Within the last 60 years, pediatric hepatology has seen many advances in improvement in timely diagnosis and management of chronic liver disease and also in liver transplantation. Growth failure and malnutrition have always been important factors in the treatment of children with liver disease, specifically cholestatic liver diseases. The liver has a central function in nutrient metabolism, and the abnormalities seen in chronic liver disease result in nutritional and metabolic deficiencies. Nutritional needs are dependent on the type of liver disease, age of the patient, and whether the disease is acute or chronic. In the setting of acute liver disease, such as acute viral hepatitis, malnutrition is unusual; however, in fulminant liver failure, nutritional modifications are needed to manage hepatic encephalopathy. Chronic liver disease may be cholestatic or noncholestatic and in most instances is associated with malnutrition. Cholestatic injury to the liver reflects a diverse group of diseases, resulting from biliary obstruction, disorders of bile synthesis or transport, metabolic and endocrine disorders, infections, and toxic effects. The most common is biliary atresia, occurring in approximately 1 of 10,000 live births; it is the most common indication for liver transplantation in children. Patients have relatively progressive hepatic disease and, often, poor nutritional status, making preoperative management of malnutrition a challenge. Malnutrition is a negative prognostic indicator of overall survival, and the inability to improve nutritional status before surgery increases the risk of postoperative complications and mortality. Adequate nutrition allows for growth, improved immunologic status, and improved transplantation outcomes. Nutritional status in the setting of liver disease can be difficult to assess.Weight alone is not a sufficient marker for nutritional status, especially if the patient has ascites or organomegaly: fluid retention and a disproportionately large organ may result in substantial weight gain, whereas the overall nutritional status is actually poor. The ascites and organomegaly, as well as portal hypertension, can also contribute to poor oral tolerance, furthering the failure to gain appropriate weight for age and preventing the often needed catch-up weight gain. Although serial abdominal circumference measurement may aid in determining whether weight gain is secondary to ascites, it is an imprecise way of differentiating true weight gain from fluid gain. More accurate measures include triceps skinfolds and middle upper arm circumferencemeasurements, with standards for age available from the World Health Organization. These measurements, however, require calipers and training in proper technique. Peripheral edema is a potential cause of overestimation of both measures and if present needs to be considered. Both the child’s age and the specific disease affecting the liver contribute to the issues of nutrition and growth facing each patient. Assessment and support are key components of effective care, which is best performed by a team of physicians AUTHOR DISCLOSURE Drs Cameron and Kogan-Liberman have disclosed no financial relationships relevant to this article. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.