Title: Global and regional prevalence, burden, and risk factors for MASLD in children and adolescents aged 5 to 24 years: a systematic review, meta-analysis, and modeling study  

Source: BMC Medicine 2026, Mar 18. [E–publication]

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Date of publication: March 2026

Publication type: Systematic review and meta analysis 

Abstract: Background: Obesity is associated with metabolic dysfunction-associated steatotic liver disease (MASLD). Despite the rising prevalence of obesity among children and adolescents, no studies have examined risk factors or developed models to estimate MASLD burden by sex, age group, or geographic location.

Objective: To estimate and predict the distribution and shifting patterns of the burden of MASLD in children and adolescents aged 5 to 24 years, globally, regionally, and in China.

Methods: We systematically searched PubMed, EMBASE, Web of Science, Cochrane, and CNKI for studies reporting the prevalence of MASLD and its closely related diagnostic constructs, including metabolic dysfunction-associated fatty liver disease (MAFLD) and non-alcoholic fatty liver disease (NAFLD), in 5-24-year-olds, and synthesized evidence across these definitions to estimate the burden of MASLD. Random-effects meta-regression synthesized age-, sex-, and year-specific prevalence and risk factors. Additionally, using data from the Global Burden of Disease, World Population Prospects, and Chinese National Survey on Students’ Constitution and Health, a risk factor-based model estimated global, regional, and provincial (China) MASLD burden. The protocol was registered in PROSPERO (CRD420251062351).

Results: Of 2747 records, 56 studies (54 English, 2 Chinese) were included; 37 informed prevalence and 38 informed risk factors. Our model indicated that the global MASLD prevalence among 5-24-year-olds was 7.0% (95% CI: 4.1, 11.7), increasing with age and year, and higher in boys. Asia had the largest number of cases in 2000 (63.8 million [51.5, 76.6]) and 2020 (160.9 million [134.5, 187.6]). Our model further indicated that Africa is projected to surpass Asia in total case numbers from 2040 onward. In China, MASLD prevalence among 6-18-year-olds was highest in Hebei, Shandong, and Beijing (2000) and in Tianjin, Shandong, and Heilongjiang (from 2020 onwards).

Conclusions: The prevalence of MASLD among children and adolescents continues to rise alongside the epidemic of obesity. Model-based estimates suggest that the burden of MASLD may shift over time towards currently less developed regions of the world, such as Africa, and less well-developed regions in China. Targeted investment in obesity prevention is urgently needed, as are health services to reduce the health impacts of MASLD during and beyond childhood and adolescence. 

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Title: Fructose-induced hepatic steatosis in non-obese children: a comprehensive review

Source: Nutrition and Health 2026, Mar 18. [E–publication]

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Date of publication: March 2026

Publication type: Review article

Abstract: Background/Objectives: Dietary fructose intake has increased markedly in Western countries, leading to an increase of children with a normal weight suffering from non-alcoholic fatty liver disease. The aim of this study is to examine current knowledge of the association between fructose consumption and hepatic steatosis in non-obese, non-diabetic children and adolescents and raise awareness of a well-known disease in a new cohort of paediatric patients.

Methods: This was a narrative literature review with systematic search elements. A literature search of PubMed, MEDLINE, EMBASE, Cochrane Library and Scopus was conducted with the final search completed on 21 September 2024. Eligible studies were peer-reviewed clinical or translational studies (including relevant animal models) reporting hepatic outcomes in paediatric populations without obesity or diabetes.

Results: Thirteen studies met inclusion criteria including experimental (n = 2) and observational (n = 4) studies and reviews (n = 4). Those studies demonstrated that high fructose intake promotes hepatic lipid accumulation via unregulated hepatic fructose metabolism, increased de novo lipogenesis, impaired VLDL secretion, oxidative stress and gut-derived inflammation.

Conclusion: Fructose-associated hepatic steatosis is a clinically relevant phenomenon in children without obesity or metabolic syndrome without symptoms, so paediatricians need to screen their patients for it. This review highlights mechanistic distinctions between fructose and glucose metabolism, discusses the complexity of clinical trials, which explains the current gap in literature, and it underscores the role of misleading health marketing and opaque food labelling in exacerbating this risk. It emphasises the need for targeted preventive strategies and clearer food labelling to reduce hidden fructose exposure in youth.

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Title: Menstrual dysfunction is associated with elevated liver enzymes in adolescent females: a United States population-based study 

Source: Journal of Adolescent Health 2026, 78 (4): 633-638

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Date of publication: March 2026 

Publication type: Population-Based Study

Abstract: Purpose: Polycystic ovary syndrome and metabolic dysfunction-associated steatotic liver disease (MASLD) both emerge during adolescence; however, it remains unknown whether menstrual abnormalities and hyperandrogenism signals increased hepatic risk.

