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fighting childhood
liver disease
Non-alcoholic Fatty Liver
Disease (NAFLD)
a guide Medical Information Series
fighting childhood
liver disease Non-alcoholic Fatty Liver Disease a guide 3
Registered charity number 1067331 (England & Wales); SC044387 (Scotland)
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How can I reduce sugar in
Welcome
my child’s diet?
■ Be aware of ‘hidden’ sugars
This leaflet has been written for: ■ Check labels to help choose foods with
■ Parents/carers of a child with non-alcoholic fatty liver disease (NAFLD) less added sugar, or go for low sugar
■ Young people with non-alcoholic fatty liver disease (NAFLD) versions
■ Try not to add sugar to foods/drinks e.g.
Others who may find this leaflet helpful are: breakfast cereal, in tea or coffee
■ Relatives and friends of families ■ Choose sugar free/diet drinks/reduced
sugar
■ Healthcare and allied professionals, school, college, university and nursery teams ■ Avoid sugary cakes, biscuits and
sweets, choose lower sugar alternatives:
This leaflet aims to: teacakes, fruit cake and fruit
■ Explain what NAFLD is ■ If needed, choose an artificial sweetener
■ Explain the causes and how it may be treated instead of sugar
■ Use small amounts of jam/marmalade
You may find it helpful to read the following CLDF leaflets: and/or use reduced sugar varieties
■ Guide to the liver Finally remember that children need the
support of the whole family. If everyone
■ Glossary of terms follows a sensible diet your child is
■ Routine investigations for liver disease much more likely to succeed. If this
■ Portal hypertension results in weight loss, general health will
improve. This can be monitored by repeat
Children’s Liver Disease Foundation (CLDF) also has leaflets in its support series which are growth measurements, blood tests and
ultrasounds. If you are still concerned and
available to download from our website – childliverdisease.org. Leaflets can be mailed to UK would like more information ask your GP
patients free of charge, our contact details are on this leaflet. You may find it helpful to have to refer you to your local dietitian who will
a copy of CLDF’s making the most of an appointment leaflet which will help you prepare be aware of local programmes to help and
for appointments and meetings following discharge. advise you.
We also have the following information packs available, free of charge: How can I increase my child’s
■ Essential 5 – CLDF’s starter kit of vital information
activity levels?
■ Education – a pack supporting children and young people under 18 in an Children and young people should be
educational setting gradually aiming to take part in physical
■ GP Practice – a pack for families to give to their GP providing a range of activity for at least one hour every day. This
information on childhood liver disease can include:
■ Friends and Relatives ■ Walking
■ Yellow Alert – a pack to support CLDF’s Yellow Alert Campaign for early ■ Climbing
diagnosis of liver disease in newborn babies ■ Gymnastics
■ Cycling
All are available on request to UK families and young adults. ■ Active play – including jumping, skipping
and dancing
Overseas families should contact CLDF to discuss their literature needs. ■ Most sports
■ Swimming
■ Games
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What is non-alcoholic fatty balance in the body. In some people muscle
and fat cells stop responding to insulin and
liver disease (NAFLD)? the body responds by the pancreas releasing
Non-alcoholic fatty liver disease (NAFLD) increasing amounts of insulin to make up
is a condition in children and in adults for this. The liver is then bombarded by
where fat builds up in the liver. The amount insulin allowing more fat into the liver cell
of fat trapped in the liver cells will vary in and decreasing the amount of fat which is
each individual. There is normally a small processed and released from the liver cell
amount of fat in liver cells; however, when (i.e. insulin increases fat stores). People
a significant amount of fat builds up in the who are prone to insulin resistance have
cells liver disease can follow. NAFLD has a high risk of developing type 2 diabetes.
been increasing in both adults and children The tendency often runs in families but not
over recent decades. It has now become always. The classic body shape of those
the most common form of chronic liver who are insulin resistant is apple shaped
disease in children. The condition usually rather than pear shaped. People who are
progresses slowly over decades and only a prone to insulin resistance and NAFLD tend
few children have serious medical problems to deposit fat around their abdomens and
in early life. Health professionals are still around the organs within the abdominal
learning about the condition but believe cavity, thus worsening the amount of fat in
that early recognition and treatment of and around the liver. In some children and
the condition is important as serious liver adults with fatty liver disease, for reasons
problems can develop in early adulthood that we do not yet understand, the liver
including cirrhosis and liver cancer. The can become irritated and fat can cause
reason the condition is called NAFLD is that inflammation and lead to liver scarring.
the liver can look like it has been exposed What are the possible reasons
to large quantities of alcohol but of course
occurs in those who have not taken any for fat in the liver?
alcohol at all.
