Background/Objectives: Fructose consumption in children is increasing, as is the prevalence of metabolic dysfunction-associated steatotic liver disease (MASLD). Despite evidence linking added sugars to metabolic syndrome, fructose's impact on liver disease in youth remains unclear, especially in pediatrics. Our study aimed to evaluate the role of fructose intake in metabolic and liver dysfunction in a cohort of pre-school children and adolescents with obesity. Methods: We recruited 41 children and adolescents with obesity (age range: 2.5-16 years, BMI SDS 2.6 ± 0.5 kg/m²). Clinical and biochemical parameters were assessed. Through ultrasound (US), MASLD, hepatorenal index (HRI), subcutaneous adipose tissue (scAT), and visceral adipose tissue (vAT) were assessed. Dietary intake was evaluated using the IDEFICS FFQ and a fructose-specific questionnaire. Results: Pubertal subjects had more scAT and vAT, higher insulin resistance, and higher liver fibrosis parameters than those prepubertal. MASLD was detected in 12 subjects, associated with higher scAT and vAT. Pubertal subjects had lower weekly fructose intake than prepubertal subjects (p < 0.02). However, they consumed less fructose from fruits (p < 0.04) and more from other sugars (p < 0.04) than younger children. Patients with MASLD reported higher fructose intake (p < 0.01), primarily from fruits (p < 0.003), likely due to misreporting, alongside higher consumption of unhealthy food, mainly rich in saturated fats. Conclusions: Fructose intake and unhealthy dietary habits were associated with MASLD in pre-school and adolescents with obesity. Advice to pay attention to fructose intake and foods rich in saturated fats is mandatory to decrease both obesity and MASLD. Further high-powered studies in any pediatric age and different geographical areas are needed to better evaluate the MASLD history.

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