As malnutrition is inevitable in 60% of children with end-stage liver disease, reversal of malnutrition is one of the key aims of liver transplantation. Although good catch-up growth may be achieved in the majority of survivors, persistent growth failure has been noted in 15% to 20% of children. The origin of posttransplant growth failure is complex. It is related to the degree of preoperative malnutrition because children who are severely stunted (height SDS <-1) pretransplant never achieve completely normal growth. Glucocorticoid administration is clearly a major factor because good catch-up growth is achieved on alternate-day steroid regimes or when steroids are discontinued. Significant hepatic dysfunction such as chronic rejection or the development of lymphoproliferative disease that requires alteration in immunosuppressive regimes or prolonged hospitalization may also inhibit linear growth. A less well recognized factor is the development of behavioral feeding problems either before or after transplantation, which reduces adequate oral intake and may be a significant cause of growth failure long term. Important strategies to prevent posttransplant growth failure include early referral for liver transplantation before the development of malnutrition, a multidisciplinary approach to pre- and postoperative nutritional intervention, and the early withdrawal of steroid therapy after transplantation.
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