Diagnosis of nonalcoholic fatty liver disease in children and adolescents: position paper of the ESPGHAN Hepatology Committee

Consensus Statement on Metabolic Dysfunction-Associated Steatotic Liver Disease in Children and Adolescents From the Joint TASL-TSPGHAN Expert Committee

Background and Objective

Metabolic dysfunction-associated steatotic liver disease (MASLD) is the most prevalent chronic liver condition in children and adolescents, driven by the global rise in pediatric obesity. In this consensus statement by the Taiwan Association for the Study of the Liver (TASL) and the Taiwan Society of Pediatric Gastroenterology, Hepatology, and Nutrition (TSPGHAN), we highlight the unique clinical challenges in diagnosing and managing this condition in Asian children.

Methods

This consensus was developed by expert members of TASL and TSPGHAN through a comprehensive review of current literature and clinical practice. Key topics included prevalence, screening policies, diagnostic criteria, disease characteristics, and management strategies relevant to pediatric MASLD.

Results

We emphasize the rising prevalence of pediatric MASLD, which correlates strongly with obesity but often remains underdiagnosed due to the lack of screening policy for at-risk individuals and variations in diagnostic criteria. This review also discusses the distinct natural history and histopathological features of pediatric MASLD, underscoring the critical need for a greater understanding of its long-term outcomes. Currently, liver enzymes and ultrasonography are commonly used for screening and diagnosis, though these methods have limitations. The diagnostic imaging and novel non-invasive biomarkers specifically tailored for pediatric MASLD are in urgent need. Clinical management continues to rely on lifestyle interventions, with no pharmacological treatments currently approved for pediatric MASLD.

Conclusion

Effective management of pediatric MASLD requires a comprehensive approach to risk assessment, early detection, and intervention, tailored to the disease's unique pathophysiology in children.

Prevotella copri-produced 5-aminopentanoic acid promotes pediatric metabolic dysfunction-associated steatotic liver disease

BACKGROUND

Recent studies suggest an association between the expansion of Prevotella copri and the disease severity in children with metabolic dysfunction-associated steatotic liver disease (MASLD). We aimed to investigate the causative role and molecular mechanisms of P. copri in pediatric MASLD.

METHODS

C57BL/6 J mice aged 3 weeks were fed a high-fat diet (HFD) and orally administered with P. copri for 5 weeks. We assessed the key features of MASLD and the gut microbiota profile. By untargeted metabolomics on mouse fecal samples and the supernatant from P. copri culture, we identified P. copri-derived metabolite and tested its effects in vitro.

RESULTS

In HFD-fed mice, administration of P. copri significantly promoted liver steatosis. Genes associated with inflammation and fibrosis were significantly upregulated in the livers from the HFD + P. copri group compared with those in the livers from the HFD group. In addition, P. copri reduced gut microbial diversity, increased the proportion of Firmicutes and decreased Bacteroidota. Importantly, 5-aminopentanoic acid (5-AVA) was significantly enriched in both mouse feces from the HFD + P. copri group and the culture supernatant of P. copri. In vitro, 5-AVA aggravated palmitic acid-induced lipid accumulation in HepG2 cells and primary mouse hepatocytes. Mechanistically, P. copri-produced 5-AVA exacerbated hepatic steatosis by promoting lipogenesis and fatty acid uptake, while also reducing hepatic very-low-density lipoprotein export.

CONCLUSIONS

Our findings demonstrated that P. copri promotes liver steatosis in HFD-fed juvenile mice through its metabolite 5-AVA, suggesting its potential as a therapeutic target for the management of pediatric MASLD.

High Prevalence of Metabolic-Associated Fatty Liver Disease (MAFLD) in Children and Adolescents with Severe Obesity

Background: Severe obesity in children and adolescents presents a particular health burden due to high prevalence of complications and comorbidities, including metabolic-associated fatty liver disease (MAFLD). The aim of this study was to assess the prevalence of MAFLD in Polish children and adolescents with severe obesity, and assess its relation to anthropometric profiles and metabolic risk factors. Patients and Methods: In 212 children and adolescents with severe obesity (aged 3-18 years), physical examination, body composition, liver ultrasound (US), and biochemical assessment were performed. MAFLD was diagnosed based on the presence of steatosis in US and/or persistently elevated alanine aminotransferase concentration. Results: MAFLD was present in 125 (59.0%) patients. Metabolic Syndrome (MetS) was diagnosed among 57.5% of patients without MAFLD, and in 66.5% of patients with MAFLD (p > 0.05). Impaired fasting glucose, impaired glucose tolerance, and high HOMA-IR occurred more frequently in MAFLD than in non-MAFLD patients (p < 0.05). In the MAFLD group, a higher number of patients with ≥4 components of MetS were observed than in the non-MAFLD group (33.6% vs. 12.6%, p = 0.0004). Conclusions: The prevalence of MAFLD among children and adolescents with severe obesity was 59%. These patients are characterised by more pronounced insulin resistance and higher number of MetS components.

A bibliometric analysis of metabolic dysfunction-associated steatotic liver disease in children from 2004 to 2024

Background

Metabolic dysfunction-associated steatotic liver disease (MASLD), once known as Non-alcoholic fatty liver disease, impacts between 3% and 10% of children and adolescents globally, as well as nearly one-third of obsessed boys and one-quarter of obsessed girls, and is the most frequent cause of pediatric liver disease associated with the obesity epidemic. With the growing attention and increasing volume of literature on pediatric MASLD, there is an urgent need for bibliometric analysis and visualization in the area of pediatric MASLD study in terms of dissecting study priorities.

Methods

Literature was searched in the Web of Science Core Collection database, followed by categorization, bibliometric study as well as visual analysis conducted by applying software including Citespace, VOSviewer, and the R language. The study concentrated on analyzing information related to key authors, spatial and temporal distribution, core keywords, and important citations.

Results

In total, 3,409 publications on pediatric MASLD were collected in the study, including 2,697 articles and 712 review articles. Between 2004 and 2024, the volume of publications had been constantly increasing per year. The country with the most numerous publications was the United States, which had extensive exchanges and collaborations with Italy, China, and England, followed by Italy. The Journal of Pediatric Gastroenterology and Nutrition had the greatest quantity of publications in this domain. The core literature was a clinical guideline. Insulin resistance, metabolic syndrome, steatohepatitis, hepatocellular carcinoma, cardiovascular risk, diabetes risk, diagnostic accuracy, lifestyle intervention, gut microbiome, probiotics, and metabolic dysfunction-associated steatotic liver disease were also hot topics and frontier trends in pediatric MASLD studies.

Conclusion

This research represents the inaugural application of bibliometric analysis to examine the developmental trajectory of pediatric MASLD studies over the past two decades, which reveals that the etiology, pathological changes of the liver, relationship with obesity, complications, comorbidities, diagnosis and treatments of pediatric MASLD are the key focuses and provides academic references for pediatric clinicians and scholars to grasp the hotspots, the cutting edge and the evolving trends in the area.

Childhood obesity: The threatening apprentice of the adiposity empire

Childhood obesity is a global health problem, with its prevalence having tripled since 1975. The increase in its prevalence has been predominantly in developing countries, but also in those with high economic status. Nowadays, there are multiple obesity definitions, however, one of the most accurate is the one which defines obesity as the accumulation of excessive body adiposity and not as an body weight excess. Nevertheless, the body mass index (BMI) is the most frequently used tool for its classification, according to the cut-off points established by the Center for Disease Control and World Health Organization tables. In children and adolescents an adiposity excess is related to the appearance of cardiovascular disease in adulthood and with many comorbidities such as metabolic syndrome, insulin resistance, type 2 diabetes, hypertension and metabolic dysfunction-associated steatotic liver disease, among others. Currently, there is still controversy about which is the ideal indicator for measuring overweight and obesity. BMI is still used as a standardized measure but may miss cases in which body composition is pathological despite a BMI within the normal-weight category. An adequate knowledge of the impact on health of dysfunctional adiposity as well as its accurate diagnosis will allow health professionals to address this condition in a more precise and comprehensive manner, and substantially improve the associated cardiometabolic risk and prognosis.

Gaps and challenges in the management of pediatric steatotic liver diseases: a narrative review

BACKGROUND

Given the rising prevalence of pediatric steatotic liver disease (SLD), it is imperative to identify and address common challenges in clinical practice. This article aims to examine key issues in managing pediatric SLD and attempts to propose evidence-based recommendations.

DATA SOURCES

We reviewed published literature on steatotic liver diseases in children focusing on overweight and obesity, including original research, systematic reviews, meta-analyses, consensus statements, and position papers. Databases searched were PubMed/MEDLINE, Cochrane Library, Web of Science, and Scopus. Search terms included: "non-alcoholic fatty liver disease", "NAFLD", "steatohepatitis", "NASH", "steatotic liver disease", "fatty liver", "children", "adolescents", "pediatric", "obesity", and "overweight".

RESULTS

Critical issues include an over-reliance on liver biochemistry, which may fail to capture the broader spectrum of SLD [e.g., metabolic dysfunction-associated steatotic liver disease (MASLD) and metabolic dysfunction associated with steatohepatitis (MASH)], and delays in recognizing metabolic comorbidities. Dietary and lifestyle recommendations are often generalized, overlooking individual patient needs, while psychological factors, such as stress and mental health, are frequently neglected despite their role in disease progression. Advanced fibrosis cases are under-referred, long-term risks like cirrhosis are underestimated, and insufficient follow-up, coupled with limited family involvement in education, further compromises care.

