat.
- The liver helps control blood sugar and cholesterol levels
- The liver makes the proteins that allow blood to clot normally.
What is NAFLD?
While it is normal for the liver to contain some fat, an excess buildup of fat – in children, greater than three percent of the liver’s weight – is called non-alcoholic fatty liver disease.
What happens to the liver in NAFLD?
As fat accumulates in the liver, it begins to swell and turns from a healthy reddish-brown color to a more yellowish color. If fat continues to build up, NAFLD can become non-alcoholic steatohepatitis (NASH), a potentially serious inflammation of the liver that can, in turn, lead to impairment of the liver’s functions and scarring. If the scarring gets severe enough, it will be called cirrhosis.
What causes NAFLD?
NAFLD is very common, affecting an estimated five percent of all children, though recent studies suggest that the rate may actually be higher. NAFLD is primarily associated with obesity, itself a significant threat to childhood health; rates of childhood and teenage obesity in the United States have tripled in the last decade. Some doctors think that nearly half of all obese children may have some level of NAFLD.
Certain medications and genetic features can predispose your child to NAFLD. Ethnicity and race may also be risk factors.
Your child may also be a greater risk of NAFLD if he or she has diabetes, though it’s not clear why some children with obesity and diabetes develop NAFLD and others don’t.
NAFLD is sometimes associated with a condition called “metabolic syndrome,” a group of factors that increase risks for heart disease and diabetes. Doctors look for three out of five risk factors when making a diagnosis of metabolic syndrome:
- Large waistline
- High blood triglyceride (fat) level
- Low HDL cholesterol (the “good” cholesterol) level
- High blood pressure
High fasting blood sugar
Insulin resistance – the inability of the body to properly use insulin and, as a consequence, process blood sugar – can also increase your child’s risk of metabolic syndrome. It is also a significant risk factor for type 2 diabetes. Children with NAFLD usually have some degree of insulin resistance.
Because NAFLD is only one of many conditions tied to obesity, it is important to know your child’s body mass index (BMI) and talk to your doctor if it is too high. And because calculating a child’s BMI is more complicated that calculating that of an adult, we recommend using a child-specific BMI calculator like the one available from the U.S. Center for Disease Control and Prevention. A BMI greater than the 90th percentile for your child’s age may be a sign that your child is at risk for NAFLD.
Signs and symptoms
What are the symptoms of NAFLD?
NAFLD itself usually causes no symptoms. Some children may complain of abdominal pain (particularly in the upper right part of the abdomen) or fatigue, and their liver may be slightly enlarged. Because of its close links to obesity, some doctors recommend that all children and adolescents who are overweight or obese should be regularly tested for NAFLD.
Some children with NAFLD develop dark, velvety patches on the skin of their neck, armpits, and hands. Children with this discoloration, called acanthosis nigricans, are at increased risk of type 2 diabetes.
If your child’s NAFLD advances to NASH then to cirrhosis, he or she may experience such symptoms as yellowing of the skin (jaundice), fatigue, weakness, spider-like blood vessels just under the skin, swelling of the legs (edema) or abdomen (ascites), and mental confusion.
How is NAFLD diagnosed?
Your child’s doctor may suspect NAFLD if your child is overweight or obese and routine blood tests suggest that the levels of certain liver enzymes are higher than normal. The diagnosis can sometimes be confirmed by ultrasound or other imaging techniques, which can show whether and how much fat has built up in the liver. Because certain medications, viral or autoimmune hepatitis, metabolic disease, and congenital liver disease can also cause fat to build up in the liver, it is important to rule these other causes out before diagnosing a child with NAFLD.
Currently the only way to tell the difference between NAFLD and NASH is with a liver biopsy. If the biopsy shows fatty accumulation, inflammation, and scarring, then a diagnosis of NASH can be made.
For details, see Tests.
How do you treat NAFLD?
Currently there are no medications that have been definitely shown to reduce the fat buildup in the liver and treat NAFLD. However, our doctors can work with you and your child to prevent the disease from worsening by:
- Controlling your child’s weight, especially through health eating and regular exercise
- Controlling cholesterol and triglyceride levels
Regular visits to a doctor who specializes in liver disease and conversations with your doctor about liver health are important parts of the treatment process. In addition, if your child has diabetes, tight blood sugar control can also help. Some studies suggest that vitamin E may provide some benefit.
The same recommendations apply to both NAFLD and NASH. Remember, though, that in many cases the goal of treatment for both conditions is management, not cure.
For details, see Treatment & care.
How can NAFLD affect my child in the long term?
If NAFLD advances to NASH, the liver may start to scar. Scar tissue (also called fibrosis) can replace the liver’s healthy, soft tissue, causing cirrhosis and preventing the organ from working properly. If not brought under control, cirrhosis can lead to complications including portal hypertension or hepatopulmonary syndrome, as well as liver failure or liver cancer. All of these are serious but preventable conditions, as long as the buildup of fat in the liver and the process of scarring can be slowed or stopped.
Because NAFLD is a chronic condition, your child may have to seek care for it for the rest of his or her life. The Center for Childhood Liver Disease can help you and your child plan for the eventual transition from pediatric to adult care.
Questions to ask your doctor
If your child has been diagnosed with NAFLD, you and your family will play an essential role in his or her care. It’s important that you share your observations and ideas with your child’s treating physician, and that you have all the information you need to fully understand the treatment team’s explanations and recommendations.
It’s often very helpful to jot down your thoughts and questions ahead of time and bring them with you, along with a notebook, to your child’s appointment. That way, you’ll have all of your questions in front of you when you meet with your child’s treating clinician and can make notes to take home with you.
Some questions to ask your doctor might include:
- How did you arrive at this diagnosis?
- Are there any other conditions my child might have instead?
- Is my child's NAFLD a complication of any other condition?
- Does my child need further testing?
- What is causing my child's NAFLD?
- What is the long-term outlook for my child?
- What medications will you prescribe, and what are the possible side effects?
- How should I talk to my child about this condition and her long-term health?
- Do I need to make any changes to my child’s home and school routines?
- Can you point me to educational and support service resources for children with NAFLD in my area?
- What other resources can you point me to for more information?