Breath volatile profiling reveals a diagnostic signature of MASLD in children
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Background & Aims
Metabolic Dysfunction–Associated Steatotic Liver Disease (MASLD) is the leading cause of chronic liver disease in children. However, accurate, noninvasive diagnostic tools remain limited. Current screening methods are invasive or lack sensitivity. Breath-based volatile organic compound (VOC) analysis offers a simple approach with potential for point-of-care screening. This study aimed to identify and validate breath VOC signatures of pediatric MASLD.
Approach & Results
We conducted a prospective IRB-approved cohort study at the Children’s Hospital of Philadelphia (CHOP). Children aged 7–20 years with MASLD (n=22), as defined by hepatic steatosis either by liver biopsy or imaging and 1 cardiometabolic risk factor, and a control group without MASLD (n=20) were enrolled. Breath samples were collected using a standardized protocol and analyzed by untargeted comprehensive two-dimensional gas chromatography-mass spectrometry (GC×GC-MS). Machine learning and unsupervised clustering were applied to identify discriminatory VOCs and assess heterogeneity. Untargeted GC×GC-MS analysis identified a distinct breath VOC signature in children with MASLD compared with non-MASLD controls. A Random Forest model achieved a sensitivity of 73% and specificity of 65%, with AUC of 0.84. The VOC 2,4-dimethyl-1-heptene demonstrated strong diagnostic performance in the discovery cohort with a sensitivity of 85%, specificity of 77% and an AUC of 0.81. Unsupervised clustering revealed four MASLD subgroups with distinct volatile phenotypes associated with differences in liver enzymes and metabolic parameters. External validation in a second pediatric cohort confirmed reproducible reductions in o/p-xylene in subjects with MASLD.
Conclusions
Pediatric MASLD is associated with a reproducible breath VOC signature identified by untargeted GC×GC-MS. These findings support breath analysis as a scalable, noninvasive screening and stratification tool for pediatric MASLD and warrant validation in larger, longitudinal studies.
IMPACT AND IMPLICATIONS
Pediatric MASLD lacks scalable, noninvasive diagnostic tools capable of early identification of at-risk children, providing strong scientific justification for the development of breath-based biomarkers. This study demonstrates that untargeted breath VOC profiling can distinguish children with MASLD from controls and reveals biologically meaningful heterogeneity in breath signatures, highlighting the potential of breath analysis for both detection and risk stratification. These findings are most relevant to physicians managing children with cardiometabolic risk and to researchers developing noninvasive liver biomarkers. Broader validation is required before clinical implementation.