CONCLUSIONS

Addressing these deficiencies through a multidisciplinary approach that incorporates early diagnosis, personalized treatment strategies, structured monitoring, and comprehensive family involvement is imperative for optimizing outcomes and mitigating the long-term impact of pediatric SLD.

The Ability of the Triglyceride-Glucose (TyG) Index and Modified TyG Indexes to Predict the Presence of Metabolic-Associated Fatty Liver Disease and Metabolic Syndrome in a Pediatric Population with Obesity

Background: Metabolic-associated fatty liver disease (MASLD) and metabolic syndrome (MetS) are increasingly prevalent among children and adolescents with obesity, posing significant long-term metabolic and cardiovascular risks. Non-invasive identification of at-risk individuals is crucial for a timely intervention. This study aimed to evaluate the diagnostic performance of the triglyceride-glucose (TyG) index and its modified versions, TyG-body mass index (TyG-BMI) and TyG-waist circumference (TyG-WC), in predicting MASLD and MetS in a large cohort of children and adolescents with obesity. Methods: A total of 758 children and adolescents with obesity (454 females, 304 males; mean age 14.8 ± 2.1 years; mean BMI 37.9 ± 6.2 kg/m2) were included. MASLD was diagnosed via ultrasonography, while MetS was defined using International Diabetes Federation criteria. TyG, TyG-WC, and TyG-BMI were calculated for all participants. Receiver operating characteristic (ROC) curves were generated to assess the diagnostic accuracy of these indexes, including sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). Results: MASLD was detected in 38.9% of participants, with a higher prevalence in males (p < 0.0001). MetS was present in 27.8% of the cohort, with higher prevalence in males (p < 0.0001). Among the indexes, TyG-WC exhibited the highest sensitivity for MASLD (77.6%), whereas TyG-BMI had the highest specificity (63.3%). In predicting MetS, all three indexes performed better than for MASLD, with TyG demonstrating the highest PPV (54.5%) and TyG-BMI the highest NPV (87.5%). Predictive performance was lower in males than females, potentially due to sex-specific differences in fat distribution and metabolic response. Conclusions: TyG, TyG-WC, and TyG-BMI are promising, non-invasive tools for identifying children and adolescents with obesity at risk for MASLD and MetS. The superior sensitivity of TyG-WC and the high specificity of TyG-BMI highlight the value of incorporating anthropometric parameters into metabolic screening. Integrating these indexes into routine clinical practice may enhance early detection, allowing for timely intervention and personalized management strategies, ultimately reducing the long-term burden of metabolic and liver diseases in pediatric populations.

Early childhood adiposity, lifestyle and gut microbiome are linked to steatotic liver disease development in adolescents

BACKGROUND/OBJECTIVES

To examine the relationship between early childhood adiposity, adolescent lifestyles, gut microbiota and steatotic liver disease (SLD) development in adolescents using data from a prospective, longitudinal cohort study.

METHODS

We included 69 adolescents (14-17 years old) with SLD and 69 adolescents without SLD, matched for BMI-z scores, sex, and age, from the 13-year longitudinal cohort the "Growth and Obesity Cohort Study". Anthropometric data between the ages of 4 and 17 and lifestyle parameters (including diet and physical activity) at 14-17 years old were evaluated. Fecal samples were collected and microbiome composition and function were assessed using 16S ribosomal RNA amplicon sequencing.

RESULTS

Principal component analysis demonstrated dietary intake factors and childhood adiposity factors expanding the distribution variation between case and control groups, respectively. Lower odds of developing SLD during adolescence was associated with higher levels of daily fiber intake during adolescence (adjusted odds ratio = 0.91) and lower childhood adiposity (triceps skinfold at 5 years of age, suprailiac skinfold at 8 and 11 years of age, and waist-to-hip ratio at age 5-9 years). SLD was associated with a lower abundance of specific microbial species, such as Bacteroides vulgatus, which was higher in the control group compared to the case group (control/case abundance ratio = 18.71). B. vulgatus abundance also positively correlated with dietary fiber intake and inversely correlated with childhood adiposity.

CONCLUSIONS

Adiposity in early childhood and a low dietary fiber intake may contribute to the pathogenesis of SLD during adolescence, possibly through alterations to the intestinal microbiome; these findings could inform early disease markers and targets for intervention.

Metabolic dysfunction-associated steatotic liver disease in children

Metabolic dysfunction-associated steatotic liver disease (MASLD), previously known as non-alcoholic fatty liver disease, is the most common cause of chronic liver disease in children. MASLD encompasses a spectrum of liver disease and can be severe, with 10% of affected children presenting with advanced fibrosis. While biopsy remains the most accurate method for diagnosing and staging the disease, MRI proton density fat fraction and magnetic resonance elastography are the most reliable non-invasive measures for assessing steatosis and fibrosis, respectively. MASLD is associated with multiple comorbidities including type 2 diabetes, hypertension, dyslipidaemia, decreased bone mineral density, obstructive sleep apnoea, anxiety and depression. Currently, there are no pharmacological treatments available for children, highlighting the urgent need for paediatric clinical trials. A diet low in free sugars is promising for reducing steatosis and decreasing alanine aminotransferase, a surrogate marker for hepatic inflammation. Emerging data indicate that steatosis can be present in children under 6 years of age, which was previously considered rare. The intricate interplay of genetics may inform future therapeutics and prognostication, with the PNPLA3 gene showing the most evidence for association with the risk and severity of steatotic liver disease and steatohepatitis. MASLD is a complex disease affecting one in ten children and is associated with increased early mortality risk. More dedicated studies are needed in children to advance our understanding of this disease and find effective treatments.

Association Between Hyperuricemia, Body Composition, and Comorbidities in an Obese Pediatric Population

Background: Childhood obesity is a global issue with multifactorial causes, leading to chronic and complex disease affecting all organs and systems with high morbidity and mortality, later in life. Elevated serum uric acid (SUA) levels are linked to several comorbidities in adults. In children, however, SUA levels vary by age, sex, and pubertal stage, and therefore, this relation is not well documented. While higher body mass index (BMI) has been associated with SUA levels, other nutritional assessment methods have not been thoroughly investigated and the link between SUA levels and obesity comorbidities in children is underexplored. Objective: This study aims to determine if hyperuricemia is related to body composition and obesity-related comorbidities in children. Methods: A retrospective analysis examined records from 505 obese children aged 5 to 18. The study evaluated the relationship between three nutritional assessment methods: BMI, waist-to-height ratio (WHtR), and body fat mass (BFM) percentage determined by bioimpedance (using InBody 270 scale), SUA levels, and blood markers associated with target organ damage. Results: A significant correlation was found between all three nutritional assessment methods (p < 0.001). WHtR showed a stronger correlation with the assessed comorbidities than the BMI z-score. SUA level correlated with HOMA-IR, ALT level, and lipid profile (p < 0.001). Multiple linear regression indicated an association between SUA level, BFM percentage, and WHtR (p < 0.001). Significant differences in body composition, SUA, and comorbidity markers were observed between children with and without hepatic steatosis (p < 0.05). Conclusion: Our results indicated a strong correlation among all nutritional assessment methods; however, WHtR and BFM percentage had a better correlation with obesity complications. SUA is a potential marker for insulin resistance, inflammation, and metabolic dysfunction-associated fatty liver disease (MAFLD) in obese children.

FISPGHAN statement on the global public health impact of metabolic dysfunction-associated steatotic liver disease

As rates of obesity rise worldwide, incidence of metabolic dysfunction-associated steatotic liver disease (MASLD), formerly referred to as nonalcoholic fatty liver disease, is increasing, worsening the burden of healthcare systems. The council of the Federation of International Societies for Pediatric Gastroenterology, Hepatology, and Nutrition (FISPGHAN) identified the topic of MASLD epidemiology, treatment, and prevention as a global priority issue to be addressed by an expert team, with the goal to describe feasible and evidence-based actions that may contribute to reducing MASLD risk. The FISPGHAN member societies nominated experts in the field. The FISPGHAN council selected and appointed members of the expert team and a chair. The subtopics included in this manuscript were chosen through a consensus of the experts involved. We review the epidemiology, natural history, and screening and management. We further expand to relevant public health measures aimed at MASLD prevention, including identifying interventions that could reduce risk factors (environmental and iatrogenic), optimize maternal and newborn health, and support healthier lifestyles for older children and adolescents on a local, national, and international scale. While recognizing that various aspects of population health and public policy can shape MASLD risk, we also review what we can do on an individual level to support our patients to reduce the significant burden of this ever rising disease in pediatrics.

Association of fatty liver with serum gamma-glutamyltransferase and uric acid in obese children in a tertiary care centre

BACKGROUND

Obesity among the young is an emerging health problem with many metabolic changes including liver damage. Our objective was to investigate the association of fatty liver with serum uric acid (UA) and gamma-glutamyltransferase (GGT) in a cohort of obese children in Sri Lanka.

METHODS

A cross-sectional analytical study was conducted among 5-15-year-old obese children (based on WHO 2007 standards). After a 12-hour overnight fast, blood was drawn for glucose, lipid profile, alanine aminotransferase (ALT), aspartate aminotransferase (AST), insulin, UA and GGT. Height, weight, waist circumference, blood pressure and fat mass were measured. Ultrasound scan of abdomen was performed to determine fatty liver.

