Nonalcoholic Fatty Liver Disease

If nonalcoholic fatty liver disease is not treated early, the disease can progress to more severe stages and eventually lead to liver failure: 

• The early stage of disease is fat buildup in the liver, also called fatty infiltration.
• Fatty infiltration can progress to inflammation (swelling) of the liver. This stage is called nonalcoholic steatohepatitis, or NASH.
• NASH can progress to scarring of the liver, also called fibrosis.
• Fibrosis can progress to severe scarring of the liver. This stage is also called cirrhosis or end-stage liver disease.
• The final stage of NAFLD is liver failure. A person who has liver failure might need a liver transplant for long-term survival. 

When NAFLD is caught in the early stages, the liver can heal. Even children with NASH and early stages of scarring (fibrosis) can stop or even reverse damage from the disease by eating a healthier diet, exercising and losing weight.

A healthy liver: 

• Filters and cleans blood
• Helps digest food
• Helps break down and store (metabolize) substances the body takes in from food
• Stores energy
• Helps fight infections
• Produces many chemicals the body needs, like glucose, proteins and bile 

When the liver is not working well, all its important functions are disrupted. Other organs, such as the kidneys and the brain, can be affected too. Read more about how the liver works.

Many children (and adults) have some fatty buildup in their liver. Doctors still don’t know exactly why some children with fat in their liver develop inflammation (nonalcoholic steatohepatitis, or NASH) and some don’t. One theory is that two events have to take place (“two-hit hypothesis”). The first event is anything that increases fatty buildup (infiltration) in the liver. The increased fatty buildup makes the liver less able to fight off injury. Children who are obese or have diabetes are more likely to have an increase in fatty buildup in their liver. The second event is when there is additional stress on the liver. This might be due to genes passed along in families (genetic predisposition) or an increase in the level of waste products in the liver that can damage cells and tissues.

Children who are obese have a higher risk of diabetes, cholesterol disease and liver disease. Doctors have medical guidelines to screen for these diseases in all children who are obese and are age 10 or older. This is done through blood tests. One of these tests tells the doctor if your child’s liver enzymes (alanine transaminase, or ALT, and aspartate transaminase, or AST) are higher than normal. High ALT or AST levels are a sign of liver inflammation but do not tell the doctor what liver condition a child has. It is important for a child who has high ALT or AST levels to see a liver specialist (hepatologist), who can find out exactly what is causing the inflammation.

When hepatologists at Seattle Children’s see a child who is at high risk for nonalcoholic fatty liver disease (NAFLD) and whose blood test shows high liver enzyme levels, sometimes we perform an ultrasound. With ultrasound, we can see if there is fatty buildup (infiltration) in the liver. The presence of fatty buildup in the liver often indicates NAFLD, especially in patients with other risk factors such as obesity. Doctors can’t tell what stage the disease has progressed to from the ultrasound. Doing a liver biopsy is the only way to know for sure what stage the disease is in.

If the doctor finds no fatty buildup with the ultrasound, they look for other causes of liver inflammation such as infections, biliary atresia, metabolic disease or hepatitis.

We work with you and your child to come up with ways to change their activity level that are realistic for them. Sometimes this means focusing on just one thing at a time. One way to do this is by setting up a “30-day challenge” that makes meeting goals more like a game. For Day 1 of the challenge, we might ask that your child do 3 pushups that day. We’ll ask that they slowly increase the number each day for a month, so that by Day 30, they are doing 60 to 90 pushups a day.

Eating healthier can start small, too. It doesn’t have to mean counting every calorie. It can start with something as simple as not packing chips in your child’s lunch (and maybe limiting them to special occasions).

Before coming up with diet and exercise suggestions for your child, we take into account their age, what they are used to eating and how much activity they are currently doing. We consider things like how much time you have to prepare meals and whether you live in an area with parks or playgrounds. We work with you to come up with activities that are practical for you to do and that your child and family will enjoy doing. We will ask you what tools and resources we can give you so that your child can succeed.

The most important factor in your child improving their health is that they find their individual reasons or motivations to change. We will help them pick the changes they want to work on. Part of that motivation will come from you, the parent. You can have a positive influence if your child sees that you are excited about moving more and eating healthier. Maybe you can start a new routine of walking around your neighborhood after dinner, or maybe you can invite your child to choose a healthy recipe and you can cook it together. If your child still lacks interest, we have counselors they can talk to. Your child may have anxiety or depression that is making it more difficult for them to make healthy changes.

Seattle Children’s is home to the Northwest’s only dedicated pediatric hepatologists (liver doctors) – Drs. Niviann Blondet and Evelyn Hsu – and Seattle Children’s Hepatology Program. From diagnosis through treatment of liver conditions, we have years of experience working with children and their families.

Every day we strive to improve the care that is available to children. Through our dedication to clinical research, we hope to be able to prevent or change the course of pediatric liver disease in the future.

We realize that treatment of nonalcoholic fatty liver disease is a challenge because it requires that your child make lifestyle changes. Such changes include eating a healthier diet and exercising more. These changes can be hard because: 

• They affect the entire family.
• It means starting new routines and habits, which is hard even for adults.
• Parents may need help themselves learning how to make healthier meals and snacks.
• Changing what you eat is not just a behavior change, because food involves culture and tradition.
• Eating can be a way to cope with depression or anxiety.
• It can be hard to get kids to leave their devices behind and go for a walk, ride a bike or participate in another activity. 

To help with these challenges, we provide multidisciplinary care to your child through our Fatty Liver Disease Program. You and your child will see a hepatologist and dietitian, and a psychologist if appropriate, at your clinic visit. We also partner with Physical Therapy and Endocrinology, and we may refer your child to a caregiver from one of these teams, depending on your child’s needs. We want to give you the support you need so that your child can improve their health. We want to give you and your child goals that are achievable and practical in real life.