Bridging the gap in paediatric MASLD screening: progress, pitfalls and the path ahead

With a significant rise in the number of children with obesity worldwide, there has been a parallel increase in metabolic dysfunction-associated steatotic liver disease (MASLD), now the most common chronic liver disease in youth. MASLD remains substantially underdiagnosed, largely due to its asymptomatic early course, variability in guideline-recommended screening thresholds, and limited access to paediatric-specific diagnostic tools. In a large real-world cohort of 908 overweight and obese children, Lehtinen et al. provide one of the most comprehensive evaluations of MASLD screening implementation in routine care. Whilst screening uptake for ALT and metabolic comorbidities was high and broadly in line with international guidelines, under-recognition persisted, with retrospective MASLD prevalence nearly double clinician-documented rates. The study highlights limitations of ALT-based screening and inconsistent diagnostic criteria. It also reinforces the importance of structured exclusion testing to avoid misclassification of inherited or treatable liver diseases as MASLD. Current non-invasive tools for steatosis and fibrosis remain inadequately validated in children, underscoring an urgent unmet need in paediatric hepatology. Together, these findings emphasise the necessity for harmonised screening pathways, improved diagnostic algorithms, and broader access to practical non-invasive tools to enable earlier MASLD detection and intervention.