RESULTS

We studied 146 obese children with a mean age (SD) 9.86 (2.1) years. The fatty liver group showed significantly elevated levels (p < 0.05) of UA, oral glucose tolerance test (OGTT), triglycerides (TG), AST, ALT, GGT, insulin resistance (HOMA-IR) and a reduced AST/ALT ratio, compared to the non-fatty liver group. Chi square test showed statistically significant associations between fatty liver and AST, ALT, AST/ALT ratio, HOMA-IR, UA and GGT. With existing cut offs, GGT (> 30 U/L) and UA (> 330 µmol/L) the sensitivity and specificity of GGT in predicting fatty liver was 26.9% and 94.1% respectively while for UA it was 38.5% and 83.8% respectively. A cut-off value of 18.5 U/L (sensitivity 76.9% and specificity 52.9%) for GGT, 277µmol/L (sensitivity 70.5% and specificity 57.4%) for UA, 27.5 U/L (sensitivity 70.5%, specificity 51.5%) for AST, 21.5 U/L (sensitivity 80.8% and specificity 61.8%) for ALT, a ratio of 0.99 (sensitivity 77.9% and specificity 55.1%) for AST/ALT and 2.02 (sensitivity 73.2%, specificity 58.5%) for HOMA-IR predicted fatty liver.

CONCLUSION

GGT and UA are associated with fatty liver and these biomarkers can be used to predict fatty liver disease.

Association of blood manganese and selenium levels with hepatic steatosis among adolescents: a nationwide cross-sectional analysis

Objective

This study aimed to investigate the association between blood manganese and selenium levels and hepatic steatosis among adolescents, using data from the National Health and Nutrition Examination Survey (NHANES) 2017-2023.

Methods

A cross-sectional analysis was conducted using data from 2,459 adolescents (aged 12-19 years) with complete data on liver ultrasound transient elastography, blood manganese, and selenium levels. Hepatic steatosis was defined as a controlled attenuation parameter (CAP) score of ≥248 dB/m, a measure of liver steatosis, which is a primary characteristic and a less severe stage of hepatic steatosis, assessed by vibration-controlled transient elastography (VCTE). Multivariate logistic regression models were used to assess the associations between blood manganese and selenium levels and hepatic steatosis, while restricted cubic splines (RCS) were employed to examine the dose-response relationships.

Results

The mean age of the participants was 15.37 years, with 52.22% boy. Higher blood manganese and selenium levels were significantly associated with an increased prevalence of hepatic steatosis. In the fully adjusted model, adolescents in the highest quartile of blood manganese had more than twice the odds of hepatic steatosis compared to those in the lowest quartile (OR = 2.41, 95% CI: 1.55-3.75, P < 0.01). Similarly, the highest quartile of blood selenium was associated with a 57% increase in hepatic steatosis prevalence compared to the lowest quartile (OR = 1.57, 95% CI: 1.19-2.08, P < 0.01). RCS analysis confirmed a linear association between both blood manganese and selenium levels and hepatic steatosis prevalence. Subgroup analyses did not reveal statistically significant interactions by age, sex, or obesity status, although associations appeared stronger in younger adolescents.

Conclusion

Elevated blood manganese and selenium levels are associated with a higher prevalence of hepatic steatosis in adolescents. These findings suggest a potential role of trace elements in the development of hepatic steatosis, highlighting the need for further research to better understand the underlying mechanisms involved in liver fat accumulation in this population.

Evaluating Pediatric NAFLD with Controlled Attenuation Parameter: A Comprehensive Narrative Review

Non-alcoholic fatty liver disease (NAFLD) in the pediatric population has emerged as a significant health concern due to its alarming rise in prevalence. In children, the characteristics of the disease differ from those seen in adults. NAFLD may progress to more severe liver disease in children compared to adults with similar profiles. Liver biopsy remains the gold standard for diagnosis; its invasive nature and high cost limit its use as a first-line tool. Alternatively, magnetic resonance imaging (MRI) techniques, such as magnetic resonance imaging-estimated liver proton density fat fraction (MRI-PDFF), have shown a good correlation with the degree of histological steatosis, although their use is limited by high costs and limited accessibility. Controlled attenuation parameter (CAP), integrated with vibration-controlled transient elastography (VCTE) (FibroScan®), is a novel non-invasive, accessible, and effective method for diagnosing hepatic steatosis. In this article, we reviewed the existing literature on the diagnostic accuracy of CAP in pediatric NAFLD. The PubMed and EMBASE databases were searched. Seven relevant studies were identified, conducted in pediatric hospital populations with specific demographic characteristics. Two of these studies compared CAP with liver biopsy, one compared CAP with liver biopsy and MRI-PDFF, and the remaining four compared CAP with MRI. Overall, CAP proved to be accurate in detecting the presence or absence of fatty infiltration, positioning it as a promising tool to simplify the diagnosis of NAFLD in children. However, further studies in larger populations are needed to confirm these findings and facilitate its implementation in routine clinical practice.

Evaluation of hepatic steatosis in obese children and adolescents using immune-inflammatory markers and shear wave elastography

Aim

To investigate the changes in liver stiffness and immune-inflammatory markers associated with obesity and the degree of hepatic steatosis in obese children and adolescents.

Methods

A total of 76 obese children and adolescents aged 6-18 years, with body mass index percentiles >95th, were included in the study. Patients with metabolic syndrome, diabetes mellitus, and chronic liver disease were excluded. A control group of 44 patients of healthy and normal-weight children was included. Laboratory values from the past month were analyzed using patient records. Shear wave elastography and ultrasound examinations were performed on a single device by the same experienced radiologist.

Results

The systemic immune-inflammation index and pan-immune inflammation values were significantly higher in obese patients with hepatic steatosis compared to obese patients without hepatic steatosis (p <0.001). Liver stiffness values were significantly higher in steatotic patients compared to nonsteatotic patients (p <0.001). A significant difference was observed between hepatic steatosis grades in terms of immune-inflammation index and pan-immune inflammation value values (p <0.001). There was a strong, positive, statistically significant correlation between liver stiffness and immune-inflammation index and pan-immune inflammation value (p <0.05).

Conclusions

Immune-inflammatory biomarkers and shear wave elastography may provide valuable insights into the diagnosis and follow-up of inflammation and fibrosis in the evaluation of hepatic steatosis in obese children and adolescents.

Celiac Disease and Liver Damage: The Gut-Liver Axis Strikes Back (Again)? A Retrospective Analysis in the Light of a Literature Review

Background/Objectives: An increasing number of studies have reported liver involvement in both children and adults with celiac disease (CD). This often manifests as isolated hypertransaminasemia or hepatic steatosis (HS). The aim of this study was to define the prevalence of hypertransaminasemia and HS in a pediatric population with CD before starting a gluten-free diet (GFD) and to analyze how the introduction of a GFD could modify this condition. We also conducted a state-of-the-art literature review of the association between hypertransaminasemia, metabolic dysfunction-associated steatotic liver disease (MASLD) and CD. Methods: We retrospectively reviewed the clinical charts of pediatric CD patients diagnosed in three different pediatric units of Sicily, analyzing clinical, laboratory, ultrasound, and histology data before and 12 months after the introduction of a GFD. Results: A total of 160 patients (65.0% females, median age 6.4 (0.8-13.2) years) were included; hypertransaminasemia and HS prevalences at diagnosis were 8.1% and 6.1%, respectively. Subjects with hypertransaminasemia were younger (p = 0.01) than those without and had higher frequencies of HS (p = 0.034) and anti-tissue transglutaminase (tTg) immunoglobulin (Ig)G positivity (p = 0.046). Subjects with HS were younger (p = 0.0001) and had a higher frequency of hypertransaminasemia (p = 0.029) compared to non-steatotic ones. After 12 months of a GFD, hypertransaminasemia and HS persisted in 53.8% and 50.0% of patients, respectively. Conclusions: The prevalences of hypertransaminasemia and HS in Sicilian pediatric CD patients seem to be lower than those reported in other geographical areas. A GFD can reverse the trend of liver involvement, although periods of longer than 12 months may be necessary. However, a GFD has been associated with an increased prevalence of HS, and so regular follow-up involving a nutritionist should be recommended to guide physicians in patient management.

Steatotic Liver Disease in Pediatric Obesity and Increased Risk for Youth-Onset Type 2 Diabetes

OBJECTIVE

To assess 1) the association between metabolic dysfunction-associated steatotic liver disease (MASLD) in pediatric obesity and youth-onset type 2 diabetes, 2) the joint effect of MASLD and intermediate hyperglycemia on type 2 diabetes risk, and 3) the effect of obesity treatment on type 2 diabetes risk.

RESEARCH DESIGN AND METHODS

A cohort study using the Swedish Childhood Obesity Treatment Register (Barnobesitas Registret i Sverige [BORIS]) (1999-2020) linked with national registers was conducted. We included 10,346 children with overweight or obesity and 59,336 matched control individuals. MASLD was defined by transaminases and diagnosis code, separately. Type 2 diabetes was ascertained from national registers.

RESULTS

In the obesity cohort, median age at type 2 diabetes diagnosis was 16.9 (quartile 1 [Q1], quartile 3 [Q3]: 14.7, 21.4) years, median follow-up was 8.1 (Q1, Q3: 5.1, 11.7) years. Cumulative incidence of type 2 diabetes at age 30 was 22.7% (obesity and MASLD), 9.9% (obesity alone), and 0.7% (control individuals). MASLD was associated with risk for type 2 diabetes (hazard ratio [HR] 2.71 [95% CI 2.14-3.43]), independently of age, sex, degree of obesity, intermediate hyperglycemia, and parental type 2 diabetes. Joint effect of MASLD and intermediate hyperglycemia increased type 2 diabetes risk (HR 9.04 [6.38-12.79]). Optimal response in obesity treatment reduced the risk (HR 0.23 [0.09-0.57]).

