Pediatric MASLD Evolution: A Distinct Entity from Adult Disease in Pathophysiology, Diagnosis, and Non-invasive Evaluation.

With growth in obesity and metabolic dysfunction globally, Metabolic Dysfunction- Associated Steatotic Liver Disease (MASLD) has emerged as the most common chronic liver disease with a rising trend in children and adolescents. Because of differences in frequency, risk factors, histology, disease progression, and therapy response, pediatric MASLD has emerged as a distinct clinical and histological disease, rather than a lesser variant of the adult disease. In addition to contributions from gut microbiota dysbiosis, epigenetic programming, and microRNA regulation, its pathogenesis also involves interactions among hepatic lipid accumulation, insulin resistance, dysregulated lipogenesis, mitochondrial dysfunction, oxidative stress, and inflammatory and fibrogenic pathways. Early onset of MASLD can progress to advanced fibrosis, cirrhosis, and increased long-term cardiovascular risk. Although liver biopsy remains the gold standard for diagnosis, its invasive nature restricts use in pediatric populations, underscoring the need for reliable non-invasive alternatives. This review compares pediatric and adult MASLD and highlights novel non-invasive and emerging biomarkers and imaging techniques for early diagnosis, staging, and risk assessment in the pediatric population.