Anorexia, malabsorption and metabolic derangements contribute to the malnutrition that occurs in most children with chronic liver
disease. Nutritional support should be started early in the management of these children with the co-operation of a paediatric dietitian to
improve quality of life and decrease post-transplant mortality.
Nutritional assessment entails a detailed dietary history, physical examination and anthropometry. Weight-based anthropometric
measures are unreliable while mid-upper-arm circumference and skinfold thickness provide more reliable estimates of nutritional status.
Special investigations such as serum vitamin levels and skeletal X-rays further guide management.
High energy (130 - 150% of recommended daily intake (RDI)) and protein (3 - 4 g/kg/day) intakes are recommended. Diets are usually
enriched with medium-chain fatty acids because of their better absorption in cholestatic liver disease. High-dose fat-soluble vitamin
supplements are given while care is taken to avoid toxicity. Initial doses are two to three times the RDI and then adjusted according to serum
levels or international normalised ratio (INR) in the case of vitamin K.
Children with good appetites are fed orally. Feeds should be more regular than for other children to avoid prolonged periods of fasting
and improve energy intake. Some children require supplementary nasogastric feeds to increase energy intake and avoid overnight fasting.