Pediatric MASLD in Severe Obesity: Current Clinical Perspectives on Diagnosis and Treatment.

Background: Metabolic dysfunction-associated steatotic liver disease (MASLD) is now one of the most common chronic liver diseases in children and closely parallels the rising prevalence of severe pediatric obesity. Methods: This review synthesizes current evidence (2019-2025) and landmark studies on the diagnosis and management of pediatric MASLD, integrating contemporary guidelines and future directions. Results: Based on current data, we propose practical algorithms for screening and management of pediatric MASLD. Screening with alanine aminotransferase (ALT) as the initial test should be initiated in all children aged 9-11 years with obesity, in those who are overweight with additional risk factors, and in children with severe obesity or a family history of MASLD. Non-invasive imaging techniques show important limitations in children with increased amount of subcutaneous tissue requiring cautious interpretation. Lifestyle modification remains the cornerstone of therapy, while pharmacological treatments are investigational. In adolescents with severe obesity and significant comorbidities, bariatric surgery represents an effective therapeutic option with durable metabolic effects. Conclusions: Early identification of high-risk children, especially those with severe obesity, and implementation of multidisciplinary management are essential to prevent MASLD progression. Refinement of screening strategies and development of validated non-invasive biomarkers remain key priorities for future pediatric care.