Metabolic dysfunction-associated steatotic liver disease (MASLD), previously called non-alcoholic fatty liver disease, has emerged as the most common chronic liver disease in children and adolescents. This is happening in parallel to the global rise in paediatric obesity. Prevalence estimates are 13% in the general population and 47% among children with obesity, with higher rates observed in certain ethnic groups and in males. MASLD is often silent in early stages but may progress to steatohepatitis, fibrosis, cirrhosis and liver failure in a subset of patients. The pathophysiology of MASLD is multifactorial, involving excess calorie intake, insulin resistance and altered lipid metabolism. Genetic variants, particularly in,andinfluence disease susceptibility and disease severity, with some increasing the risk while others exhibiting a protective effect. The gut-liver axis, through mechanisms like increased intestinal permeability and dysbiosis, also contributes to hepatic fat accumulation and inflammation. The natural history of MASLD in children is variable. Some children may remain in remission while others may progress to advanced liver disease. Management is centred on lifestyle modification. A balanced, calorie-controlled diet, particularly a Mediterranean diet, has been shown to be beneficial in children and adolescents with MASLD, along with regular physical activity. Weight loss has been associated with histological improvement. Role of pharmacotherapy remains limited in the management of MASLD. Interventions like vitamin E, omega-3 fatty acids and GLP-1 receptor agonists are being explored in clinical trials with positive results. This narrative review is timely and relevant, as the growing burden of MASLD in children and adolescents calls for greater awareness and updated knowledge among clinicians and researchers. Despite notable progress in understanding the condition, important gaps remain regarding its natural history, early identification, and effective therapeutic options in the younger population. By bringing together current evidence and highlighting these areas of uncertainty, this review aims to support ongoing research and inform more age-appropriate approaches to care. PNPLA3TM6SF2, GCKR, MBOAT7HSD17B13
