MASLD in Children and Adolescents: Journal of Hepatology | March 2026

Introduction

Pediatric metabolic dysfunction-associated steatotic liver disease is increasingly recognized as one of the most important chronic liver diseases in children and adolescents, paralleling the global rise in obesity and metabolic dysfunction. This review highlights that MASLD in youth is not a benign condition, but a multisystem disease associated with early metabolic comorbidities, progression of liver fibrosis, and clinically meaningful liver-related outcomes in young adulthood. The article is particularly valuable because it brings together recent advances in epidemiology, genetics, natural history, non-invasive risk stratification, and therapeutic approaches, while also addressing the unique challenges of diagnosing and managing MASLD in children.

Summary

The review emphasizes that pediatric MASLD is rising worldwide, with the highest burden reported in the Middle East and North Africa, and that boys are affected more often than girls. The disease is strongly linked to obesity, insulin resistance, and early-life exposures such as maternal obesity, unhealthy diet, and metabolic programming in utero. The strongest genetic risk factor remains the PNPLA3 variant, although the overall genetic architecture appears broadly similar to that in adults. Importantly, pediatric MASLD is not simply a smaller version of adult disease, because children often display a portal-dominant pattern of injury, which may be linked to progression and advanced fibrosis.

A major clinical message of this review is that pediatric MASLD should be approached as a multisystem disorder rather than an isolated liver condition. It is associated with increased risk of youth-onset type 2 diabetes, cardiovascular risk factors, renal impairment, and major adverse liver outcomes in early adulthood. Because liver biopsy is not practical for most children and existing adult fibrosis scores perform poorly in pediatrics, the article highlights the need for pediatric-specific non-invasive tests and proposes a pragmatic risk-stratified clinical framework. In terms of treatment, the authors strongly reinforce that multidisciplinary lifestyle intervention remains the foundation of care, while emerging signals from semaglutide, bariatric surgery, and intensive weight-loss programs suggest that meaningful liver improvement is possible. However, dedicated pediatric drug trials are urgently needed before pharmacologic treatment can be confidently recommended for liver-specific benefit.