###### Abstract  
Pediatric obesity has become a major public health problem worldwide, resulting in a wide spectrum of systemic complications. Liver disease associated with obesity, also known as nonalcoholic fatty liver disease (NAFLD), is currently the most common chronic liver condition in children. Therefore, its timely and proper diagnosis is essential for preventing further development of cirrhosis. Multiple studies focused on identifying the most accurate non-invasive diagnostic method for liver fibrosis or cirrhosis. Although liver biopsy remains the gold-standard in terms of this hepatopathy, elastography methods emerged as a relatively reliable alternative to liver biopsy. Thus, recent studies revealed the great importance of these non-invasive methods not only in diagnosing pediatric NAFLD, but also in its staging. MRE is commonly considered to have a greater accuracy than ultrasound-based elastography methods, but with lower availability and higher costs. Ultrasound-based elastography methods (transient elastography (TE), p-SWE, and 2-dimensional shear wave elastography (2D-SWE)) were proved to have similar accuracy in NAFLD staging. Nevertheless, multiple confounding factors account for potential challenges when using elastography for liver stiffness measurement, such as age, obesity itself (i.e., BMI), transaminase levels, or portal flow. A potential solution for facing these challenges might be represented by a complex approach based on the combination between elastography, clinical and laboratory findings. Although the studies that assessed the role of elastography in pediatric NAFLD staging are scarce, the current knowledge underlines a crucial role of these techniques taking into account their ability to distinguish between fibrosis degrees, their non-invasive patterns, lower costs and side effects when compared to liver biopsy. Therefore, elastography might become a cornerstone in staging pediatric NAFLD. el 28 February 2021 1 April 2021 4 April 2  
Liver disease in the setting of obesity is currently acknowledged as one of the most frequent complications of children with this nutritional disorder. Thus, non-alcoholic fatty liver disease (NAFLD) was reported in approximately 50% of children with obesity, being considered the most common pediatric chronic liver disease, with an incidence ranging between 5 and 17% among children from Western countries [7]. NAFLD, defined as accumulation of fat in the liver, is generally a silent, potentially reversible condition, but it might also progress into a more severe form, i.e., non-alcoholic steatohepatitis (NASH) associating steatosis, inflammation and cellular injury with or without fibrosis [8], with an increased the risk for cirrhosis and end-stage liver disease [9; 10]. The gold-standard in providing an accurate diagnosis and staging of NAFLD is undoubtedly liver biopsy, which also allows a proper assessment of other hepatic conditions. Nevertheless, this procedure carries multiple risks in children and parents' refusal is a major hindrance for this approach in young ages. Therefore, the early diagnosis and staging of NAFLD might represent a real challenge in children since no free national screening programs similar to other conditions are currently available [11; 12]. A complex approach consisting of the assessment of several laboratory parameters combined with different imaging tools represents an alternative for liver biopsy. Most of the studies sustain that elevated liver transaminases represent a common finding associated with liver disease in children with obesity [5]. Taking into account their fluctuations over time and even their normal levels in children with NAFLD, or even NASH, their role as single parameter in diagnosing this hepatic condition is doubtable [13].