Professor Deirdre Kelly CBE, of the European Society for Paediatric Gastroenterology, Hepatology and Nutrition, discusses what can be done to tackle the particular threat of obesity-related liver disease in children.
Childhood obesity is a rapidly growing public health crisis. According to the World Health Organization (WHO), some 41 million children under the age of five were overweight or obese in 2016, a figure which is expected to rise to 70 million by 2025 if current trends continue. This worrying epidemic is contributing in no small part to the high burden of diseases such as cancer, diabetes and obesity-related liver disease (or non-alcoholic fatty liver disease), which is now the most common cause of chronic liver disease among children and adolescents in Western countries.
To find out more about the growing burden of liver disease in children, Health Europa spoke to renowned liver expert Professor Deirdre Kelly, professor of paediatric hepatology at Birmingham Women’s and Children’s NHS Foundation Trust, UK, and chair of the Public Affairs Committee at ESPGHAN – the European Society for Paediatric Gastroenterology, Hepatology and Nutrition.
Here, Kelly discusses the importance of encouraging healthy lifestyles among children, the pros and cons of screening, and the need for better transition services to support young people with liver disease.
What are the main causes of liver disease in children?
The main cause of liver disease in children is genetic, which is most likely to present in babies but can also be late-onset. Autoimmune liver disease is more likely to be diagnosed in older children, which is when the body’s defence system attacks the liver. The other common cause in older children is obesity-related liver disease which tends to affect children from five years upwards. Both these diseases are ‘secret diseases’, as the liver disease may only become obvious when they are adults, even though it begins in childhood.
Understanding what causes liver disease and being more aware of liver disease in children is vital if we are to diagnose obesity-related liver disease early, so that treatment can begin as soon as possible.
In terms of obesity-related liver disease, could more be done to empower children to take care of their own health?
We could certainly do more to encourage children to play a bigger role in their own health. It’s interesting how responsible children actually are. If you teach children the importance of healthy eating habits and regular exercise early in life, they can really become quite passionate about it. Empowering children in this way all depends on early education, on their family behavior and culture.
We also need to rethink the way we promote healthier lifestyles among children: simply telling them that they shouldn’t eat sweets isn’t always as constructive or effective as demonstrating to them what they can achieve by living more healthily.
It is also important to reduce temptation; reducing advertising and removing sweets at supermarket tills, for example, can help parents trying to discourage their children from having too much sugar. Not all parents have time to take their children to exercise classes or sports groups and so on, so encouraging that healthy lifestyle is easier said than done.
What is the typical care pathway a child would go through if suspected of having liver disease?
Most children with fatty liver disease due to obesity are not symptomatic at all. They are picked up by accident – perhaps they have tummy ache and the GP has run some blood tests and seen slightly abnormal liver function tests. In that case, the child would be taken to a clinic where they’d have some blood tests done and an ultrasound scan of the liver. If the scan showed a bit of fat in the liver, then the clinician would look for inherited and metabolic causes of obesity, of which there are several, but usually those tests are negative and the cause is obesity.
The child would be referred for physiotherapy and to a dietician, who would recommend exercise and a healthier diet. The consultant would explain that the child most likely has fatty liver, which may progress to liver disease later in life. In general, families find this difficult to believe and may not take this advice seriously. The child would then be followed up twice a year to encourage weight loss, which is difficult for growing children, but the only proven treatment in adults.
If the child has a more acute form of liver disease, they would likely go through much the same pathway, but they might present with jaundice or fatigue, they might have lost weight or their appetite, and they might complain that they do not have enough energy to get through the whole school day. In that case, a blood test might show abnormal liver function, and the child would be admitted for more detailed investigation, including a liver biopsy, an endoscopy (of the lining of the stomach) and further diagnostic tests. Depending on the cause of the liver disease, they would start on treatment and be followed up for the rest of their lives.
Given that children with obesity-related liver disease are typically asymptomatic, how can their earlier diagnosis be encouraged? Is screening a useful tool, for example?
The trouble with screening is that fatty liver disease is less common (so far) than the number of overweight children. There is considerable controversy about who to screen and how best to do it. For instance, should we screen only obese children or all children? Blood tests and scans can be quite invasive, especially for children.
Is the care provided to children with liver disease sufficiently tailored to support children’s specific needs?
In the UK we have three national liver units, all of which are national centres, and care is focused on children and their families. It is not appropriate for children to be monitored or followed up in an adult unit. I am not sure that such specialised units are found everywhere in Europe, but France, Spain, Germany and Sweden have specific paediatric centres focusing on liver and gut disorders. The days of children being followed up in adult care units are thankfully behind us.
The problem comes when children turn 18+ and need to move to adult services. Those services are not remotely geared towards young people; they’re geared towards people in their 50s and 60s.
In the UK, each of the three paediatric liver units has transition programmes and works with specific adult doctors who take over the care of these young people. This works in most cases but is still a problem if the child has learning difficulties.
Everyone is aware that these transition services need to improve, but because the number of young people with liver disease growing into adult life is increasing, the numbers are much less than the numbers of adult patients.
Professor Deirdre Kelly CBE
Public Affairs Committee
This article will appear in issue 6 of Health Europa Quarterly, which will be published in August.