Increase Pharmacist Awareness and Intervention in Pediatric Nonalcoholic Fatty Liver Disease
Health professionals only recently discovered that signs of heart disease may appear in young children, and now, another adult condition can be added to the list—pediatric nonalcoholic fatty liver disease (NAFLD). It’s vital to identify pediatric NAFLD before it progresses to debilitating liver disease, yet symptoms are often too mild to notice. Since obesity is the one obvious sign, pharmacists need to find a compassionate and comfortable way to reach out to parents, talk about weight and its association with liver disease, and encourage consultation with a physician.
Facts About Pediatric Nonalcoholic Fatty Liver Disease
It’s difficult to determine the prevalence of pediatric NAFLD due to diagnostic issues. A true diagnosis requires a liver biopsy, which isn’t feasible in a population-based study and is the last diagnostic choice in clinical practice. Physicians and researchers rely on ultrasound and levels of serum aminotransferase to identify fatty liver disease. Various studies using these two diagnostic tools report that prevalence of fatty liver in children and adolescents is 3 to 4 percent, but that’s low according to other estimates.1
A group from the University of California, San Diego School of Medicine estimated NAFLD prevalence after reviewing autopsies performed on 742 children and adolescents. After adjusting for age, gender, race and ethnicity, the estimated rates reported in 2007 were2:
- NAFLD prevalence of 9.6 percent in children and adolescents aged 2 to 19 years.
- Prevalence ranged from 0.7 percent in children aged 2 to 4 to 17.3 percent for ages 15 to 19 years.
- Highest rate—38 percent—occurred in obese children.
- Prevalence varies by race and ethnicity—11.9 percent in Hispanic children, 10% in Asian, 8.6 percent in whites and only 1.5 in black people.
Experts agree that obesity drives the prevalence of pediatric NAFLD. In 2007, the prevalence of obesity in children and adolescents aged 2 to 19 years was 16.9 percent.3 As it turns out, obesity prevalence remained at 17 percent in 2014, according to the CDC.4 Based on levels of obesity, the 2007 prevalence should still be applicable. In fact, it does fit within the results of a 2013 study in the Journal of Hepatology, which reported a global prevalence of pediatric NAFLD of 3 to 10 percent.5
Early Identification is Difficult Due to Vague Symptoms
An early diagnosis is critical to prevent simple steatosis from progressing to inflammation and fibrosis. As if liver damage and the ultimate threat of cirrhosis aren’t bad enough, children with NAFLD also face a higher risk of atherosclerosis, increased carotid intima media thickness, and type 2 diabetes. The bad news is that it’s not easy to catch the disease based on symptoms.
Children with NAFLD may be asymptomatic or they may experience mild, generic symptoms such as fatigue, malaise, and constipation. Right-sided abdominal pain is often the symptom that prompts parents to take their children to the doctor. About half of these patients also have acanthosis nigricans, which is a dark discoloration found on the neck, armpits or groin that signals insulin resistance. Otherwise, the only obvious sign is obesity, especially the presence of visceral fat.
With such general symptoms, it’s a challenge for pharmacists to create an outreach protocol. If parents approach with questions about fatigue, constipation or pain—or if you fill prescriptions for their children that treat associated health conditions—then you have an open door to bring up concerns about NAFLD. You could also put up posters that draw attention to the association between weight and liver disease in children, urge parents to “ask the pharmacist,” then be prepared for the discussion.
It’s hard to approach counseling based on weight. Some parents may be defensive about their child’s weight—many pharmacists are just as uncomfortable about broaching the topic—and you have to be more sensitive if the child is present. But remember that most parents don’t know about the risk for pediatric NAFLD and its serious consequences. It’s important to educate them and encourage a visit to the pediatrician or family physician.
Lifestyle Intervention is First Line Treatment
When initial lab tests point to NAFLD, the diagnostic algorithm recommends lifestyle changes with follow-up tests in a few months.6 While weight loss is always a goal, you can inspire parents by letting them know that modest changes in diet and physical activity can improve liver function tests, whether or not their child drops pounds. Of course, they’ll get better results with a 5 percent drop in weight, but it’s always best to start with little steps.
When it comes to dietary intervention, the recommendation will sound familiar: Follow a well-balanced diet that’s filled with fruits, vegetables, whole grains, beans, low-fat dairy products and lean meat. Some experts recommend a low-fat diet, but the precise mix of fat, carbohydrate and protein should be determined in consultation with a doctor or registered dietitian because it must be based on each child’s overall health and physical requirements. Two specific dietary recommendations are essential:
- Avoid added sugar – Added sugar causes high levels of triglycerides. More specifically, children with NAFLD may be more sensitive to dietary fructose than healthy children.7 A large percentage of added sugar in the form of high-fructose corn syrup comes from caloric beverages like sodas, but parents shouldn’t overlook any type sugar-sweetened beverage, including fruit drinks.
- Avoid saturated fats and cholesterol – Consuming healthy unsaturated fats while avoiding saturated fats from butter and red meat will help reduce serum lipids. Dietary cholesterol may also be a risk factor for NAFLD.
Pharmacist Outreach Helps Guide and Support Parents
If there’s anything worse than being a parent with a sick child, it’s being a parent who doesn’t know their child could be developing a deadly disease that could be stopped with dietary changes and weight loss. So first they need to learn about the risks of NAFLD—even in children—which will shock most parents. Then they need some guidance with diet and many will search for OTC dietary products to help reach the goal. Guidance from pharmacists provides immense support for parents at every step of the process.
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- “Pediatric Nonalcoholic Fatty Liver Disease: A Clinical and Laboratory Challenge,” July 2010, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2998974/ ↩
- “Prevalence of Fatty Liver in Children and Adolescents,” October 2006, https://www.ncbi.nlm.nih.gov/pubmed/17015527 ↩
- “Prevalence of Obesity Among Children and Adolescents: United States, Trends 1963-1965 Through 2007-2008,” June 2010, http://www.cdc.gov/nchs/data/hestat/obesity_child_07_08/obesity_child_07_08.htm ↩
- “Prevalence of Childhood Obesity in the United States, 2011-2014,” November 2016, https://www.cdc.gov/obesity/data/childhood.html ↩
- “Paediatric Nonalcoholic Fatty Liver Disease,” June 2013, http://www.medscape.com/viewarticle/802845 ↩
- “The Growing Problem of Pediatric Fatty Liver Disease,” March 2015, http://www.medscape.com/viewarticle/841749_3 ↩
- “Children With NAFLD Are More Sensitive to the Adverse Metabolic Effects of Fructose Beverages Than Children Without NAFLD,” April 2012, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3387406/ ↩