■ Complication of overweight / obesity
What causes NAFLD? ■ Insulin resistance
■ Certain types of metabolic liver disease
Fat is a normal part of the make up of such as Wilson’s Disease, Fructosaemia
our bodies. It has a role in storing energy and Cystic Fibrosis
producing calories for use in situations of ■ Artificial feeding such as feeding directly
stress and provides insulation from the into a vein (parenteral feeding)
cold. The liver has a role in the control of ■ Malnutrition
the storage of fat in the body and the use ■ Excess use of alcohol
of fat as an energy source. The body needs ■ Medication such as steroids
fatty substances to function properly and ■ Unknown
therefore fat in moderation should be part
of a well balanced diet. So fat is part of
a normal balanced diet. If the body takes Why might NAFLD be
in more calories than is needed then the suspected in your child?
excess is stored as fat. Some may be stored
in the liver and thus cause fatty liver disease. ■ Children often present to their GP with
Insulin is a hormone which is released by abdominal pain and undergo routine
the pancreas and acts on the muscle as liver function tests (blood tests) and an
well as fat cells. It has an important role in ultrasound scan which turns out to be
controlling sugar levels and food and energy abnormal.
Non-alcoholic Fatty Liver Disease a guide 01
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■ An enlarged liver and/or an enlarged Your child will have a general examination ■ 24 hour urine collection for copper to
spleen may be found on routine and measurements taken such as: exclude another liver disease called
examination (hepatomegaly and/or ■ Height Wilson’s Disease
splenomegaly). ■ Weight ■ Oral Glucose Tolerance Test (OGTT)
■ On blood testing for other reasons and ■ Waist circumference ■ This is a test looking for insulin
abnormal liver function tests are found. ■ Blood pressure resistance and type 2 diabetes which
If your child is undergoing investigations ■ Urine analysis are closely associated with NAFLD.
for type 2 diabetes or for overweight, liver The height and weight will be compared to ■ Your child will need to fast overnight
function tests and an ultrasound are often national averages to find out whether your (usually from midnight) and come in
part of the screen. child’s measurements are above or below for an early appointment (usually in the
Why do children with average. It will also determine whether the day ward). A cannula (plastic straw
child fits the measurements that exist to into the vein) will be inserted into your
suspected NAFLD need to define being overweight or obese. child’s hand; blood tests are withdrawn
be investigated? ■ An estimate of Body Mass Index (BMI) through the cannula over the course
will be made. This uses the height and of the morning. Your child will then be
Investigations provide information about weight readings. This can be compared asked to drink a sugary drink provided
your child, which enables your medical to expected values at various ages. by the nurses – this is usually lucozade
team to discuss with you the extent of the Your child will have a range of tests which or similar. Bloods will be drawn from
problem, what the future holds and the best may include some or all of the following: the cannula at 30 minutes, 60 minutes,
way to manage the condition. 90 minutes and 120 minutes after the
■ It is important to find out to what extent ■ Blood tests drink is finished. The blood tests are
your child is affected by the fat in the These will be used to look for: done to look at the body’s sugar levels
liver. For example children may have and insulin levels in response to a
both inflammation and scarring in their ■ General tests of health sugar load. Children in whom the sugar
liver alongside their fat. — Full Blood Count (FBC) levels rise to excess levels may have
■ It is important to make sure that no other — Glucose level and other so-called type 2 diabetes. If insulin levels rise to
liver disease is present which will need “metabolic tests” excess levels the child may have insulin
other types of treatment. (See list — Insulin levels resistance or ‘pre-diabetes’.
of conditions on the previous page.) ■ Kidney tests ■ Ultrasound
■ To look for other health issues which are — Urea and Electrolytes (U&Es) This takes place in the X-ray department
known to be associated with fatty liver — Causes of liver disease (radiology). This will look at all the organs
e.g. high blood pressure, early signs of — Infections of the abdomen, but particularly at the
diabetes. — Chemical abnormalities liver. It can show up some abnormalities
■ Extent of liver disease and help to decide whether further
What investigations are — Liver Function Test (See CLDF investigation is needed. Sometimes
leaflet on Routine Investigations related changes such as gallstones
needed? of Liver Disease) or an enlarged spleen are found.
■ Clinical Examinations and History Taking Some of these may be on samples at a ■ Liver Biopsy
This involves at least one and often time when your child has been fasting from In some cases the doctor may
several members of the team discussing food and sugary drinks. You will be told by recommend a liver biopsy. This is a
with you about your child’s past growth, your hospital team about this if needed. procedure in which a small sample of liver
development, lifestyle and health. This will ■ Urine tests tissue is obtained by passing a specially
be specifically looking for factors that may ■ Urine metabolic screen to exclude designed needle though the skin. This
have contributed to the condition. chemical abnormalities especially in will be explained in greater detail to
younger children you by your medical team. The tissue
is studied later under a microscope by
doctors specially trained in examining
02 Non-alcoholic Fatty Liver Disease a guide
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