CONCLUSIONS

MASLD, defined by transaminases or diagnosis code, in pediatric obesity is associated with increased risk for youth-onset type 2 diabetes. MASLD interacts synergistically with intermediate hyperglycemia to dramatically increase the risk. Optimal response in obesity treatment reduces type 2 diabetes risk, despite MASLD.

Pediatric MASLD: current understanding and practical approach

Metabolic dysfunction-associated steatotic liver disease (MASLD) is now the most prevalent chronic liver disease in children in industrialized countries mainly due to the rise in obesity and overweight. Besides risk of progressive liver damage, MASLD also carries an increased risk of extra-hepatic morbidity, most importantly type 2 diabetes mellitus and cardiovascular disease. Important challenges remain in the prevention, detection, and treatment of this prevalent disorder. This review outlines the epidemiology and risk factors of MASLD and provides an approach to screening, diagnosis, and treatment based on current best available evidence and expert opinion. What is known: • NAFLD/MASLD is a common disorder in children strongly related to obesity/overweight and insulin resistance. • This silent disorder is underdiagnosed due to lack of awareness and lack of simple diagnostic criteria. What is new: • New diagnostic criteria have transformed NAFLD/MASLD from a diagnosis of exclusion to a positive diagnosis with simple criteria. • Effective treatments are emerging for adults and will likely become available for children. • Identifying children with NAFLD/MASLD has become even more important due to this new treatment perspective.

Effect of obesity and NAFLD on leukocyte telomere length and hTERT gene MNS16A VNTR variant

It is known that telomere length (TL) (evaluated with T/S ratio) is shortened in the presence of obesity. In this study, we aimed to investigate how obesity in adolescents and non-alcoholic liver disease (NAFLD) within the obese group affect TL and the clinical significance of the human telomerase reverse transcriptase (hTERT) gene MNS16A VNTR variant in terms of NAFLD. Adolescents with exogenous obesity and healthy controls (aged 10-19 years) who applied to our adolescent outpatient clinic between May-October 2023 were included in this study. We performed upper abdominal ultrasonography to investigate the presence of NAFLD in adolescents with obesity and divided into two groups: those without hepatosteatosis (obese NAFLD (-)) and those with hepatosteatosis (obese NAFLD (+)). We recorded body weight, height, waist circumference, and blood pressure measurements and measured the T/S ratio (telomere sequence copy number/gene single copy number) by the Quantitative Polymerase Chain Reaction method. The groups were compared using frequentist and Bayesian methods. Eighty-three obese adolescents [63 NAFLD(+) 20 NAFLD(-)] and 69 lean controls were included in the study. Pairwise comparisons revealed that T/S ratio was significantly lower in the obese NAFLD (-) group than the obese NAFLD (+) and the control group (p = 0.025, p = 0.007, respectively). T/S ratio was lower in the LL allele group than in the other alleles (p = 0.022) and slightly higher in the obese group with metabolic syndrome compared to the obese group without metabolic syndrome (p = 0.072). hTERT-MNS16A-VNTR gene variant LL allele had a negative correlation with T/S ratio among the obese adolescent group. Patients with LL alleles had higher ALT, GGT, HOMA-IR, and ALT/AST. Diastolic blood pressure had a significant correlation with the T/S ratio. The T/S ratio was shorter in the obese adolescent group compared to healthy ones but was higher in the NAFLD (+) obese compared to the NAFLD (-) obese. ALT level and ALT/AST ratio were higher, T/S ratio was lower in the hTERT MNS16A VNTR variant LL allele group among obese adolescents. In addition, there was a significant correlation between the T/S ratio and diastolic blood pressure in obese adolescents.

Practice Recommendations for Metabolic Dysfunction-Associated Steatotic Liver Disease by the Indian Society of Pediatric Gastroenterology, Hepatology and Nutrition (ISPGHAN)

JUSTIFICATION

There has been an alarming increase in metabolic dysfunction-associated steatotic liver disease (MASLD) and it is now the most common chronic liver disease worldwide, in both adult and pediatric populations. The lack of regional guidelines has hampered the formulation of national policies for prevention and management of MASLD in children. Therefore, we formulated recommendations for steatotic liver disease in children.

OBJECTIVES

To review the existing literature on the burden and epidemiology of pediatric MASLD and formulate recommendations for diagnostic evaluation, prevention, and management strategies.

PROCESS

The Indian Society of Pediatric Gastroenterology, Hepatology, and Nutrition invited national and international stakeholders to participate in a consensus meeting held on April 20, 2024, in Mumbai, Maharashtra, India. Various aspects of pediatric steatotic liver disease were deliberated upon and a consensus document and recommendations were formulated after several rounds of discussion.

RECOMMENDATIONS

Metabolic dysfunction-associated steatotic liver disease (MASLD) should be used as the preferred term in place of non-alcoholic fatty liver disease (NAFLD). There is a high prevalence of steatotic liver disease (SLD) among Indian children and adolescents, especially those who are overweight or obese. This condition may be progressive in childhood and associated with increased morbidity and mortality in adulthood. Various lifestyle, dietary, and genetic factors may predispose individuals to MASLD, including an increased intake of calorie-dense processed foods, sweetened sugar beverages, excessive screen time, higher sedentary time and lack of moderate to vigorous physical activity. MASLD is usually asymptomatic or presents with mild, non-specific symptoms and therefore, a high degree of suspicion is required for early diagnosis. MASLD is usually associated with cardiometabolic factors (hypertension, insulin resistance/diabetes mellitus, and/or dyslipidemia) and secondary causes should be excluded in all cases, particularly in the presence of red flag signs. Screening for MASLD should be considered in all obese children (body mass index or BMI ≥95th percentile) and in all overweight children (BMI ≥ 85th and <95thpercentile) with additional risk factors, such as prediabetes/diabetes, dyslipidemia, positive family history of metabolic syndrome, obstructive sleep apnea, and hypopituitarism. Abdominal ultrasound in combination with alanine aminotransferase (ALT) levels should be used as a screening test for MASLD in Indian children as per the proposed algorithm. Diet (any hypocaloric diet) and exercise (aerobic, resistance, or a combination of both; moderate to high intensity; regular in frequency) remain the cornerstones of pediatric MASLD management. Pharmacotherapy and/or endoscopic/surgical techniques for obesity should be considered as adjuncts and should be considered only after a failed adequate trial of lifestyle modifications.

Efficacy of the Mediterranean diet in treating metabolic dysfunction-associated steatotic liver disease (MASLD) in children and adolescents: a systematic review and meta-analysis

BACKGROUND

There are limited treatment options for metabolic dysfunction-associated steatotic liver disease (MASLD), formerly known as non-alcoholic Fatty Liver Disease (MASLD) in children and adolescents.

AIM

To evaluate the effectiveness of the Mediterranean diet in improving liver function in children and adolescents with MASLD.

METHODS

In this systematic review and meta-analysis, we searched PubMed, Scopus, Embase, CINAHL, and Cochrane CENTRAL for interventional studies investigating the effect of Mediterranean diet on MASLD in children and adolescents. The primary outcome was a change in liver function measured using these liver enzymes; Alanine Transaminase (ALT), Aspartate Transaminase (AST) and Gamma-glutamyl transferase (GGT). The secondary outcomes were lipid profile, body weight, and insulin resistance. The risk of bias was assessed using the MASTER scale. Bias-adjusted inverse variance heterogeneity models were used to synthesize overall weighted mean differences for the treatment effect (WMD) and their 95% confidence intervals. Heterogeneity and publication bias were evaluated using the I2 statistics, Tau-squared and Doi plots, respectively.

RESULT

Out of 5915 study records identified from database searches, five studies with 308 participants, two randomized controlled trials, and three quasi-experimental studies, met the inclusion criteria. In overall synthesis, the Mediterranean diet was associated with moderate improvements in liver function as shown by reductions in the liver enzymes [ALT - WMD - 10.85 U/L, 95% CI -20.03 to -1.68, I2 = 42, T2 = 38.8, AST - WMD - 9.26 U/L, 95% CI -17.14 to -1.38, I2 = 70.7, T2 = 42.7, and GGT - WMD - 1.99 95% CI -5.09 to 1.11)], but changes in body weight, lipid profile and insulin resistance were small and insignificant.

CONCLUSION

The Mediterranean diet may improve liver function in children with MASLD. More randomized controlled trials are needed to develop high-certainty evidence on these findings.

REGISTRATION

This protocol was registered on the International Prospective Register of Systematic Reviews (PROSPERO) CRD42023426939. 31/05/2023.

