• Very young or normal-weight children found to have fatty liver should be assessed for monogenic causes of chronic liver disease (such as fatty acid oxidation defects, lysosomal storage diseases, and peroxisomal disorders), as well as the potential causes usually considered among adults.
• High serum titers of autoantibodies, particularly when associated with high aminotransferase and high globulin levels, require a liver biopsy to identify possible autoimmune hepatitis.
• The histopathology of NAFLD in children can differ from that in adults, and can include marked macrovesicular hepatocellular steatosis, portal inflammation, and portal fibrosis in the absence of ballooning.
• Addressing obesity is the first step in treatment, and intensive lifestyle modification is recommended, although no particular diet or exercise program is advocated at this time.
• Metformin is not recommended because it has not been shown to benefit children.
• Vitamin E cannot be recommended for children until confirmatory studies verify that it improves liver histology in NASH.
Dr. Chalasani and his coauthors disclosed relationships with multiple companies; these relationships include research support and paid consulting related to NAFLD.