Methods: We analyzed 2011-2020 National Health and Nutrition Examination Survey data for 1,651 females aged 12-19 years in the United States who were at least 2 years postmenarche. Amenorrhea was defined as self-reported absence of menses in the past 12 months. Biochemical hyperandrogenism was defined as free androgen index ≥5. Elevated alanine aminotransferase (ALT; >22 U/L) was the primary hepatic outcome; suspected MASLD was defined as elevated ALT plus ≥1 cardiometabolic risk factor. Survey-weighted logistic regression models adjusted for age, race and ethnicity, and body mass index (BMI) percentile.

Results: Amenorrhea was reported by 2.8% of participants and was associated with higher odds of elevated ALT (adjusted odds ratio 2.5, 95% confidence interval 1.1-5.7). Biochemical hyperandrogenism was also associated with elevated ALT (adjusted odds ratio 2.6, 95% confidence interval 1.4-4.8). The positive association between insulin resistance and ALT was stronger among adolescents with amenorrhea (β = 2.7 vs. 1.1). Although ALT levels rose with increasing BMI, adolescents with amenorrhea had consistently higher ALT prevalence, including those with a normal BMI.

Discussion: Amenorrhea and hyperandrogenism, hallmark features of polycystic ovary syndrome, are independently associated with elevated ALT and suspected MASLD in adolescent females. These findings support ALT screening for youth with menstrual dysfunction, even in the absence of obesity, to enable earlier detection and more integrated endocrine-hepatic care. 

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Title: Liver function indicators as risk factors of pediatric metabolic (dysfunction)-associated fatty liver disease: a systematic review and meta-analysis  

Source: Translational Pediatrics 2026, 15 (2): 49 

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Date of publication: February 2026 

Publication type: Systematic review and meta-analysis

Abstract: Background: Metabolic (dysfunction)-associated fatty liver disease (MAFLD) is the most common chronic liver disorder in children and adolescents, with its prevalence rising alongside the global childhood obesity epidemic. Liver function indicators offer a potential non-invasive screening alternative, but existing evidence on their association with pediatric MAFLD is inconsistent due to heterogeneous study designs and populations. Therefore, this systematic review and meta-analysis aimed to synthesize global evidence to definitively evaluate liver function indicators as risk factors for MAFLD in children and adolescents.

Methods: Four databases-The Cochrane Library, Embase, Web of Science, and PubMed-were searched from inception to July 5, 2025. The eligible studies were observational in design and focused on children and adolescents (<18 years), comparing MAFLD prevalence/risk between those with abnormal versus normal liver function indicators. Two independent researchers performed literature screening, information collection, and quality evaluation per the eligibility criteria. The ‘meta’ package in R was adopted to compute the odds ratio (OR) and corresponding 95% confidence interval (CI) for the association between liver function indicators and MAFLD. Heterogeneity and publication bias were also assessed.

Results: This meta-analysis incorporated 27 studies, involving 3,237 confirmed MAFLD cases. Levels of alanine aminotransferase (ALT) [OR (95% CI): 1.15 (1.01, 1.30)], gamma-glutamyl transferase (GGT) [1.30 (1.09, 1.56)], and high-density lipoprotein (HDL) [0.97 (0.96, 0.98)] were associated with MAFLD risk. Elevated ALT [OR (95% CI): 20.63 (2.39, 178.09)], total cholesterol (TC) [3.36 (1.15, 9.82)], triglycerides (TG) [4.86 (2.37, 9.98)], low-density lipoprotein (LDL) [3.74 (1.15, 12.19)], and decreased HDL [2.77 (1.97, 3.91)] were identified as potential risk factors for MAFLD in children and adolescents. Overall, subgroup analyses (by confounder adjustment status and study design), sensitivity analyses, and meta-regression did not identify potential sources of heterogeneity. No significant publication bias was observed.

Conclusions: Liver function indicators show promise as screening tools for the early detection of MAFLD susceptibility. This study has several limitations, including a small number of included studies, resulting in heterogeneity, as well as the inherent risk of bias (ROB) in observational designs and the imprecision of some results.

