Title: Breastmilk and medium-chain triglyceride supplementation: retrospective study on outcomes in biliary atresia infants after Kasai  

Source: Journal of Pediatric Gastroenterology and Nutrition 2026, Feb 23. [E–publication]

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Date of publication: February 2026  

Publication type: Retrospective study

Abstract: Objective: To relate post-surgical feeding regimens to growth and surgical outcomes in children with biliary atresia (BA) after hepato-portoenterostomy (Kasai).

Methods: Retrospectively, all children with BA from Denmark and the Netherlands who underwent Kasai from 2014 to 2022 were included. The effect of breastmilk intake on anthropometry after Kasai was evaluated using jointed modeling of longitudinal and survival data, removing children from the analysis at transplantation. Mixed linear models were used to assess surgical outcomes in relation to breastmilk intake and anthropometry in relation to medium-chain triglycerides (MCT) intake, adjusted for calorie intake.

Results: We included 116 children. After Kasai, breastmilk with MCT supplementation was received in 22% for at least 1 month, 9% for 1 week, and 68% did not receive breastmilk. Those receiving breastmilk after Kasai had stable length-for-age z-score (LAZ) over 12 months whereas LAZ decreased in infants without breastmilk feeding (-0.48; 95% confidence interval [CI] 0.24, 0.72). Infants receiving breastmilk for at least 1 month had lower total bilirubin at 3 months (79 vs. 116 µmol/L, p = 0.028) and a lower incidence of cholangitis compared with infants not receiving breastmilk after Kasai. Of those only receiving formula after Kasai, 4% received <40% MCT, 72% received 40-59% MCT and 24% received ≥60% MCT. LAZ was lower in children with MCT intake <40% than in children with MCT intake ≥40%.

Conclusion: Feeding regimens in children with BA after Kasai are related to growth and surgical outcomes. Further studies with infants randomized to receive breast milk and to different MCT levels are needed.

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Title: The impact of the mediterranean diet, physical activity, and nutrition education on pediatric metabolic dysfunction-associated steatotic liver disease (MASLD): a review

Source: Nutrients 2025, 18 (1): 28  

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Date of publication: December 2025

Publication type: Review article 

Abstract: Background/Objectives: Metabolic dysfunction-associated steatotic liver disease (MASLD) is now the most prevalent chronic liver disorder among children and adolescents, mirroring the rise in pediatric obesity. The Mediterranean diet (MD) has demonstrated anti-inflammatory, antioxidant, and beneficial effects on different health outcomes across different life stages. The MD’s effect has been explored in adult MASLD, but there is limited information on the pediatric population. However, evidence on pediatric MASLD should be explored given its rising prevalence. Therefore, the aim of this review is to collect human studies assessing the effect of MD interventions on pediatric MASLD, focusing on key pathophysiological mechanisms. It also examines other interventions, including specific energy/macronutrient prescriptions, nutrition education or counseling, and physical activity components.

Methods: A comprehensive search of PubMed, Scopus, and Web of Science was conducted using terms related to the Mediterranean diet, nutrition education, physical activity, pediatrics, and MASLD/NAFLD. Pre-determined inclusion and exclusion criteria were used to collect eligible studies to be included in the review. Study quality was assessed using the Academy of Nutrition and Dietetics Quality Criteria Checklist. Screening, data extraction, and appraisal were performed independently, with discrepancies resolved through discussion, and the findings were synthesized qualitatively.

Results: This review synthesizes findings from eight human studies evaluating the impact of the MD, alone or integrated with structured exercise and nutrition education, on pediatric MASLD. Interventions consistently demonstrated reductions in hepatic steatosis, liver stiffness, and fibrosis markers, alongside improvements in inflammatory cytokines, oxidative stress defenses, and liver enzymes. The MD also enhanced lipid and glycemic profiles, lowering triglycerides, total cholesterol, and insulin resistance indices. Nutrition education and family-centered approaches improved adherence, while structured, enjoyable physical activity enhanced outcomes and long-term sustainability.

