Background <p>Pediatric living donor liver transplantation (PLDLT) is a life-saving option for children with end-stage liver diseases. However, the growing prevalence of metabolic dysfunction-associated steatotic liver disease (MASLD) raises concerns regarding the use of steatotic donor grafts, particularly in vulnerable pediatric populations.</p> Methods <p>This study retrospectively investigated the impact of steatotic liver grafts on post-transplant outcomes in PLDLT recipients. 905 PLDLT recipients at Renji Hospital, Shanghai Jiao Tong University School of Medicine, from January 2019 to December 2021 were screened using computed tomography (CT) liver/spleen ratio and classified into three groups according to the degree of steatosis. This study evaluated early liver function, post-transplant complications, and long-term graft and patient survival.</p> Results <p>Recipients in the moderate-to-severe group exhibited higher incidence of rejection. However, there were no significant differences in early liver function and the 1-year and 3-year graft and patient survival among three groups.</p> Conclusions <p>The use of steatotic livers in PLDLT can be considered a viable option, with careful donor selection and vigilant postoperative management. These findings highlight the potential of MASLD as an expansion of the donor pool owing to its rising incidence and offer new insights into optimizing pediatric transplant outcomes while addressing the scarcity of suitable donor organs.</p> Graphical abstract <p></p>