Reclassifying Paediatric NAFLD Under the SLD Framework: Hepatology | July 2026

Introduction:

The transition from non alcoholic fatty liver disease (NAFLD) to the steatotic liver disease (SLD) nomenclature has redefined metabolic dysfunction–associated steatotic liver disease (MASLD) as the principal subtype. While studies in adults have shown substantial overlap between NAFLD and MASLD, the applicability of this new framework in children has remained uncertain. This multicenter NASH CRN study evaluated how paediatric NAFLD patients are reclassified using the SLD framework.

Why was this study needed?

. The new SLD nomenclature has not been extensively validated in paediatric populations.

. Children with hepatic steatosis may have metabolic, medication-related, or alcohol-related contributors.

. Accurate classification is essential for diagnosis, research, and future clinical trials.

. Understanding reclassification patterns can improve individualized patient evaluation and management.

Results:

Among more than 1,000 children with biopsy-confirmed NAFLD enrolled in the NASH Clinical Research Network, 84% fulfilled the diagnostic criteria for MASLD. Most children had multiple cardiometabolic risk factors, highlighting the central role of metabolic dysfunction in paediatric steatotic liver disease. However, the updated SLD framework reclassified nearly 1 in 6 patients into alternative categories. A small but clinically relevant proportion met criteria for Met-ALD, with prevalence increasing during adolescence, while others were reclassified as having drug-induced steatotic liver disease because of hepatotoxic medication exposure. These findings demonstrate that relying solely on a historical diagnosis of NAFLD may overlook important etiologic contributors.

Clinical Impact:

The SLD framework encourages a more comprehensive evaluation of paediatric steatotic liver disease by systematically assessing metabolic risk factors, alcohol exposure, and medication history. Adoption of this classification may improve diagnostic accuracy, facilitate more appropriate counseling and management, and standardize patient selection for future paediatric MASLD research and therapeutic trials.

Bottom Line:

Most children previously diagnosed with NAFLD are reclassified as MASLD, but the new SLD framework identifies a significant minority with Met-ALD or drug-induced steatotic liver disease, supporting a more comprehensive etiologic assessment in paediatric practice.