Children and infants with liver diseases are at an increased risk of malabsorption, under-nutrition and nutritional deficiencies. They often have a high energy requirement, disordered or faster metabolism, inefficient energy use and increased respiratory effort. They may also have a poor appetite for a number of reasons including enlarged liver and spleen reducing the amount of room for their stomach causing them to feel full quicker, unpalatable formula or diets, or frequent hospitalisation.
Appropriate and ongoing nutrition management is vital in providing optimal care and preventing further damage to the liver. The Children's Liver Disease Foundation has a useful guide for the nutrition of infants and children with liver disease.
Nutrition management
Nutrition management needs to be individualised and is dependent on the presenting liver disease and symptoms, whether it is acute or chronic and what concurrent medical management is required.
Sara Clarke, Senior Specialist Dietitian at Birmingham Children’s Hospital explains that dietetics are essential in the management of paediatric liver disease as there is the “added complication that the body has increased nutrient requirements associated with chronic disease and may be unable to absorb all the nutrients it needs from food.”
The role of a dietitian is to monitor the child, offer advice, track progress and take measurements of the child's weight, height, body fat and muscle development to assess whether the child is growing as they should. They can then advise on the optimal nutrition to promote growth, improves immunological status, and maximise the success of liver transplantation.
Feeding method
All infants should be encouraged to feed orally where possible, and solids should be introduced at 6 months and encouraged to support the development of the child's feeding skills. However if the cholestatic infant has poor oral uptake and are unable to meet their energy needs and maintain growth, feeding via a nasogastric (NG) tube is very effective, particularly if the child is too sick to eat. Although the parent may wish to continue to feed the child orally, NG feeding can overall reduce parental anxiety and increase the well-being of infants as their nutritional needs are consistently met.
Diet
Children with liver disease are prone to malnourishment, thus a high-calorie diet with energy intakes of 130-150% of normal energy intake is suggested. This can be maximised by including high-fat and high-carbohydrate foods, as well as additional regular snacks.
They are also likely have interrupted or absent bile flow (cholestasis) and malabsorb fat so a high-fat diet is recommended. Essential fatty acids (EFA) may need to be supplemented. In formula-fed infants this can be achieved using walnut oil. Older children can increase their EFA intake by adding canola, sunflower and soybean oils to their diets, as well as eating more fish and eggs. Oil adds calories and is easier to digest without bile than other types of fats.
Dietary supplements may also be required, particularly for the fat-soluble vitamins A, D, E and K to avoid deficiencies. Medium-chain triglyceride (MCT)-oil can also be added to foods, liquids or formula to help improve the absorption of nutrients. If infants refuse the formula, small amounts of flavouring such as vanilla essence or golden syrup can be used to initiate bottle-taking and reduced once the infant is feeding well.
When reaching adulthood, it would be advised for the affected person to not drink alcohol without consulting their dietitian or healthcare professional first.
Post liver transplant
Once a child has had a liver transplant they should re-discover their appetite and most can go back to a normal diet. This will involve making lower fat, lower calorie choices than before to prevent them from becoming overweight. Vitamin supplements may still be required as some medications used to prevent the body from rejecting the new liver can affect calcium and magnesium levels.
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