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Title: Assessment of non-invasive fibrosis scoring systems in pediatric MASLD: a retrospective comparison across healthy, MASLD, and biopsy-staged groups 

Source: Clinica Chimica Acta 2026, Apr 15. [E–publication]

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Date of publication: March 2026 

Publication type: Retrospective review

Abstract: Background: Metabolic dysfunction-associated steatotic liver disease (MASLD) is increasingly recognized in pediatric populations due to rising rates of obesity and insulin resistance. Non-invasive indices such as FIB-4, APRI, and the AST/ALT ratio are commonly used to estimate liver fibrosis risk in adults, but their diagnostic performance in children remains unclear. This study evaluated the utility and limitations of FIB-4, APRI, and AST/ALT ratio in identifying hepatic injury among children with and without suspected MASLD and assessed their correlation with biopsy or elastography-confirmed fibrosis.

Methods: A retrospective review was conducted on 788 pediatric patients at Texas Children’s Hospital between 2020 and 2025, divided into three groups: healthy controls (n = 191), children with suspected MASLD (n = 565), and patients with biopsy- or elastography-confirmed fibrosis (n = 32). FIB-4, APRI, and AST/ALT ratio were calculated using standard formulas. Score distributions were analyzed across groups and stratified by metabolic risk factors such as BMI and diabetes mellitus (DM).

Results: Children with suspected MASLD showed significantly higher FIB-4 values than healthy controls (p < 0.001). Median FIB-4 was 0.22 in MASLD vs. 0.19 in controls; the 90th percentile reached 0.65 vs. 0.35 respectively. Diabetic MASLD children had further elevation (median: 0.28) compared to non-diabetics (0.18; p < 0.05), with pre-diabetics showing intermediate values. In biopsy-confirmed MASLD, FIB-4 did not distinguish between early (stage ≤2) and advanced fibrosis (stage ≥3); all values remained below adult high-risk thresholds.

Conclusion: FIB-4, APRI, and AST/ALT ratio can differentiate children with suspected MASLD from healthy peers, especially with metabolic risk factors. However, adult thresholds underestimate pediatric disease severity. Percentile-based cutoffs may better suit pediatric screening.

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Title: Atypical antipsychotics and metabolic dysfunction-associated steatotic liver disease in children and adolescents: a systematic review 

Source: International Journal of Psychiatry in Medicine 2026, Feb 10. [E–publication]

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Date of publication: February 2026  

Publication type: Systematic review

Abstract: Objective: Atypical antipsychotics (AAP) are commonly prescribed to children and adolescents and are associated with important adverse effects, including weight gain and metabolic syndrome. Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD) is the most common pediatric liver disease and is associated with serious complications, including liver cirrhosis. Given that MASLD and AAP are associated with liver cirrhosis and metabolic syndrome, a systematic review and meta-analysis was conducted to examine the association between AAP and MASLD in children and adolescents.

Methods: The systematic review examined studies exploring MASLD in subjects younger than 18 years taking AAP. All studies published in the English language between 1950 and 2020 were screened following PRISMA (Preferred Reporting items for Systematic Reviews and Meta-Analysis) guidelines.

Results: A total of 407 articles were initially retrieved, although only 3 studies met inclusion criteria. These included retrospective cohort and case-control studies with varying sample sizes and methodologies. Shedlock et al found increased obesity related risks in children with autism spectrum disorder; Kumra et al observed risperidone induced hepatotoxicity; and Mouzaki et al linked psychotropic use with more severe MASLD. Meta-analysis showed a small and statistically insignificant positive association between AAP and MASLD, with significant heterogeneity among studies, indicating a need for careful interpretation of results. Risk of bias ratings varied from fair to good.

Conclusion: These findings will serve as a foundation for future studies, assist in devising interventions, and may help to reform clinical guidelines for using AAP in children and adolescents to ensure patient safety.

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Title: Long-term systemic effects of metabolic dysfunction-associated steatotic liver disease (MASLD, formerly NAFLD/MAFLD) in children: a systematic review of persistence and progression into adulthood

Source: Annals of Hepatology 2026, Feb 27. [E–publication]

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Date of publication: February 2026

Publication type: Review article  

Abstract: Metabolic dysfunction associated steatotic liver disease (MASLD), previously referred to as nonalcoholic fatty liver disease (NAFLD) and metabolic associated fatty liver disease (MAFLD), is increasingly prevalent among obese children and adolescents. It is associated with significant long-term health risks, including type 2 diabetes, cardiovascular disease, advanced liver conditions, and liver-related mortality. This systematic review analyzed 26 longitudinal studies with follow-up durations ranging from 4.5 to 39 years to investigate the persistence and progression of liver steatosis from childhood into adulthood and its associated complications. Prevalence data were derived from studies using varying diagnostic criteria, including NAFLD, MAFLD, and MASLD, which may reflect differences in patient populations due to distinct inclusion criteria. Diagnostic methods included imaging, liver biopsy, and biomarkers such as alanine aminotransferase (ALT), aspartate aminotransferase (AST), and genetic variants like patatin-like phospholipase domain-containing protein 3 (PNPLA3) and transmembrane 6 superfamily member 2 (TM6SF2). Despite its systemic impact, MASLD often progresses silently in pediatric populations with limited awareness among parents, affected children, and healthcare providers. Fragmented medical records and low follow-up rates further hinder effective management during the transition from pediatric to adult care. This review highlights the need for more comprehensive longitudinal research to better understand the progression of liver steatosis and its systemic effects. By synthesizing current evidence, it emphasizes the importance of early identification, timely intervention, and sustained care to mitigate long-term health consequences and improve outcomes.