Conclusions: Collectively, the MD, particularly when combined with exercise and tailored education, offers a safe, effective, and comprehensive lifestyle intervention for pediatric MASLD. Nonetheless, current evidence remains limited by small sample sizes, heterogeneity in protocols, and short follow-ups. Larger, multicenter randomized trials with standardized designs are needed to establish best practices and long-term efficacy.

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Title: Nutrition support adequacy in children with biliary atresia after liver transplant  

Source: Nutrients 2025, 18 (1): 133  

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Date of publication: December 2025 

Publication type: Retrospective cohort study 

Abstract: Background: The nutrition support of children with biliary atresia after liver transplant is affected by multiple factors, and a connection between these factors and conditions present before transplant can potentially make the nutrition support more challenging. We aim to assess the adequacy of nutrition support, specifically energy and protein, during the first week of admission to the Pediatric Intensive Care Unit (PICU) in children after liver transplant secondary to biliary atresia. 

Methods: We performed a retrospective cohort study of 138 patients [13.9 median (9-33.4) IQR months; 62% female] with a diagnosis of biliary atresia admitted to the PICU after liver transplantation at Texas Children’s Hospital over a 14-year study period. We obtained nutrition adequacy of enteral and parenteral nutrition support for the first week after transplant during their PICU admission. 

Results: Goal adequacy was reached at the end of the first week of admission when combined enteral and parenteral nutrition support was provided (median 98% for energy and 101% for protein). Infants achieved significantly higher adequacies than older children during the first week (136% < 1 year vs. 0% > 1 year, p < 0.001 for calories, and 157% < 1 year vs. 0% > 1 year for protein; p < 0.01). 

Conclusions: These findings highlight the complex nutritional challenges faced by this population, and strategies are needed to meet the unique needs of children after liver transplantation.

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Title: Early-life nutritional determinants of pediatric MASLD

Source: Nutrients 2025, 17 (24): 3871

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Date of publication: December 2025  

Publication type: Review article

Abstract: Metabolic dysfunction-associated steatotic liver disease (MASLD) is the most prevalent chronic liver disorder in both children and adults. Pediatric MASLD, however, is not simply an early form of adult disease, as it exhibits distinct developmental, histological, and metabolic features. Emerging evidence suggests that these characteristics arise from a complex, multi-hit continuum that begins in utero. Maternal obesity, gestational diabetes, and poor diet quality during pregnancy have been associated with greater hepatic steatosis in offspring, raising the possibility that intrauterine exposure to dyslipidemia, hyperglycemia, and elevated free fatty acid flux may contribute to early hepatic lipid deposition. After birth, feeding behaviors such as a prolonged breastfeeding appear protective, whereas formula feeding, especially high added-sugar formulations, may accelerate rapid weight gain and increase susceptibility to later steatosis. Early childhood diets high in added sugars, saturated fats, and ultra-processed foods may further promote hepatic lipogenesis and inflammation and interact with underlying genetic susceptibility. Given the heterogeneity of available human cohort studies and mechanistic model systems, this narrative review summarizes converging evidence from prenatal, postnatal, and early childhood nutritional exposures and their relationship to offspring hepatic lipid accumulation, emphasizing early-life windows for intervention to reduce the burden of pediatric MASLD.

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Title: Nutritional considerations for children with liver disease  

Source: Gastroenterology Clinics of North America 2025, 54 (4): 891-905

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Date of publication: November 2025

Publication type: Review article  

Abstract: Childhood is an essential period for growth and development during which time chronic liver disease can have compounding negative effects on patient health. Aggressive screening and nutritional intervention strategies are key for improving patient outcomes and should involve a multidisciplinary approach with support from a skilled dietitian.

