In September 2024, Rebecca Herrick took her son, Cash Macon, to get an ultrasound at Seattle Children’s Hospital. It was a routine appointment to check on the kidney disorder Cash, 14, had been born with.
After looking at Cash’s kidneys, the ultrasound tech – whom they hadn’t seen before – did something no one else had: She lingered around Cash’s liver with her ultrasound wand, taking more pictures. Then she stepped out to chat with the radiologist.
Later that day, a liver specialist broke the news: Cash had fatty liver disease.
“I was completely shocked,” Herrick says. “That’s not what we were there for.”
Cash had no unusual symptoms. “I didn’t feel bad in my body,” he recalls.
In fact, fatty liver disease – the kind unrelated to alcohol use – often goes unnoticed. Doctors call it metabolic dysfunction-associated steatotic liver disease, or MASLD. It happens when too much fat builds up in the liver. And it often has no symptoms at first.
The condition is on the rise, both in adults and in kids. Pediatricians are watching for it more vigilantly, especially when they see a child who might be at risk due to being very overweight or having diabetes.
“I’ve seen a lot of kids over the past few years as young as 2. Even yesterday, I saw a 6-year-old,” says Niviann Blondet, MD, a pediatric gastroenterologist and fatty liver expert at Children’s. “And their [liver enzyme] levels are in the hundreds, but normal for their age would be less than 30.”
If fatty liver disease goes unchecked, it can lead to serious conditions such as permanent liver scarring, liver failure, or even liver cancer. “If you’re already having these issues [as a child], it’s really, really hard to break the cycle once you get into adulthood,” Blondet warns.
As the diagnoses climb in numbers, experts advocate for more routine screening of children with risk factors, including obesity, prediabetes or diabetes, and family history of fatty liver disease. Doctors should also take it into account when kids come from Hispanic backgrounds, as they are several times more likely to have fatty liver disease. That may be due to higher rates of obesity and diabetes, which raises the risk of fatty liver, and higher rates of certain genes linked to the disease, notes Rohit Loomba, MD, a gastroenterologist and founding director of the MASLD Research Center at the University of California, San Diego.
In most cases, if MASLD is caught early, it can be reversed through diet and exercise. “We’re trying to capture them earlier and earlier,” Blondet says.
Reversing Fatty Liver Disease
After getting Cash’s diagnosis, Herrick, a patient care coordinator at a dental office near Tacoma, WA, immediately started researching MASLD (formerly called non-alcoholic fatty liver disease, or NAFLD). When she learned that the condition was reversible, she and Cash got to work. They hoped they could avoid further liver damage or potential surgery down the line.
After two months of flying blind, and half a dozen phone calls to see a specialist, Herrick finally managed to book an appointment with Blondet in November 2024.
“I’m so thankful that we got her. She is so amazing,” Herrick says, her voice wavering. “She drew every organ on a whiteboard and explained it in a way that [Cash] could understand.”
With Blondet’s help and the guidance of a nutrition specialist, they came up with a more concrete diet plan tailored to Cash.
It was a big undertaking, Herrick says. But she was determined to help Cash make healthy changes that would stick.
“Drastic” Changes
“He’s a 15-year-old-boy. Trying to change everything for a 15-year-old boy is, well … it was drastic. No more Doritos, no more Kool-Aid, no more Takis or doughnuts,” she says.
The trick, she adds, was finding ways to make healthy foods taste good and feel more exciting to eat. Cash also started exercising at home, and they changed his school schedule to get him in an elective walking class, where he and his classmates walk the school grounds and work to meet their step goals.
Cash rose to the challenge. “I just knew it was a thing we had to get out quickly so that it didn’t affect me later on,” he says matter-of-factly. Herrick adds admiringly, “This is how he is all the time.”
Diet and exercise are the best initial treatment for kids with MASLD. There are no fatty liver medications approved for use in children. Some popular drugs like GLP-1 agonists are approved for teens, but they are often expensive, and many of them aren’t covered by insurance if their purpose is to manage weight, says Blondet. Healthy lifestyle changes are safe in the long term, and they reduce other major health risks such as heart disease.
But when it comes to pediatric fatty liver, while diet may be the best defense, it’s certainly not easy.
First of all, a child can’t do it on their own. “You have to encompass the whole family,” Blondet says. “You have to have buy-in from everybody who takes care of the child if you want to be successful.”