Pediatric metabolic (dysfunction)-associated fatty liver disease: current insights and future perspectives

The historical use of the term non-alcoholic fatty liver disease (NAFLD) in obese/overweight children has been controversial as to the appropriateness of this terminology in children, and lately, in adults too. Newer game-changer terminology, metabolic (dysfunction)-associated fatty liver disease (MAFLD), for this condition signifies a positive step forward that addresses the limitations of the previous definition for both adults and children. The prevalence of MAFLD has surged in tandem with the global rise in obesity rates, establishing itself as a predominant cause of chronic liver disease in both adult and pediatric populations. The adoption of the recently proposed nomenclature reflects a more encompassing comprehension of the disease and its etiology compared to its predecessor, NAFLD. Notably, the revised terminology facilitates the recognition of MAFLD as an autonomous condition while acknowledging the potential coexistence of other systemic fatty liver disorders. Particularly in children, this includes various paediatric-onset genetic and inherited metabolic disorders, necessitating thorough exclusion, especially in cases where weight loss interventions yield no improvement or in the absence of obesity. MAFLD presents as a multifaceted disorder; evidence suggests its origins lie in a complex interplay of nutritional, genetic, hormonal, and environmental factors. Despite advancements, current non-invasive diagnostic biomarkers exhibit limitations in accuracy, often necessitating imaging and histological evaluations for definitive diagnosis. While dietary and lifestyle modifications stand as cornerstone measures for MAFLD prevention and management, ongoing evaluation of therapeutic agents continues. This article provides an overview of the latest developments and emerging therapies in the realm of paediatric MAFLD.

Converging Pathways between Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD) and Diabetes in Children

In the past thirty years, childhood obesity rates have risen significantly worldwide, affecting over 340 million children in affluent nations. This surge is intricately tied to metabolic disorders, notably insulin resistance, type 2 diabetes mellitus (T2DM), and the continually evolving spectrum of metabolic-associated (dysfunction) steatotic liver disease (MASLD). This review underscores the alarming escalation of childhood obesity and delves comprehensively into the evolving and dynamic changes of nomenclature surrounding diverse conditions of hepatic steatosis, from the initial recognition of non-alcoholic fatty liver disease (NAFLD) to the progressive evolution into MASLD. Moreover, it emphasizes the crucial role of pediatric endocrinologists in thoroughly and accurately investigating MASLD onset in children with T2DM, where each condition influences and exacerbates the progression of the other. This review critically highlights the inadequacies of current screening strategies and diagnosis, stressing the need for a paradigm shift. A proposed solution involves the integration of hepatic magnetic resonance imaging assessment into the diagnostic arsenal for children showing insufficient glycemic control and weight loss post-T2DM diagnosis, thereby complementing conventional liver enzyme testing. This holistic approach aims to significantly enhance diagnostic precision, fostering improved outcomes in this vulnerable high-risk pediatric population.

Triglyceride Glucose Index is Associated with Ultrasonographic Fatty Liver Indicator in Children and Adolescents with Non-alcoholic Fatty Liver Disease

Objective

Non-alcoholic fatty liver disease (NAFLD) is defined as chronic hepatic steatosis and is becoming prevalent, along with the increasing trend for obesity in children and adolescents. A non-invasive and reliable tool is needed to differentiate non-alcoholic steatohepatitis from simple steatosis. This study evaluated the association between the triglyceride glucose (TyG) index and the ultrasonographic fatty liver indicator (US-FLI), and the possibility of using the TyG index for prediction of severity of pediatric NAFLD.

Methods

One hundred and twenty one patients who were diagnosed with NAFLD by ultrasonography were included. They were categorized into three groups according to body mass index (BMI). Ninety-two were obese, and 19 and 10 were overweight and normal weight, respectively.

Results

The homeostatic model assessment for insulin resistance (HOMA-IR) was highest in the group with obesity (p=0.044). The TyG index and US-FLI did not differ significantly among the three BMI groups (p=0.186). Fourteen (11.6%) of the 121 patients had US-FLI ≥6, in whom the BMI-SDS and TyG index were higher (p=0.017, p=0.004), whereas HOMA-IR did not differ significantly from the group with US-FLI <6 (p=0.366). US-FLI was associated with BMI-SDS and the TyG index. TyG index was significantly associated with US-FLI after adjustment for BMI-SDS. The cut-off value for the TyG index for predicting US-FLI ≥6 was 8.91, with an area under the curve of 0.785.

Conclusion

TyG index was associated with the degree of hepatic steatosis, suggesting that it might be a useful tool for predicting the severity of pediatric NAFLD.

Diet, exercise, and supplements: what is their role in the management of the metabolic dysfunction-associated steatotic liver disease in children?

Metabolic dysfunction-associated steatotic liver disease (MASLD), previously known as nonalcoholic fatty liver disease (NAFLD), is the main cause of chronic liver disease in children and adolescents. Indeed, epidemiological studies have shown that MASLD affects up to 40% of children with obesity. Despite the recent approval of medications that target weight loss in adolescents that could have benefits on pediatric MASLD, lifestyle interventions, such as diet and exercise, remain the mainstay of our therapeutic approach. More specifically, studies on diet alone have focused on the possible role of carbohydrate or fat restriction, albeit without a definite answer on the best approach. Weight loss after dietary intervention in children with obesity and MASLD has a beneficial effect, regardless of the diet used. In relation to the role of exercise in MASLD reversal, indirect evidence comes from studies showing that a sedentary lifestyle leading to poor fitness, and low muscle mass is associated with MASLD. However, research on the direct effect of exercise on MASLD in children is scarce. A combination of diet and exercise seems to be beneficial with several studies showing improvement in surrogate markers of MASLD, such as serum alanine aminotransferase and hepatic fat fraction, the latter evaluated with imaging studies. Several dietary supplements, such as vitamin E, probiotics, and omega-3 fatty acid supplements have also been studied in children and adolescents with MASLD, but with equivocal results. This review aims to critically present available data on the effects of lifestyle interventions, including diet, exercise, and dietary supplements, on pediatric MASLD, thus suggesting a frame for future research that could enhance our knowledge on pediatric MASLD management and optimize clinicians' approach to this vexing medical condition.

Non-Invasive Assessment of Metabolic Dysfunction-Associated Steatotic Liver Disease in Adolescents with Severe Obesity; Patient Characteristics and Association with Leptin-A Cross-Sectional Overview of Baseline Data from a RCT

Background: Metabolic dysfunction-associated steatotic liver disease (MASLD) is the most common liver disease in adolescents with obesity. Nonetheless, the guidelines for screening and managing this disease are contradictory. The purpose of this study is to non-invasively assess the prevalence, patient characteristics, and potential associated factors of MASLD in this demographic. Methods: This study used baseline data from an RCT in adolescents eligible for bariatric surgery. MASLD was determined by measuring the hepatorenal index (HRI) with ultrasonography, blood liver tests, and the fatty liver index (FLI). Results: A total of 56 adolescents enrolled in the analyses; the majority were female n = 44 (79%); the mean age was 15.75 (±1.01) years; the average body mass index (BMI) was 44.08 (±5.16) kg/m2. In 35 (62.5%) of the patients, the HRI was abnormal. This group had a higher waist/hip ratio, elevated liver biochemistry, and significantly lower leptin levels (mean difference = -46.35, 95% CI -76.72, -15.99) compared to the group with a normal HRI. In 32 (55.2%) of the patients, ALT levels were elevated and the FLI was abnormal in all (100%) participants. Linear regression analysis indicated associations between the HRI and typical anthropometric and metabolic measurements; and an inverse association between HRI and leptin B = -0.003 (95% CI -0.005, -0.00), independently of sex- and age-adjusted BMI. Conclusions: MASLD is highly prevalent in adolescents with severe obesity. However, the prevalence strongly depends on which tool is used, namely the HRI (62.5%), alanine transaminase levels (55.2%), and FLI (100%). Our findings suggest that leptin may be a valuable biomarker in supporting the diagnosis of MASLD.

Adaptation of Clinical Practice Guideline for Assessment of Liver Fibrosis in Patients with Non Alcoholic Fatty Liver Disease in Isfahan Province

Non-alcoholic fatty liver disease (NAFLD) refers to the presence of hepatic steatosis (accumulation of fat in the liver to over 5% of its weight) in the absence of secondary causes of fat accumulation in the liver such as excessive alcohol use. NAFLD is divided into two types: non-alcoholic fatty liver (NAFL) and non-alcoholic steatohepatitis (NASH). Therefore, in this clinical guideline, we sought to determine general and important policies for this disease and modify its managment approaches. We adapted this guideline for the management of NAFLD in Isfahan Province. This guideline was developed by clinical appraisal and review of the evidence, available clinical guidelines, and in consultation with members of the Isfahan Chamber of the Iranian Association of Gastroenterology and Hepatology. Biopsy is recommended as the most reliable method (gold standard) to diagnose steatohepatitis and fibrosis in patients with NAFLD. NAFLD fibrosis score (NFS) and fibrosis-4 (FIB-4) are recommended as the test with the highest predictive value for advanced fibrosis in patients with NAFLD compared to other serologic tests. Among the noninvasive methods used to assess liver fibrosis, transient elastography (TE) is preferable to other methods.