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Title: Nutritional management for pediatric biliary atresia patients preparing for liver transplantation

Source: Children (Basel) 2025, 12 (3): 391

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Date of publication: March 2025  

Publication type: Article

Abstract: Biliary atresia, a rare pediatric liver condition, results in blocked bile ducts, impeding bile secretion and causing significant nutritional challenges. This perspective emphasizes the critical role of nutrition in supporting children with biliary atresia awaiting liver transplantation. The liver’s multifaceted functions in energy metabolism, vitamin storage, and waste excretion emphasize the importance of tailored dietary interventions. Medium-chain triglyceride (MCT) oil serves as a crucial energy source, addressing fat malabsorption, while specialized water-soluble formulations deliver essential fat-soluble vitamins. Additionally, weaning strategies and developmental food practices are discussed to ensure optimal growth and development despite dietary restrictions. Feeding assistance through nasogastric or gastrostomy tubes is explored as a means to combat malnutrition and support liver function. The collective efforts of caregivers and healthcare providers are pivotal in preparing these children for successful liver transplantation, aiming to secure their future health and quality of life.

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Title: Medium-chain triglyceride supplementation and the association with growth, nutritional status and clinical outcomes in infants with biliary atresia

Source: Clinical Nutrition 2025, 44: 134-146

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Date of publication: January 2025

Publication type: Article

Abstract: Background and aims: Infants with biliary atresia experience gastrointestinal malabsorption of long-chain triglycerides and are commonly supplemented with medium-chain triglyceride (MCTs) that can be passively absorbed. The aim was to investigate the association of MCT supplementation with growth, nutritional status and clinical outcomes in infants with biliary atresia.

Methods: Infants who underwent Kasai portoenterostomy and were followed up for at least two years or until death or transplantation were reviewed. Infants with comorbidities affecting growth or outcome were excluded. Data were extracted from medical records from more than a decade in relation to MCT supplementation, growth, nutritional status and clinical outcome at baseline, 6-weeks, 3-, 6-, 12- and 24-months. Mixed-effects modelling was used to test associations of MCT in the first six months with these outcomes.

Results: Of 200 infants (108 male), 108 (54 %) were alive with native liver at two years, 84 (42 %) underwent liver transplantation and eight (4 %) died. MCT percentage prescribed was mean 57.3 % (SD 11.2) while MCT intake was median 2.7 (IQR 2.2, 3.8) g/kg/d. For every g/kg/d MCT consumed, the rate of change in z-score for weight was -0.27 (95 % CI -0.37 to -0.17) and length was -0.31 (-0.42 to -0.17) (both p < 0.001). Compared to the low MCT group (<2.7 g/kg/d), the high group (≥2.7 g/kg/d) consumed more energy (118 vs. 108 kcal/kg; p < 0.001), however, at 3-months they had lower weight (-1.7 (1.2) v. -1.0 (1.2) and length (-1.3 (1.1) v. -0.6 (1.4) z-scores (both p < 0.001) but no differences in growth at later time points. There was no overall association between MCT and nutritional status or clinical outcomes.

Conclusions: This is the first study to investigate the association of MCT with growth, nutritional status and clinical outcomes in biliary atresia. No association was found between MCT with growth beyond 3-months, overall nutritional status or clinical outcomes. The association between MCT (g/kg/d) and poorer growth in the first 3-months may be explained by infants with poorer growth drinking more or being prescribed more MCT formula milk. A randomised controlled trial could help to better understand this association.

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Title: Efficacy of the Mediterranean diet in treating metabolic dysfunction-associated steatotic liver disease (MASLD) in children and adolescents: a systematic review and meta-analysis

Source: BMC Public Health 2024, 24 (1): 2701

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Date of publication: October 2024

Publication type: Systematic review and meta analysis  

Abstract: Background: There are limited treatment options for metabolic dysfunction-associated steatotic liver disease (MASLD), formerly known as non-alcoholic Fatty Liver Disease (MASLD) in children and adolescents.

Aim: To evaluate the effectiveness of the Mediterranean diet in improving liver function in children and adolescents with MASLD.

Methods: In this systematic review and meta-analysis, we searched PubMed, Scopus, Embase, CINAHL, and Cochrane CENTRAL for interventional studies investigating the effect of Mediterranean diet on MASLD in children and adolescents. The primary outcome was a change in liver function measured using these liver enzymes; Alanine Transaminase (ALT), Aspartate Transaminase (AST) and Gamma-glutamyl transferase (GGT). The secondary outcomes were lipid profile, body weight, and insulin resistance. The risk of bias was assessed using the MASTER scale. Bias-adjusted inverse variance heterogeneity models were used to synthesize overall weighted mean differences for the treatment effect (WMD) and their 95% confidence intervals. Heterogeneity and publication bias were evaluated using the I² statistics, Tau-squared and Doi plots, respectively.

