Introduction Non-alcoholic fatty liver disease (NAFLD) is a major cause of liver dysfunction in adults. Much less is known about this disease in children, although obesity and metabolic dysfunction are believed to be risk factors. In England the prevalence rates of obesity in children in Reception classes (age 4) and Year 6 (age 11) are 10.8% and 22.4%  respectively in 2012/13. In inner city populations such as those served by The Royal London Hospital (RLH), these rates are even higher (12.3% to 13.2% in Reception and 22.9% to 27.3%1 in Year 6). Our aims were to determine the prevalence of NAFLD in our specialist clinics in our unit and to identify key characteristics of children with NAFLD.
Methods Clinical records of patients who attended specialist paediatric Hepatology and Metabolic clinics at RLH in 2012 were reviewed. We recorded demographic information, serum biochemistry (abnormal ALT- females >35 U/L, males >40 U/L), liver screening tests, hepatic ultrasound results and insulin resistance (HOMA-IR) were calculated.
Results Twelve of 155 patients (8%) (7/62 Hepatology (11%), 5/93 Metabolic (5%) clinics) had evidence of hepatic steatosis on ultrasound. The mean BMI percentile in the Hepatology clinic for NAFLD patients was the 93rd (vs 63rd in non-NAFLD patients, P = 0.005), whereas all patients in the metabolic clinic (irrespective of NAFLD) had BMI above 3.5 standard deviations for age. The mean age of patients with NAFLD was similar to that of patients without NAFLD (12.5 vs. 12.1 years), and there was no significant difference in the proportion of males with NAFLD compared to children without.
All NAFLD patients had elevated ALT (mean 93, range 38–168). Nine patients with normal ALT (mean 16, range 12–23) had undergone abdominal ultrasound and none of these had signs of steatosis. The mean HOMA-IR in those with radiological evidence of steatosis was significantly greater than those with normal ultrasound (7.64 vs. 3.37, p = 0.005). Only two patients had a liver biopsy, both of which showed advanced fibrosis. Nine patients in the metabolic clinic (10%) with elevated ALT (mean 59, range 36–115) had not had a liver screen or ultrasound.
Conclusion Paediatric NAFLD is common in this setting and is associated with raised BMI and elevated insulin resistance. All patients with raised ALT, and none with normal ALT, had steatosis on ultrasound in our cohort. This highlights the importance of screening for liver disease including the use of ultrasonography in at-risk patients with abnormal liver chemistry. There is a need for an evidence-based algorithm to guide liver investigation and referral in children with deranged LFTs.
Reference 1 Health and Social Care Information Centre. National Child Measurement Programme – England, 2012–13 school year [NS]. 2013; http://www.hscic.org.uk
Disclosure of Interest None Declared.
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