Effects of Zinc Supplementation on Inflammatory Status and Nonalcoholic Steatohepatitis in Overweight or Obese Children: a Randomized Clinical Trial

The purpose of the present clinical trial was to determine the impact of zinc supplementation on serum liver enzymes, steatosis severity, lipid profile, and inflammatory status in overweight or obese children with nonalcoholic steatohepatitis (NASH). This randomized controlled trial was conducted by enrolling 60 children with NASH, aged 10-18 years old. The participants were randomly assigned to two groups that received either 30 mg/day of elemental zinc or placebo for 16 weeks. The severity of liver steatosis was evaluated using liver ultrasonography. Fasting blood samples were collected from each patient at the beginning and after 16 weeks of intervention to measure biochemical parameters. Following a 16-week intervention, zinc supplementation compared with placebo significantly decreased serum alanine aminotransferase (ALT) concentrations and high-sensitivity C-reactive protein and considerably enhanced HDL-cholesterol values. However, zinc intake had no considerable impact on aspartate aminotransferase, the severity of liver steatosis, anthropometric parameters, and other lipid indices versus the placebo group. Overall, zinc supplementation showed a promising impact on serum ALT, HDL-cholesterol, and inflammatory status in overweight or obese children suffering from NASH. Zinc supplementation may be a new strategy for the amelioration of NASH in overweight or obese children. This trial has been registered on the Iranian website for registration of clinical trials with the special ID of IRCT20200531047614N1 ( https://www.irct.ir/trial/48543 ).

Ultrasound screening of paediatric non-alcoholic fatty liver disease (NAFLD): A critical literature review

INTRODUCTION

Paediatric NAFLD is an increasing global health concern, which can be effectively managed with early detection. Screening, using accurate, affordable, and accessible tests is recommended, however, there is currently no consensus on the most appropriate tests. Although ultrasound techniques are widely used, their performance against reference tests have not been fully assessed.

METHODS

A literature search of related databases for peer-reviewed original articles published from January 2010-March 2024 was conducted. Appropriate tools were used to systematise and document the search results and selected studies were quality assessed and critically appraised. Extracted data was subjected to thematic analysis and narrative synthesis.

RESULTS

Eighteen articles met the inclusion criteria. B-mode and Quantitative ultrasound techniques were compared against MR spectroscopy, MRI-PDFF and Liver biopsy.

CONCLUSION

Liver echogenicity and Steato-scores were the B-mode methods used. The former was less effective, with a maximum reported sensitivity of 70%. The latter reached up to 100% sensitivity, and >80% specificity. Ultrasound performed better with moderate-severe steatosis. There was not enough evidence to support steatosis grading, possibly due to small sample sizes and lack of established cut-off values. QUS (Quantitative Ultrasound)) methods including Continuous Attenuation Parameter (CAP), Attenuation Coefficient (AC), Ultrasound derived fat fraction (UDFF), Tissue Scatter Imaging (TSI) Hepato-Renal Index (HRI), Heterogeneity Index (HIA), Computer Assisted Ultrasound (CAUS) and Picture Archiving and Communication System (PACS-based Image analysis performed better than B-mode methods. Although QUS demonstrated excellent performance, with sensitivity and specificity of up to 100%, this will require further verification before implementation in practice.

PRACTICE IMPLICATIONS

Ultrasound techniques can effectively be used for paediatric NAFLD screening, especially in higher-risk subjects. The steato-scores method is currently recommendable for this, with excellent potential for the use of QUS, after cut-off values and validation requirements have been addressed.

Evaluation of the ability of insulin resistance and lipid-related indices to predict the presence of NAFLD in obese adolescents

BACKGROUND

Nonalcoholic fatty liver disease (NAFLD) has become an important health issue in adolescents. Although several parameters and indices have been investigated for the evaluation of NAFLD in adults, these indices are limited in adolescents. In this study, body mass index, waist circumference, triponderal mass index, HbA1c, homeostatic model assessment insulin resistance (HOMA-IR), triglyceride/high-density lipoprotein (Tg/HDL), the lipid accumulation product (LAP) index, the triglyceride-glucose (TyG) index and the aminotransferase (AT) index were examined together, and their diagnostic values in the clinical treatment of NAFLD were compared.

MATERIALS AND METHODS

Seventynine adolescents (10-19 years old) with obesity who were admitted to a pediatric clinic between January and August 2022 and who were diagnosed with exogenous obesity without any comorbidities were included in the study. The presence of NAFLD was evaluated by liver magnetic resonance imaging. The laboratory findings were obtained retrospectively from system records. Parameters were compared between the NAFLD (+) and NAFLD (-) groups. Logistic regression analysis was used to determine the most effective factors for NAFLD treatment. Receiver operating characteristic (ROC) analysis was performed with significant indices. Sex, HOMA-IR, TyG and AT indices were evaluated together with multivariate analysis to design a diagnostic scale.

RESULTS

HbA1c, HOMA-IR, AT indices and TyG indices were greater in the NAFLD (+) group (P = 0.012; P = 0.001; P = 0.012; P = 0.002, respectively). There was a positive correlation between liver fat percentage and HOMA-IR, the TyG index, the AT index, and Tg/HDL. According to the regression analysis, male sex and elevated HOMA-IR were determined to be significant risk factors for the presence of NAFLD. A probability scale with 4 parameters [sex, HOMA-IR, the TyG index, and alanine aminotransferase (ALT)] was designed with 82.5% specificity and 80% sensitivity.

CONCLUSION

Evaluation of the HOMA-IR and TyG indices, especially in high-risk patients, will support the diagnosis of NAFLD via ultrasonography. A probability scale with ALT, HOMA-IR, TyG, and sex data with a diagnostic accuracy of 80% may aid in the diagnosis of NAFLD in adolescents with obesity.

The evaluation of non-alcoholic fatty liver disease in children with obesity with vibration-controlled transient elastography

INTRODUCTION

Parallel to the worldwide increase in obesity, the epidemic of chronic liver disease is increasing also in pediatric population. Our aim is to provide a different outlook on the current screening confusion in pediatric non-alcoholic fatty liver disease (NAFLD) with the non-invasive vibration-controlled transient elastography (VCTE) method.

MATERIALS AND METHODS

This single-center, cross-sectional, comparative study was performed at the tertiary center, included 95 patients with obesity and 116 controls, both groups were 9-18 years of ages. VCTE examinations performed in all patients. The cut-off values for controlled attenuation parameter (CAP) and liver stiffness measurement (LSM) were established by comparing the study and control groups.

RESULTS

The cut-off for CAP was determined as >236 dB/m when comparing the two groups. The AUC was 0.900 (95% CI, 0.851-0.937) and the diagnostic accuracy was 77.9% and 91.4% for sensitivity and specificity, respectively. The cut-off value for LSM >5 kPa was determined by comparison of the two groups. The AUC was 0.794 (95% CI, 0.733-0.846) and the diagnostic accuracies were 50.5% and 90.5% for sensitivity and specificity, respectively.

CONCLUSIONS

There is no benchmark method for screening pediatric NAFLD. However, VCTE is a promising method for screening pediatric NAFLD. It is accessible, repeatable and practical.

Measurement practices of alanine aminotransferase in children: Temporal changes and etiology for increased values

Data on alanine aminotransferase (ALT) measurement practices and diagnoses associated with increased values are limited. We evaluated these issues by collecting ALT measurements from 1- to 16-year-old patients investigated in 1992-2018 in a tertiary center. Diagnoses were gathered in 2008-2018. Altogether 145,092 measurements from 28,118 children were taken 42% undergoing repeated testing. Testing increased from 21/1000 to 81/1000 children and the prevalence of elevated values fluctuated between 18% and 26%. An increase was seen especially in emergency care and departments of rheumatology, gastroenterology, hemato-oncology, and psychiatry. Common acute causes associated with elevated ALT were infections (45%), hemato-oncologic conditions (17%), and external reasons (13%), whereas autoimmune diseases (28%), psychiatric conditions (14%), and metabolic-dysfunction associated steatotic liver disease (10%) were common chronic causes. In conclusion, ALT testing increased 3.9-fold while the proportion of increased values remained stable, indicating that increased testing was justified. However, in some departments the testing efficiency was low.

Prevalence of nonalcoholic fatty liver disease in pediatrics and adolescents: a systematic review and meta-analysis

BACKGROUND

As childhood obesity escalates worldwide, the prevalence of nonalcoholic fatty liver disease (NAFLD) in pediatric and adolescent populations is also increasing. However, systematic studies and meta-analyses evaluating the prevalence of pediatric NAFLD remain limited.

METHODS

The MEDLINE, Korean Medical Database (KMBASE), Embase, Global Health, and Cochrane Library databases were searched from January 1997 to April 2023. Search terms included NAFLD or steatosis; nonalcoholic or steatohepatitis; child(ren), adolescent, or teenager; and prevalence, incidence, or epidemiology. A random-effects meta-analysis model was used to estimate the prevalence of pediatric NAFLD.

RESULTS

A total of 2116 publications were found, of which 62 were included in the meta-analysis. Among them, 27 reported the prevalence in the general population and 39 in the obese population. The worldwide pooled prevalence of pediatric NAFLD was 13% [95% confidence interval (CI) 9-18%] in the general population and 47% (95% CI 41%-53%) in the obese population. Among 16 studies in the general population and 18 in the obese population, NAFLD prevalence varied by gender. In the general population, the prevalence of NAFLD was 15% (95% CI 8%-23%) in males and 10% (95% CI 6%-15%) in females. In the obese population, it was 54% (95% CI 46%-61%) in males and 39% (95% CI 30%-49%) in females.

CONCLUSIONS

The global prevalence of pediatric NAFLD is rising in both the general and obese populations. Given the increasing rates of childhood obesity, epidemiological studies on the prevalence and incidence of NAFLD are needed.

