Pediatricians' practices and knowledge of metabolic dysfunction-associated steatotic liver disease: An international survey.

OBJECTIVE: Metabolic dysfunction-associated steatotic liver disease (MASLD) is the leading cause of chronic liver disease in children. It is associated with significant intra- and extrahepatic comorbidity. Current guidelines lack consensus, potentially resulting in variation in screening, diagnosis and treatment practices, which may lead to underdiagnosing and/or insufficient treatment. The increasing prevalence of MASLD and associated long-term health risks demand adequate clinical management and consensus in guidelines. This study aims to evaluate the daily practices of pediatricians in screening, diagnosis and treatment of MASLD in children. METHODS: An online survey with 41 questions (single/multiple response options) was sent to pediatricians (with/without subspecialty) in Europe and Israel, via members of the ESPGHAN Fatty Liver Special Interest Group, between June and November 2022. The 454 pediatricians were included in this study. RESULTS: 51% of pediatricians indicated using any guideline for diagnosis and treatment of MASLD, with 68% reporting to follow recommendations only partially. 63% is of the opinion that guidelines need revision. The majority of pediatricians screen for MASLD with liver function tests and/or abdominal ultrasound. A large variety of treatment options is utilized, including lifestyle management, supplements and probiotics, with a notable 34% of pediatricians prescribing pharmacotherapy. When asked how often pediatricians request a liver biopsy in children with MASLD, 17% indicates they request a liver biopsy in more than 10% of cases. CONCLUSIONS: There is limited awareness and considerable variation in screening, diagnosis and treatment practices among European pediatricians, and a clear demand for new, uniform guidelines for MASLD in children.

Noninvasive scores are poorly predictive of histological fibrosis in paediatric fatty liver disease.

OBJECTIVES: Nonalcoholic fatty liver disease (NAFLD) is the most common chronic liver disease in children. Roughly a quarter of paediatric patients with NAFLD develop nonalcoholic steatohepatitis and fibrosis. Here, we evaluated the diagnostic accuracy of previously published noninvasive fibrosis scores to predict liver fibrosis in a large European cohort of paediatric patients with NAFLD. METHODS: The 457 patients with biopsy-proven NAFLD from 10 specialized centers were included. We assessed diagnostic accuracy for the prediction of any (F ≥ 1), moderate (F ≥ 2) or advanced (F ≥ 3) fibrosis for the AST/platelet ratio (APRI), Fibrosis 4 score (FIB-4), paediatric NAFLD fibrosis score (PNFS) and paediatric NAFLD fibrosis index (PNFI). RESULTS: Patients covered the full spectrum of fibrosis (F0: n = 103; F1: n = 230; F2: n = 78; F3: n = 44; F4: n = 2). None of the scores were able to accurately distinguish the presence of any fibrosis from no fibrosis. For the detection of moderate fibrosis, area under the receiver operating characteristic curve (AUROC) were: APRI: 0.697, FIB-4: 0.663, PNFI: 0.515, PNFS: 0.665, while for detection of advanced fibrosis AUROCs were: APRI: 0.759, FIB-4: 0.611, PNFI: 0.521, PNFS: 0.712. Fibrosis scores showed no diagnostic benefit over using ALT ≤ 50/ > 50 IU/L as a cut-off. CONCLUSIONS: Established fibrosis scores lack diagnostic accuracy to replace liver biopsy for staging of fibrosis, giving similar results as compared to using ALT alone. New diagnostic tools are needed for Noninvasive risk-stratification in paediatric NAFLD.

Sleep duration is associated with liver steatosis in children depending on body adiposity.

Sleep is a factor associated with overweight/obesity risk, wherein interactions with fatty liver should be ascertained. The aim of this cross-sectional study was to analyze the possible relationships of sleep with liver health and whether this interplay is related to body adiposity distribution in children and adolescents. Anthropometric, clinical, and biochemical measurements were performed in children and adolescents (2-18 years old) with overweight/obesity (n = 854). Body fat distribution was clinically assessed, and several hepatic markers, including hepatic steatosis index, were calculated. Sleep time mediation (hours/day) in the relationship between the hepatic steatosis index and body fat distribution was investigated. Differences among diverse fatty liver disease scores were found between children with overweight or obesity (p < 0.05). Linear regression models showed associations between hepatic steatosis index and lifestyle markers (p < 0.001). Hepatic steatosis index was higher (about + 15%) in children with obesity compared to overweight (p < 0.001). Pear-shaped body fat distribution may seemingly play a more detrimental role on liver fat deposition. The association between sleep time and hepatic steatosis index was dependent on body mass index z-score. Post hoc analyses showed that 39% of the relationship of body fat distribution on hepatic steatosis index may be explained by sleep time.  Conclusion: An association of sleep time in the relationship between body fat distribution and hepatic steatosis index was observed in children and adolescents with overweight/obesity, which can be relevant in the prevention and treatment of excessive adiposity between 2 and 18 years old. CLINICAL TRIAL: NCT04805762.    Import: As part of a healthy lifestyle, sleep duration might be a modifiable factor in the management of fatty liver disease in children. WHAT IS KNOWN: • Sleep is an influential factor of overweight and obesity in children. • Excessive adiposity is associated with liver status in children and adolescents. WHAT IS NEW: • Sleep time plays a role in the relationship between body fat distribution and liver disease. • Monitoring sleep pattern may be beneficial in the treatment of hepatic steatosis in children with excessive body weight.

The Side-Effects of the COVID-19 Pandemic: Increased BMI z-Score in Children with Overweight and Obesity in a Personalised Lifestyle Intervention One Year after the Start of the Pandemic in The Netherlands.

