From the Guidelines
Elevated ALT and AST in a 6-year-old child requires prompt evaluation by a pediatrician or pediatric gastroenterologist to rule out underlying liver disease, with a focus on non-alcoholic fatty liver disease (NAFLD), viral hepatitis, and other potential causes. The initial workup should include a comprehensive history focusing on medications, supplements, family history of liver disease, and symptoms like jaundice, abdominal pain, or fatigue 1. Physical examination should assess for hepatomegaly, jaundice, and growth parameters. Laboratory testing should include complete liver function tests, viral hepatitis serologies, autoimmune markers, ceruloplasmin (for Wilson's disease), alpha-1 antitrypsin levels, and metabolic screening 1.
Key Considerations
- Ultrasound of the liver is recommended to evaluate for structural abnormalities, steatosis, or signs of chronic liver disease 1.
- While awaiting results, the child should avoid hepatotoxic medications including acetaminophen.
- No specific medications are indicated until a diagnosis is established.
- Mild elevations (less than 2-3 times normal) may be monitored with repeat testing in 2-4 weeks, while more significant elevations warrant more urgent evaluation 1.
- Liver enzymes can be transiently elevated after viral illnesses or with certain medications, but persistent elevation requires thorough investigation to prevent progression of potential underlying liver disease.
Diagnostic Approach
- The most common causes of elevated ALT and AST in children include NAFLD, viral hepatitis, medication effects, autoimmune hepatitis, Wilson's disease, and alpha-1 antitrypsin deficiency 1.
- The AST:ALT ratio can help differentiate between alcohol-induced fatty liver disease and metabolic disease-related fatty liver, with a ratio generally >2 in alcohol-induced fatty liver disease and <1 in metabolic disease-related fatty liver 1.
- Viral hepatitis serologies and HBV DNA levels should be examined to confirm viral replication in children with continuously elevated ALT 1.
From the Research
ALT and AST Elevation in a 6-Year-Old
- The elevation of alanine aminotransferase (ALT) and aspartate aminotransferase (AST) in children can be due to various reasons, including liver disease, muscle injury, or other conditions 2, 3.
- A study published in 2022 found that isolated AST elevation in healthy pediatric patients may be associated with macro-AST (m-AST) and has a benign course 2.
- The same study found that 22% of patients with isolated AST elevation were m-AST positive, and 44% had borderline levels of m-AST 2.
- Another study published in 2013 discussed the differential diagnostic work-up of elevated serum transaminase levels in adults, highlighting the importance of considering liver damage, cardiac and skeletal muscle injury, and other conditions 3.
- The American Journal of Gastroenterology published a clinical guideline in 2017 for the evaluation of abnormal liver chemistries, including ALT and AST, which emphasizes the importance of considering the degree of elevation and the clinical setting 4.
- A study published in 2015 found that liver chemistry distributions, including ALT and AST, vary with age and gender in children, and require customized pediatric reference ranges 5.
- The study also found that the median ALT varied little with age, while the median and 97.5th percentile AST decreased with age, and the 97.5th percentile ALT increased with age in males 5.