European Society for Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN), European Association for the Study of the Liver (EASL), North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN), Latin‐American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (LASPGHAN), Asian Pan‐Pacific Society for Pediatric Gastroenterology, Hepatology and Nutrition (APPSPGHAN), Pan Arab Society for Pediatric Gastroenterology and Nutrition (PASPGHAN), Commonwealth Association of Paediatric Gastroenterology & Nutrition (CAPGAN), Federation of International Societies of Pediatric Hepatology, Gastroenterology and Nutrition (FISPGHAN). Paediatric steatotic liver disease has unique characteristics: A multisociety statement endorsing the new nomenclature

Nonalcoholic fatty liver disease (NAFLD) has been a commonly used term and diagnosis in paediatric hepatology, gastroenterology, and endocrinology clinics for over 30 years. A multisociety Delphi process has determined a new name "Steatotic Liver Disease" (SLD) as the overarching term for disorders associated with hepatic lipid accumulation. Our Societies give our support to steatotic liver disease as the best overarching term for use in our communities. Metabolic dysfunction-associated steatotic liver disease (MASLD) overcomes many of the shortcomings of the name NAFLD. Here, we highlight several points of the new nomenclature that are of particular importance for our community and their consequences for implementation including: diagnostic criteria, considering alternate diagnoses, practical implementation, research, advocacy, and education for paediatricians. As with all nomenclature changes, it will take a concerted effort from our paediatric societies to help integrate the optimal use of this into practice.

A practical evidence-based approach to management of type 2 diabetes in children and young people (CYP): UK consensus

BACKGROUND

Type 2 diabetes in young people is an aggressive disease with a greater risk of complications leading to increased morbidity and mortality during the most productive years of life. Prevalence in the UK and globally is rising yet experience in managing this condition is limited. There are no consensus guidelines in the UK for the assessment and management of paediatric type 2 diabetes.

METHODS

Multidisciplinary professionals from The Association of Children's Diabetes Clinicians (ACDC) and the National Type 2 Diabetes Working Group reviewed the evidence base and made recommendations using the Grading Of Recommendations, Assessment, Development and Evaluation (GRADE) methodology.

RESULTS AND DISCUSSION

Young people with type 2 diabetes should be managed within a paediatric diabetes team with close working with adult diabetes specialists, primary care and other paediatric specialties. Diagnosis of diabetes type can be challenging with many overlapping features. Diabetes antibodies may be needed to aid diagnosis. Co-morbidities and complications are frequently present at diagnosis and should be managed holistically. Lifestyle change and metformin are the mainstay of early treatment, with some needing additional basal insulin. GLP1 agonists should be used as second-line agents once early ketosis and symptoms are controlled. Glycaemic control improves microvascular but not cardiovascular risk. Reduction in excess adiposity, smoking prevention, increased physical activity and reduction of hypertension and dyslipidaemia are essential to reduce major adverse cardiovascular events.

CONCLUSIONS

This evidence-based guideline aims to provide a practical approach in managing this condition in the UK.

Lifestyle intervention in children with obesity and nonalcoholic fatty liver disease (NAFLD): study protocol for a randomized controlled trial in Ningbo city (the SCIENT study)

BACKGROUND

The increasing prevalence of childhood obesity has become an urgent public health problem, evidence showed that intervention for childhood obesity bring enormous health benefits. However, an effective individualized intervention strategy remains to be developed, and the accompanying remission of related complications, such as nonalcoholic fatty liver disease (NAFLD), needs to be assessed. This study aimed to develop an m-Health-assisted lifestyle intervention program targeting overweight/obese children and assess its effectiveness on indicators of adiposity and NAFLD.

METHODS

This is a cluster-randomized controlled trial that conducted in children with overweight/obesity in Ningbo city, Zhejiang Province, China. Students in Grade 3 (8-10 years old) were recruited from six primary schools, with three be randomized to intervention group and three to usual practice group. The intervention program will last for one academic year and consists of health education, dietary guidance, and physical activity reinforcement. This program is characterized by encouraging four stakeholders, including School, Clinic, famIly, and studENT (SCIENT), to participate in controlling childhood obesity, assisted by m-Health technology. Assessments will be conducted at baseline and 3 months, 9 months, 24 months, and 36 months after baseline. The primary outcome will be the differences between the two groups in students' body mass index and fatty liver index at the end of the intervention (9 months after baseline). During the implementation process, quality control methods will be adopted.

DISCUSSION

The program will test the effectiveness of the m-Health-assisted lifestyle intervention on children with obesity and NAFLD. The results of this study will provide evidence for establishing effective lifestyle intervention strategy aimed at childhood obesity and NAFLD and may help develop guidelines for the treatment of obesity and NAFLD in Chinese children.

TRIAL REGISTRATION

Clinicaltrials.gov NCT05482191. Registered on July 2022.

Alanine aminotransferase cutoffs for the pediatric fatty liver disease: Major impact of the reference population

OBJECTIVES AND STUDY

The often-recommended alanine aminotransferase (ALT) cutoffs (girls 21 U/l, boys 25 U/l) are based on a NHANES cohort. A novel concept of metabolic dysfunction associated steatotic liver disease (MASLD) emphasizes the role of ALT. We tested the prevalence of increased ALT and MASLD in children with overweight or obesity applying population-based and NHANES-based cut-offs.

METHODS

Six- to seventeen-year-old children underwent data collection in a prospective Physical Activity and Nutrition in Children (PANIC) study. ALT 95th percentiles were calculated from 1167 separate measurements considering various confounders. Test cohort comprised 1044 children with overweight/obesity.

RESULTS

ALT values increased at puberty onset (p = 0.031) and correlated negatively with age in girls (r = -0.222, p < 0.001). Particularly overall and central obesity increased ALT, whereas underweight or metabolic abnormalities had smaller effect. After applying the tested exclusions, the age-related ALT 95th percentiles were 24-29 U/l for girls and 29-32 U/l for boys. In 6-8-year-old children with overweight/obesity, the prevalence of increased ALT and MASLD were 21.6% and 2.4% with age-specific PANIC cutoffs. In older children, when NHANES-based cutoffs were used, there was a trend for higher prevalence of increased ALT and MASLD in all age groups for both sexes, reaching significance for increased ALT in 12-16-year-old boys (NHANES 63.5%, 95% confidence interval [CI]: 56.4%-70.0% vs. PANIC 47.1%, 95% CI [40.1%-54.2%]) and 9-11-year-old girls (60.0% [49.4%-69.8%] vs. 31.8% [22.8%-42.3%]), respectively. Increased ALT/MASLD were more common in boys than in girls, and in boys these increased with age, whereas in girls these peaked at age 9-12 years.

CONCLUSION

A reference population impacts on the prevalence of increased ALT and MASLD. Considering this help optimizing screening while avoiding unnecessary investigations and surveillance. The prospective part of this study is registered in clinicaltrials.gov; identifier NCT01803776.

Pediatricians' practices and knowledge of metabolic dysfunction-associated steatotic liver disease: An international survey

OBJECTIVE

Metabolic dysfunction-associated steatotic liver disease (MASLD) is the leading cause of chronic liver disease in children. It is associated with significant intra- and extrahepatic comorbidity. Current guidelines lack consensus, potentially resulting in variation in screening, diagnosis and treatment practices, which may lead to underdiagnosing and/or insufficient treatment. The increasing prevalence of MASLD and associated long-term health risks demand adequate clinical management and consensus in guidelines. This study aims to evaluate the daily practices of pediatricians in screening, diagnosis and treatment of MASLD in children.

METHODS

An online survey with 41 questions (single/multiple response options) was sent to pediatricians (with/without subspecialty) in Europe and Israel, via members of the ESPGHAN Fatty Liver Special Interest Group, between June and November 2022. The 454 pediatricians were included in this study.

RESULTS

51% of pediatricians indicated using any guideline for diagnosis and treatment of MASLD, with 68% reporting to follow recommendations only partially. 63% is of the opinion that guidelines need revision. The majority of pediatricians screen for MASLD with liver function tests and/or abdominal ultrasound. A large variety of treatment options is utilized, including lifestyle management, supplements and probiotics, with a notable 34% of pediatricians prescribing pharmacotherapy. When asked how often pediatricians request a liver biopsy in children with MASLD, 17% indicates they request a liver biopsy in more than 10% of cases.

CONCLUSIONS

There is limited awareness and considerable variation in screening, diagnosis and treatment practices among European pediatricians, and a clear demand for new, uniform guidelines for MASLD in children.

Identification of commensal gut bacterial strains with lipogenic effects contributing to NAFLD in children

Gut microbiota is known to have a significant impact on nonalcoholic fatty liver disease (NAFLD), particularly in children with obesity. However, the specific functions of microbiota at the strain level in this population have not been fully elucidated. In this study, we successfully isolated and identified several commensal gut bacterial strains that were dominant in children with obesity and NAFLD. Among these, four novel isolates were found to have significant lipogenic effects in vitro. These strains exhibited a potential link to hepatocyte steatosis by regulating the expression of genes involved in lipid metabolism and inflammation. Moreover, a larger cohort analysis confirmed that these identified bacterial strains were enriched in the NAFLD group. The integrated analysis of these strains effectively distinguished NASH from NAFL. These four strains might serve as potential biomarkers in children with NAFLD. These findings provided new insights into the exploration of therapeutic targets for NAFLD.

Metabolic Dysfunction-Associated Fatty Liver Disease (MAFLD) and Thyroid Function in Childhood Obesity: A Vicious Circle?

