title: Review article: the management of paediatric nonalcoholic fatty liver disease.
abstract: BACKGROUND
  Paediatric nonalcoholic fatty liver disease (NAFLD) is a major public health concern given the recent increase in its prevalence and link to obesity and other metabolic comorbidities. Current treatment strategies involve lifestyle changes. Other surgical and pharmacologic interventions have been proposed; however, limited randomised controlled trials (RCTs) in the paediatric population restrict their use.
  
  
  OBJECTIVE
  To review the current management of paediatric NAFLD, including lifestyle and pharmacologic interventions, and to formulate recommendations for study design for future studies.
  
  
  METHODS
  A MEDLINE, Pubmed and Cochrane Review database search used a combination of keywords, including NAFLD, nonalcoholic steatohepatitis (NASH), paediatric, treatments, lifestyle changes, bariatric surgery, orlistat, metformin, thiazolidinediones, vitamin E, cysteamine bitartrate, ursodeoxycholic acid (UDCA), probiotics, omega-3 fatty acids, pentoxyfylline, farnesoid X receptor agonist and toll-like receptor modifiers. The articles were selected based on their relevance to the review.
  
  
  RESULTS
  Lifestyle interventions involving diet and exercise remain first-line treatment for paediatric NAFLD. Bariatric surgery, orlistat, insulin sensitisers and UDCA have been evaluated but are not recommended as first or second-line therapy. Medications such as cysteamine bitartrate, probiotics, polyunsaturated fats and pentoxyfilline share beneficial effects in trials, however, there is a paucity of adequately powered RCTs in which liver histology is evaluated. Vitamin E has been shown to be effective and safe in improving NASH histology in children.
  
  
  CONCLUSIONS
  Lifestyle intervention should be first-line treatment for paediatric NAFLD. Vitamin E should be considered for those with biopsy-proven NASH or borderline NASH failing first-line therapy. Other therapeutics show promising results but require larger RCTs with convincing endpoints. Improved screening techniques, objective validated inclusion criteria and outcome measures as well as rigour in study design are necessary for propelling therapeutic discovery.
authors.affiliation: Division of Pediatric Gastroenterology, Hepatology and Nutrition, Columbia University, New York, NY, USA.
authors.forename: E B
authors.initials: EB
authors.lastname: Mitchel
authors.forename: J E
authors.initials: JE
authors.lastname: Lavine
mesh_terms: D002648:Child; D004032:Diet; D006801:Humans; D008019:Life Style; D009043:Motor Activity; D065626:Non-alcoholic Fatty Liver Disease / Q000628:therapy*; D014810:Vitamin E / Q000627:therapeutic use; D015431:Weight Loss
chemical_list: D014810:Vitamin E