Clinical Practice Approach to Nonalcoholic Fatty Liver Disease by Pediatric Gastroenterologists in the United States

Abstract

Objectives: Nonalcoholic fatty liver disease (NAFLD) is common; however, no information is available on how pediatric gastroenterologists in the United States manage NAFLD. Therefore, study objectives were to understand how pediatric gastroenterologists in the US approach the management of NAFLD, and to identify barriers to care for children with NAFLD. Methods: We performed structured one-on-one interviews to ascertain each individual pediatric gastroenterologist's approach to the management of NAFLD in children. Responses were recorded from open-ended questions regarding screening for comorbidities, recommendations regarding nutrition, physical activity, medications, and perceived barriers to care. Results: Response rate was 72.0% (486/675). Mean number of patients examined per week was 3 (standard deviation [SD] 3.5). Dietary intervention was recommended by 98.4% of pediatric gastroenterologists. Notably, 18 different dietary recommendations were reported. A majority of physicians provided targets for exercise frequency (72.6%, mean 5.6 days/wk, SD 1.6) and duration (69.9%, mean 40.2 minutes/session, SD 16.4). Medications were prescribed by 50.6%. Almost one-half of physicians (47.5%) screened for type 2 diabetes, dyslipidemia, and hypertension. Providers who spent more than 25 minutes at the initial visit were more likely to screen for comorbidities (P = 0.003). Barriers to care were reported by 92.8% with 29.0% reporting ≥3 barriers. Conclusions: The majority of US pediatric gastroenterologists regularly encounter children with NAFLD. Varied recommendations regarding diet and exercise highlight the need for prospective clinical trials. NAFLD requires a multidimensional approach with adequate resources in the home, community, and clinical setting.

Recent advances in the epidemiology of nonalcoholic fatty liver disease in children

“…Although screening is recommended for hypertension, dyslipidemia, and type 2 diabetes in children with NAFLD, Shapiro et al found that only half (47.5%) of paediatric gastroenterologists screened for these comorbidities. 27 Notably, time constraints were associated with poor screening. Providers who spent more than 25 min at the initial visit were more likely to screen, illustrating the need for sufficient time to address comorbidities in children with NAFLD.…”

Perspectives on youth‐onset nonalcoholic fatty liver disease

“…However, despite these recommendations, only approximately half of paediatric gastroenterologists screen for those comorbidities. 86 Acknowledgement and evaluation of NAFLD comorbidities is an essential tool that will reduce the impact of severe outcomes in young adults and is an important consideration for next-generation, whole child treatment regimens.…”

“…Thus, it is not surprising that, aligning with the evidence outlined above, the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) suggests screening for comorbidities such as T2DM, hypertension and dyslipidemia in children with NAFLD, 85 and this list of comorbidities may increase in the future as more evidence is generated. However, despite these recommendations, only approximately half of paediatric gastroenterologists screen for those comorbidities 86 . Acknowledgement and evaluation of NAFLD comorbidities is an essential tool that will reduce the impact of severe outcomes in young adults and is an important consideration for next‐generation, whole child treatment regimens.…”

Identifying Predictors of Response to Vitamin E for the Treatment of Pediatric Nonalcoholic Steatohepatitis

“…These data suggest that there is a role for vitamin E in the treatment of NAFLD but that only a subset of patients respond. Despite this, according to a recent nationwide survey of US pediatric gastroenterologists (72% response rate), 51% reported using medications to treat NAFLD, and the most commonly used medication was vitamin E . Therefore, studies are needed to determine the characteristics of patients, who are more likely to respond to this intervention.…”