Metabolic dysfunction-associated fatty liver disease (MAFLD) is a multisystem disorder characterized by the presence of fatty liver degeneration associated with excess adiposity or prediabetes/type 2 diabetes or metabolic dysregulation. An intricate relationship between the liver and thyroid has been reported in both health and disease. Simultaneously, there is a strong correlation between obesity and both MAFLD and thyroid dysfunction. In this narrative review, we highlighted the relationship between MAFLD and thyroid function in children and adolescents with obesity in order to explore how thyroid hormones (THs) act as predisposing factors in the onset, progression, and sustainability of MAFLD. THs are integral to the intricate balance of metabolic activities, ensuring energy homeostasis, and are indispensable for growth and development. Regarding liver homeostasis, THs have been suggested to interact with liver lipid homeostasis through a series of processes, including stimulating the entry of free fatty acids into the liver for esterification into triglycerides and increasing mitochondrial β-oxidation of fatty acids to impact hepatic lipid accumulation. The literature supports a correlation between MAFLD and obesity, THs and obesity, and MAFLD and THs; however, results in the pediatric population are very limited. Even though the underlying pathogenic mechanism involved in the relationship between MAFLD and thyroid function remains not fully elucidated, the role of THs as predisposing factors of MAFLD could be postulated. A potential vicious circle among these three conditions cannot be excluded. Identifying novel elements that may contribute to MAFLD could offer a practical approach to assessing children at risk of developing the condition.

Noninvasive scores are poorly predictive of histological fibrosis in paediatric fatty liver disease

OBJECTIVES

Nonalcoholic fatty liver disease (NAFLD) is the most common chronic liver disease in children. Roughly a quarter of paediatric patients with NAFLD develop nonalcoholic steatohepatitis and fibrosis. Here, we evaluated the diagnostic accuracy of previously published noninvasive fibrosis scores to predict liver fibrosis in a large European cohort of paediatric patients with NAFLD.

METHODS

The 457 patients with biopsy-proven NAFLD from 10 specialized centers were included. We assessed diagnostic accuracy for the prediction of any (F ≥ 1), moderate (F ≥ 2) or advanced (F ≥ 3) fibrosis for the AST/platelet ratio (APRI), Fibrosis 4 score (FIB-4), paediatric NAFLD fibrosis score (PNFS) and paediatric NAFLD fibrosis index (PNFI).

RESULTS

Patients covered the full spectrum of fibrosis (F0: n = 103; F1: n = 230; F2: n = 78; F3: n = 44; F4: n = 2). None of the scores were able to accurately distinguish the presence of any fibrosis from no fibrosis. For the detection of moderate fibrosis, area under the receiver operating characteristic curve (AUROC) were: APRI: 0.697, FIB-4: 0.663, PNFI: 0.515, PNFS: 0.665, while for detection of advanced fibrosis AUROCs were: APRI: 0.759, FIB-4: 0.611, PNFI: 0.521, PNFS: 0.712. Fibrosis scores showed no diagnostic benefit over using ALT ≤ 50/ > 50 IU/L as a cut-off.

CONCLUSIONS

Established fibrosis scores lack diagnostic accuracy to replace liver biopsy for staging of fibrosis, giving similar results as compared to using ALT alone. New diagnostic tools are needed for Noninvasive risk-stratification in paediatric NAFLD.

Leukocyte cell-derived chemotaxin 2 correlates with pediatric non-alcoholic fatty liver disease

Non-alcoholic fatty liver disease (NAFLD), newly renamed metabolic dysfunction-associated liver disease (MASLD), is a leading cause of liver disease in children and adults. There is a paucity of data surrounding potential biomarkers and therapeutic targets, especially in pediatric NAFLD. Leukocyte cell-derived chemotaxin 2 (LECT2) is a chemokine associated with both liver disease and skeletal muscle insulin resistance. Our aim was to determine associations between LECT2 and common clinical findings of NAFLD in pediatric patients. Enzyme-linked immunosorbent assay (ELISA) was used to measure serum LECT2 concentrations in children (aged 2-17 years) with and without NAFLD. LECT2 concentrations were then correlated to clinical parameters in NAFLD. Mean LECT2 was significantly elevated in children with NAFLD versus healthy controls (n = 63 vs. 42, 5.83 ± 1.98 vs. 4.02 ± 2.02 ng/mL, p < 0.005). Additionally, LECT2 had strong correlations with body mass index (BMI) (Pearson r = 0.301, p = 0.002). A LECT2 concentration of 3.76 mg/mL predicts NAFLD with a sensitivity of 90.5% and specificity of 54.8%. Principal component analysis and logistic regression models further confirmed associations between LECT2 and NAFLD status. This study demonstrates increased serum LECT2 concentrations in pediatric NAFLD, which correlates with BMI and shows strong predictive value within these patients. Our data indicate that LECT2 is a potential diagnostic biomarker of disease and should be further investigated in pediatric as well as adult NAFLD.

The benefit of metformin in the treatment of pediatric non-alcoholic fatty liver disease: a systematic review and meta-analysis of randomized controlled trials

This is the first meta-analysis of the available literature about the efficacy of metformin exclusively in pediatric patients with non-alcoholic fatty liver disease (NAFLD). We conducted a systematic literature search through major electronic databases till March 12, 2023, investigating the efficacy and safety of metformin in pediatric NAFLD. Weighted mean difference (WD) and standard deviation (SD) were used for continuous outcomes. In total, 4 randomized controlled trials (RCTs) with 309 pediatric patients with NAFLD were included in the meta-analysis. Metformin could not reach a statistically significant improvement in alanine aminotransferase (ALT) levels [(ALT: WMD =  - 1.55 IU/L, 95% CI: - 5.38 to 2.28, I2 = 16%, p = 0.43), but had a statistically significant impact (p < 0.05) in insulin and HOMA-IR regulation, triglycerides, and high-density lipoprotein level improvement.   Conclusion: According to the data of this meta-analysis, treatment with metformin failed to statistically improve liver enzymes but may be beneficial in the improvement of lipid parameters and insulin metabolism regulation in pediatric patients with NAFLD. As there are not enough available studies in the literature, the influence of metformin on liver ultrasonography or histology in pediatric NAFLD should be further analyzed in future studies. What is Known: • Lifestyle modification with weight loss through physical activity and dietary modification is the recommended treatment option for pediatric NAFLD. • Metformin may reduce steatosis on ultrasound and may have a beneficial role in liver histology collated with insulin resistance improvement. What is New: • Metformin may improve insulin sensitivity and lipid parameters in children with obesity and NAFLD. • Metformin does not have a significant effect on transaminase levels in children with obesity and NAFLD.

Updates in Metabolic Dysfunction-Associated Fatty Liver Disease (MAFLD) in Children

The obesity epidemic is one of the major health concerns of the 21st century. Nonalcoholic fatty liver disease (NAFLD) is linked with the increased adiposity associated with obesity. NAFLD has become the most frequent cause of chronic liver disease in adults and children worldwide. Metabolic dysfunction-associated fatty liver disease (MAFLD) also known in children as pediatric fatty liver disease (PeFLD) type 2 has begun to supersede NAFLD as the preferred nomenclature in the pediatric population. Evidence suggests the etiology of MAFLD is multifactorial, related to the complex interplay of hormonal, nutritional, genetic, and environmental factors. Current limitations in accurate diagnostic biomarkers have rendered it a diagnosis of exclusion and it is important to exclude alternative or coexisting causes of PeFLD. Lifestyle changes and modifications remains the primary treatment modality in MAFLD in children. Weight loss of 7%-10% is described as reversing MAFLD in most patients. The Mediterranean diet also shows promise in reversing MAFLD. Pharmacological intervention is debatable in children, and though pediatric trials have not shown promise, other agents undergoing adult clinical trials show promise. This review outlines the latest evidence in pediatric MAFLD and its management.

Clinical epidemiology of non-alcoholic fatty liver disease in children and adolescents. The LiverKids: Study protocol

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD) is rapidly increasing alongside overweight and obesity, not only in adults but also in children and adolescents. It is unknown what impact the development of NAFLD in childhood may have in later life. The importance of early detection and treatment lies in its potential for progression to cirrhosis, liver cancer and liver-related death, as well as its associated extrahepatic comorbidities. Vibration-Controlled Transient Elastography (VCTE) with Controlled Attenuation Parameter (CAP) is an effective, non-invasive and safe diagnostic method to estimate the degree of fibrosis and steatosis in the liver, but little is known about its applicability in the paediatric population.

AIMS

1) To assess the prevalence of significant liver fibrosis (Liver Stiffness Measurement (LSM) ≥6.5 kPa) using VCTE, and that of non-alcoholic fatty liver disease (≥225 dB/m) using CAP in children and adolescents. 2) To determine the optimal cut-off points of the CAP to achieve maximum concordance with the Magnetic Resonance Imaging (MRI) findings in the diagnosis of mild, moderate and severe NAFLD in children and adolescents.

METHODS

Cross-sectional population-based study which will include 2,866 subjects aged between 9 and 16 years. Participants will undergo: anamnesis, physical examination, blood extraction, VCTE, MRI and questionnaires on socio-demographic data, personal and family medical history and lifestyle assessment.

APPLICABILITY AND RELEVANCE

The study aims to establish the foundations for the use of VCTE in children and adolescents in order to achieve early diagnosis of NAFLD. Moreover, it will serve to understand in further detail the disease and to identify the risk groups of children and adolescents who may be at risk of developing it. Ultimately, this will help determine to which subgroups of the population we need to target resources for prevention and early detection of this entity, as well as possible intervention for its treatment.

TRIAL REGISTRATION

The LiverKids study is registered on Clinicaltrials.gov (NCT05526274).