Result: Out of 5915 study records identified from database searches, five studies with 308 participants, two randomized controlled trials, and three quasi-experimental studies, met the inclusion criteria. In overall synthesis, the Mediterranean diet was associated with moderate improvements in liver function as shown by reductions in the liver enzymes [ALT – WMD – 10.85 U/L, 95% CI -20.03 to -1.68, I² = 42, T² = 38.8, AST – WMD – 9.26 U/L, 95% CI -17.14 to -1.38, I² = 70.7, T² = 42.7, and GGT – WMD – 1.99 95% CI -5.09 to 1.11)], but changes in body weight, lipid profile and insulin resistance were small and insignificant.

Conclusion: The Mediterranean diet may improve liver function in children with MASLD. More randomized controlled trials are needed to develop high-certainty evidence on these findings.

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Title: Transplant-acquired food allergy in children

Source: Nutrients 2024, 16 (18): 3201

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Date of publication: September 2024

Publication type: Review article

Abstract: Background: Organ transplantation in children is a vital procedure for those with end-stage organ failure, but it has been linked to the development of post-transplant allergies, especially food allergies. This phenomenon, known as transplant-acquired food allergy (TAFA), is becoming increasingly recognized, though its mechanisms remain under investigation. Pediatric transplant recipients often require lifelong immunosuppressive therapy to prevent graft rejection, which can alter immune function and heighten the risk of allergic reactions. Our review aimed to gather the latest evidence on TAFA.

Methods: We conducted a PubMed search from 25 June to 5 July 2024, using specific search terms, identifying 143 articles. After screening, 36 studies were included: 24 retrospective studies, 1 prospective study, 2 cross-sectional researches, and 9 case reports/series.

Results: Most studies focused on liver transplants in children. The prevalence of food allergies ranged from 3.3% to 54.3%. Tacrolimus, alongside corticosteroids, was the most commonly used immunosuppressive therapy. In addition to food allergies, some patients developed atopic dermatitis, asthma, and rhinitis. Allergic symptoms typically emerged within a year post-transplant, with common allergens including milk, eggs, fish, nuts, soy, wheat, and shellfish. Both IgE-mediated and non-IgE-mediated reactions were observed, with treatment often involving the removal of offending foods and the use of adrenaline when necessary.

Conclusions: Consistent immunological monitoring, such as skin prick tests and IgE level assessments, is essential for early detection and management of allergies in these patients. Understanding the link between transplantation and allergy development is crucial for improving long-term outcomes for pediatric transplant recipients.

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Title: Nutrition in pediatric end-stage liver disease

Source: Current Opinion in Clinical Nutrition and Metabolic Care 2024, Sep 12. [E–publication]

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Date of publication: September 2024

Publication type: Review article  

Abstract: Purpose of the review: The aim of this review is to outline recent studies relating to nutritional status and outcomes in pediatric end-stage liver disease.

Main findings: Pediatric patients with chronic and end-stage liver disease are at high risk of malnutrition. Given additional growth demands in children and the inherent complications of chronic liver disease, achieving adequate nutrition in these patients remains a challenge. In addition, while guidelines on nutrition in chronic liver disease exist, global approaches and definitions of malnutrition vary. Recent literature has focused on sarcopenia and nutrition-related transplant outcomes, with some studies exploring nutritional assessment and management. Pediatric studies however continue to lag adult research, with limited prospective and interventional studies.

Summary: Optimizing nutrition in pediatric end-stage liver disease remains a challenge, however understanding of the mechanisms and clinical manifestations of malnutrition in this population is improving. Despite these efforts, high quality studies to determine optimal nutrition strategies and interventions are lacking behind adult evidence and should be the focus of future research.

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