Abstract / Summary
Metabolic dysfunction-associated steatotic liver disease (MASLD) is a major chronic liver disease in children. The comparative effects and safety of dietary supplements in children with MASLD remain uncertain. This systematic review and network meta-analysis compared their effects and summarized reported safety outcomes. We searched seven bibliographic databases and two trial registries from inception to February 6, 2026, for randomized controlled trials of dietary supplements in children with MASLD. Frequentist network and pairwise meta-analyses estimated mean differences (MDs) and 95% confidence intervals (CIs) for liver enzymes, insulin resistance, lipid profiles, and body mass index z scores. Confidence in network estimates was assessed using CINeMA; safety findings were summarized descriptively. PROSPERO registration: CRD420261301044. Twenty-eight randomized controlled trials involving 1,979 participants were included. Compared with conventional treatment, the vitamin D + probiotics regimen was associated with reductions in alanine aminotransferase (ALT: MD = −32.61 U/L, 95% CI [− 63.46, −1.76]), aspartate aminotransferase (AST: MD = −28.17 U/L, 95% CI [− 43.12, −13.23]), homeostasis model assessment for insulin resistance (HOMA-IR: MD = −1.46, 95% CI [− 2.02, −0.90]), and triglycerides (TG: MD = −51.16 mg/dL, 95% CI [− 79.81, −22.51]). Compared with conventional treatment or placebo, vitamin E was associated with reductions in ALT (MD = −16.76 U/L, 95% CI [− 30.23, −3.29]), AST (MD = −8.57 U/L, 95% CI [− 16.14, −1.01]), and HOMA-IR (MD = −1.18, 95% CI [− 1.49, −0.88]). Ginger was associated with lower total cholesterol levels (MD = −23.56 mg/dL, 95% CI [− 35.75, −11.36]), whereas the DHA + vitamin D regimen was associated with lower TG levels (MD = −74.59 mg/dL, 95% CI [− 120.95, −28.23]) and higher high-density lipoprotein cholesterol levels (MD = 8.31 mg/dL, 95% CI [2.82, 13.80]). CINeMA rated 89/92 comparisons (96.7%) as having low or very low confidence. Eight trials had high overall risk of bias and 16 raised some concerns. Several combination regimens were supported by single trials, with interpretation limited by sparse evidence and imprecision. Incomplete harms reporting precluded reliable safety comparisons. As adjunctive approaches to guideline-recommended lifestyle interventions, some dietary supplements were associated with favorable changes in selected biochemical and metabolic outcomes. These findings are insufficient to support routine supplementation for pediatric MASLD but may help prioritize candidate regimens and outcomes for future trials. Guideline-recommended lifestyle management remains first-line care.