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Title: Updates in clinical medicine: MASLD in children and adolescents  

Source: Journal of Hepatology 2026, Feb 21. [E–publication]

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Date of publication: February 2026 

Publication type: Review article

Abstract: Pediatric metabolic dysfunction-associated steatotic liver disease (MASLD) is an increasingly common liver disease, with a global prevalence estimated up to 7.5% and substantial concern for hepatic and extrahepatic complications even in early life. In this paper, we review recent advances in epidemiology, genetics, early-life risk factors, natural history and comorbidities, focusing on emerging data published in the last 3 years. We also outline a practical approach to the management of MASLD in children, integrating newly developed non-invasive tests. Lastly, we provide key research questions to be studied in the coming years.

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Title: Fighting the epidemic of pediatric metabolic dysfunction-associated steatotic liver disease: role of non-invasive diagnostics and early pharmacological intervention

Source: World Journal of Hepatology 2026, 18 (1): 111211  

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Date of publication: January 2026  

Publication type: Review article 

Abstract: The global rise in childhood obesity has made metabolic dysfunction-associated steatotic liver disease (MASLD) the leading cause of pediatric liver disease. Studies have consistently reported alarmingly high rates of advanced fibrosis in up to 20% of adolescents with MASLD. There is evidence that pediatric MASLD may run a more severe clinical course compared to adults, as well as pose an independent risk factor for mortality than pediatric obesity or type 2 diabetes mellitus alone. This underscores the necessity for timely recognition, accurate diagnosis and early institution of therapeutic interventions for pediatric MASLD. In this minireview, we discuss the various non-invasive diagnostic modalities used for the evaluation of MASLD, and propose an updated diagnostic and monitoring algorithm incorporating recent multi-societal statements. The advent of non-invasive diagnostics such as vibration-controlled transient elastography in children allows for earlier recognition of liver fibrosis, and may prioritize the need for early pharmacological therapy. We also discuss the importance of early pharmacological intervention in pediatric MASLD, in particular the use of glucagon-like peptide 1 receptor agonists which may have potential to halt MASLD progression if instituted early, and the potential role for novel anti-fibrotic therapy in this population.

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Title: The epidemiology of metabolic dysfunction-associated steatotic liver disease among pediatric patients with type 2 diabetes: systematic review and meta-analysis

Source: European Journal of Pediatrics 2026, 185 (2): 120  

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Date of publication: January 2026 

Publication type: Systematic review and meta analysis

Abstract: Metabolic dysfunction-associated steatotic liver disease (MASLD) is strongly associated with type 2 diabetes (T2D) in adults; however, its epidemiology in the pediatric population remains unclear. We conducted a systematic review and meta-analysis to estimate the prevalence of MASLD among children and adolescents with T2D. We systematically searched PubMed and Embase databases from inception until March 18, 2025 to identify observational studies investigating the prevalence of MASLD (diagnosed by liver biopsy, imaging methods, or blood-based biomarkers) in children and adolescents (aged ≤ 21 years) with T2D. Data from eligible studies were extracted, and meta-analysis was performed using a generalized linear mixed model. This study was registered in PROSPERO (ID CRD420251013625). Eighteen unique studies with 3926 pediatric patients with T2D were included. The pooled prevalence of MASLD in pediatric T2D was 36.61% (95% confidence interval [CI] 26.45 to 48.12), with substantial heterogeneity (I² = 97.1%). Prevalence estimates differed significantly by the diagnostic method used for MASLD (p = 0.014) but remained consistent across subgroups based on world region, median year of enrollment, and sample size. Sensitivity analysis restricted to magnetic resonance-based studies showed a high prevalence (55.0%, 95% CI 38.20 to 70.78, I² = 73.7%). The funnel plot did not reveal any significant publication bias.

Conclusions: MASLD affects over one-third of pediatric patients with T2D. These findings support early liver health screening in this high-risk group. Future research is needed to validate non-invasive tests for liver disease assessment in pediatric diabetes care.

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