With the increasing prevalence of obesity in children and adolescents, NAFLD is now the most common liver disease in the pediatric population. Nevertheless, there are important gaps in our knowledge of the natural history, diagnostic tools and therapeutic options in this setting. Serum risk scores, employed ubiquitously in adults, are currently lacking. An important question in this field is whether the pathophysiology is equivalent to adults, or whether certain pathways and events are uniquely relevant in children. With few pediatric NAFLD drug trials being performed, the focus is on lifestyle management, although the optimal strategy and schedule has not yet been determined.