BACKGROUND: Early research showed weight gain in children during the COVID-19 pandemic. OBJECTIVE: To compare changes in BMI z-score of children with overweight and obesity in a personalised lifestyle intervention before and during the pandemic. METHODS: Changes in BMI z-score half a year (T6) and twelve months (T12) after the first lockdown were included for 71 children in the '2020 during COVID' group and compared to 48 children in the '2019 before COVID' group, using a marginal model for repeated measures (model 1). Model 2 corrected for lifestyle intervention characteristics, and model 3 corrected additionally for family characteristics. RESULTS: The mean difference in BMI z-score change was significantly different at T12 (+0.07 in 2020 versus -0.09 in 2019, p = 0.022). Model 3 showed significant differences in BMI z-score change at both T6 (+0.15, p = 0.024) and T12 (+0.18, p = 0.016). This model also defined 'having a mother with obesity' (+0.13, p = 0.019) and the frequency of no-show consultations (+0.41 per missed consultation per month, p = 0.025) as related factors. CONCLUSIONS: Lifestyle intervention in children with overweight and obesity is less successful in decreasing BMI z-score during the COVID-pandemic. Identified risk factors for less success could contribute to identifying children with higher risks for, and possibly prevent, BMI z-score increase.

The Effect of a Multidisciplinary Lifestyle Intervention on Health Parameters in Children versus Adolescents with Severe Obesity.

Lifestyle interventions are the common treatment for children and adolescents with severe obesity. The efficacy of these interventions across age groups remain unknown. Therefore, this study aimed to compare the effectiveness of a lifestyle intervention on health parameters between children and adolescents with severe obesity. A longitudinal design was carried out at the Centre for Overweight Adolescent and Children's Healthcare (COACH) between December 2010 and June 2020. Children (2-11 years old, n = 83) and adolescents (12-18 years old, n = 77) with severe obesity received a long-term, tailored, multidisciplinary lifestyle intervention. After 1 year, 24 children (28.9%) and 33 adolescents (42.9%) dropped out of the intervention. The primary outcome was the change in body mass index (BMI) z-score after one and two years of intervention. The decrease in BMI z-score over time was significantly higher in children compared to adolescents, the mean decrease was 0.15 (0.08-0.23) versus 0.03 (-0.05-0.11) after one year and 0.25 (0.15-0.35) versus 0.06 (-0.06-0.17) after two years of intervention; p values for the difference between children and adolescents were 0.035 and 0.012. After two years, multiple improvements in cardio metabolic health parameters were observed, especially in children. In conclusion, during our tailored lifestyle intervention, a positive and maintained effect on health parameters was observed in children with severe obesity. Compared to children, the effect on health parameters was less pronounced in adolescents.

Weight Gain in Children during the COVID-19 Pandemic and the Protective Effect of Lifestyle Intervention in Children with Obesity.

INTRODUCTION: School closures due to the COVID-19 pandemic affect children's daily structure, mealtimes, physical activity, and sleeping habits, possibly exacerbating weight gain, particularly in vulnerable children with overweight and obesity. This study aimed to evaluate both perceived and objectively measured weight gain in children in the Netherlands during the COVID-19 pandemic and the effect of prior lifestyle intervention. METHODS: A total of 150 children of the Children, Obesity and Lifestyle during COVID-19 (COLC) study (cohort A) reported perceptions of weight change during the COVID-19 pandemic. Anthropometric data of 65 children with overweight and obesity were collected at the expertise Centre for Overweight Adolescent and Children's Healthcare in the same period (COACH; cohort B). RESULTS: In cohort A, 43% of children with overweight and obesity perceived weight gain during the pandemic, compared to 15% of lean children. In cohort B, the BMI z-score increased significantly (+0.065 SD) within 5 months. Participation in a lifestyle intervention for >1 year and having parents with Dutch background was associated with less weight gain, specifically in children with obesity. DISCUSSION/CONCLUSION: In particular, children with overweight and obesity seem to be at risk for accelerated weight gain during the COVID-19 pandemic. Prior long-term participation in a lifestyle intervention protects against this weight gain, which emphasizes the importance of strong support for vulnerable populations during health crises and pleads for wide implementation of lifestyle interventions for children.

Physical activity behaviour and screen time in Dutch children during the COVID-19 pandemic: Pre-, during- and post-school closures.

BACKGROUND: Measures during the COVID-19 pandemic, including the closure of schools and sports facilities, may have lasting impact on the physical activity (PA) of children that persists for a long time. OBJECTIVE: To investigate the effect of COVID-19 measures on screen time and PA in Dutch children pre-, during- and post-school closures. METHODS: In cohort A (n = 102, 10.5 ± 3.6 years, 42.4% boys), data on PA and screen time during the lockdown were collected using a questionnaire. In cohort B (n = 131, 10.2 ± 0.9 years, 43.5% boys), data on PA and screen time were collected using a questionnaire and accelerometry 1 year before and after school closure. RESULTS: In cohort A, 62% reported less total PA. Self-reported screen time on week days increased 34 ± 105 min/d during the lockdown. In cohort B, sedentary time as measured by accelerometry, increased by 45 ± 67 min/d and only 20% reached PA levels of 60 min/d compared to 64% in May 2019. Self-reported screen time increased by 59 ± 112 min/d and 62 ± 130 min/d during week and weekend days, respectively. CONCLUSIONS: Children were less physically active, and screen time was higher during and after the school closures due to the COVID-19 lockdown. This is alarming as an active lifestyle in children is crucial in preventing chronic diseases such as obesity.