Non-Alcoholic Fatty Liver Disease (NAFLD)

What is NAFLD/NASH?

• NAFLD:(Non-Alcoholic Fatty Liver Disease) means extra fat is stored in the liver.
• NASH:(Non-Alcoholic Steatohepatitis) is when that fat causes inflammation and mild injury to the liver.
• Over many years, some children can develop scarring (fibrosis) and, rarely, cirrhosis.

Who is affected?

• NAFLD is most common in children with overweight or obesity.
• It is strongly linked to the metabolic syndrome:
  • High blood pressure
  • High blood sugar or insulin resistance
  • High cholesterol or triglycerides
  • Central (belly) weight gain
• Children who are physically active are at lower risk, but NAFLD can still occur even in kids who exercise if weight and metabolism are affected.

Symptoms and physical findings

• NAFLD usually has no symptoms and is often found incidentally on bloodwork or imaging.
• Some children may have fatigue or vague abdominal discomfort.
• Acanthosis nigricans (dark, velvety patches of skin, especially on the neck or underarms) is a common sign of insulin resistance.

How is it diagnosed?

The diagnosis is suspected when liver blood tests are abnormal or when fat is seen on imaging. Workup is needed to rule out other causes of liver disease.

• Lab testing: check for viral, autoimmune, genetic, and metabolic causes of liver disease.
• Imaging: ultrasound can detect fat in the liver.
• Sometimes further testing is needed if liver numbers remain high.

Treatment

There is no medication that cures NAFLD in children. The mainstay of treatment is lifestyle changes:

• Weight reduction if overweight or obese
• Daily physical activity (at least 60 minutes of active play/exercise most days)
• Healthy diet with fewer processed foods
• Limit sugary beverages (soda, juice, sports drinks)

Medications that may be considered

• Metformin (used for insulin resistance) and GLP-1 agonists (like liraglutide or semaglutide, used in obesity/diabetes) may be prescribed in certain cases to help with weight and insulin sensitivity, but they do not directly cure fatty liver.

Key points for families

• NAFLD means fat in the liver; NASH means inflammation on top of that.
• Most kids have no symptoms; it is often picked up on labs or ultrasound.
• Linked closely to metabolic syndrome and lifestyle factors.
• Rarely progresses to cirrhosis in childhood but important to address early.
• Best treatment is healthy diet, daily activity, and limiting sugary drinks.
• Medicines can help with weight/insulin resistance, but there is no cure pill.

References

 NASPGHAN. GI Kids: Patient Education Resources. North American Society for Pediatric  Vos MB, Abrams SH, Barlow SE, et al. NASPGHAN Clinical Practice Guideline for the Diagnosis and Treatment of Nonalcoholic Fatty Liver Disease in Children. J Pediatr Gastroenterol Nutr. 2017;64(2):319-334.

 Armstrong MJ, Adams LA, Canbay A, Syn WK. Extrahepatic Complications of Nonalcoholic Fatty Liver Disease. Hepatology. 2014;59(3):1174-1197.

 Schwimmer JB, Behling C, Newbury R, et al. Histopathology of Pediatric Nonalcoholic Fatty Liver Disease. Hepatology. 2005;42(3):641-649.

 AAP Clinical Report. Nonalcoholic Fatty Liver Disease in Children and Adolescents. Pediatrics. 2021;147(5):e2020043730.

 NASPGHAN. Nonalcoholic Fatty Liver Disease (NAFLD). GI Kids. https://www.gikids.org

 Blaufuss, T. Common Sense Pediatric GI: Practical Guidance for Families. Dakota Pediatric Gastroenterology, Fargo, ND, 2025.