In cultures where “food is love,” this can be a particular challenge. Blondet, who is Hispanic, remembers even her own mom having a certain level of “obesity denial” regarding their family. “What it took to change is that pediatricians had to convince my parents that this was not a healthy approach to life. And [more importantly], my brothers wanted to change. It clicked at some point,” she says. That ‘click’ looks different for each person, whether it’s bullying at school or simply not feeling good on the inside. When working with families from backgrounds where food is often used as a reward, Blondet counsels them on how to honor that culture while still keeping an eye on sugars and highly processed foods.
In San Diego, where there are big populations of high-risk kids, Loomba says, experts are working hard to raise awareness and reduce the disease. “We’ve followed a lot of patients over the last 20 years,” he says. “There are a lot of positive stories, but there are also a lot of missed opportunities in our community.”
When Healthy Food Is Out of Reach
For many families, getting healthy food is a big hurdle.
“It’s certainly challenging,” Loomba says. “The cheapest food available is fast food, but that can be particularly harmful. Food that’s high in trans fat or cholesterol can be very bad for the liver.” A parent who works full-time to feed their family, sometimes at multiple jobs, relies on food that saves time, adds Blondet, and that means a lot of processed, premade meals and snacks.
There’s also a unique stigma tied to weight-related care in kids, says Blondet, and it needs a delicate approach. Sometimes pediatricians even delay having the conversation with families whose kids appear to be at risk, she says, for fear that it will open an unnecessary can of worms.
“You don’t want to trigger an eating disorder when your goal is to get them healthier,” she says. “I don’t have the same conversation with a 12-year-old girl that I might have with a 17-year-old boy, for example.”
This is another reason screening for things like liver enzymes can be a really valuable tool in helping pediatric patients. “Your weight is just a number,” she says. “A lot of the anger comes when you focus too much on the weight and not necessarily on the disease. Once you have an elevated liver number or fasting glucose, you have something you can track. You say, ‘let’s focus on that.’”
Celebration and Relief
At Cash’s appointment last November, his alanine transaminase (ALT) – a liver enzyme used to detect liver damage – was at 80. The normal range would be between about 5 and 52.
Two months later, Cash had his first follow-up appointment. When his labs came back, Cash had curbed his ALT down to 67 – not normal yet, but their hard work was paying off. “It was impressive how quickly they were able to implement changes in such an effective way,” Blondet says. His numbers could be back in the normal range by his summer follow-up, Herrick says.
For the family, it was a day of celebration and relief. “It felt amazing when I heard that it was getting better,” Cash says.
With regular exercise, Cash has also lost over 30 pounds since September. He was always a big, tall kid, says Herrick, towering over his peers even in kindergarten. As he got older, other kids began to bully him for his larger frame. He started to become self-conscious of his size and withdrew to his room most days after school, Herrick remembers.
“I just wanted to be fit,” he says. Now he feels healthier, he says, and laughs as he says he needed a whole new wardrobe for Christmas.
Cash’s success shows that lifestyle changes – and hard work – can pay off. But each person’s journey will look different.
Obesity, and the conditions that often come with it, “is not really a choice,” Blondet says. It’s a result of many things, including genetics, metabolism, and access to healthy food and organized sports. “This is why it’s so important for whoever is taking care of these children to understand the complexity of the factors contributing to the disease and try to mitigate the ones that we can.”
Sometimes it comes down to helping families access available resources without demanding more from parents with tight budgets or packed schedules. Blondet sends lots of letters to schools, for example, to request special accommodations to prevent obesity-related issues. This might include making sure these kids get to go to PE every day or letting them bypass tryouts for certain sports teams.
The goal: Meet the child’s needs, so they’re set up for success.
New, Confident Mindset
Having a chance to thrive made all the difference for Cash.
“He’s changed,” Herrick says a teacher told her at a recent conference. “He’s found himself. He’s found his voice. He participates. He has built his self-confidence so much.”
In this new mindset, where he thinks carefully about his diet, Cash has also taken the wheel from a culinary standpoint. He experiments with cottage cheese, sourdough bread, and other healthy foods.
“You’re so good at concocting stuff,” Herrick tells him. It might even shape his future. Now 15, Cash sets his sights on the other side of the globe, where he wants to be a chef and a bartender at his own franchise of bars in Europe.
