Background/objectives <p>Being born small-for-gestational-age (SGA), is associated with an increased risk of cardiometabolic disease in adulthood. We studied the influence of birth size on hepatocellular lipid (HCL) concentrations in prepubertal children. Methods: A total of 195 prepubertal Caucasian children (4.4–9.7 years) were studied in three cohorts. Twenty-one children were born small-for-gestational-age (SGA), 132 were appropriate-for-gestational-age (AGA), and 42 were large-for-gestational-age (LGA). The outcomes were body fat by dual-energy X-ray absorptiometry (DXA), liver fat MRI and MR spectroscopy (MRS), anthropometric measurements at examination, and biochemical markers of metabolism and inflammation.</p> Results <p>MRS revealed higher HCL in SGA children, as determined from the methylene (-CH₂-) resonance (<i>p</i> = 0.02). The high-sensitivity c-reactive protein (hs-CRP) level was also significantly higher in the SGA group than in the AGA (<i>p </i>= 0.01) or LGA groups (<i>p </i>= 0.002). The HCL concentrations were correlated with hs-CRP values in the whole cohort (<i>R </i>= 0.51, <i>p </i>= 0.03), independently of traditional anthropometric markers. Other laboratory parameters were not associated with HCL.</p> Conclusions <p>Our study shows a link between SGA status, elevated hs-CRP, and elevated MRS-detectable HCL. MRS may thus be important in identifying prepubertal children at risk for metabolic sequelae.</p> Impact <p><UnorderedList Mark="Bullet"> <ItemContent> <p>Prepubertal children born small-for-gestational-age (SGA), although still shorter and leaner than their peers, exhibit elevated liver triglyceride concentrations on proton MR spectroscopy associated with elevated hs-CRP levels.</p> </ItemContent> <ItemContent> <p>Elevated hs-CRP and liver triglyceride concentrations can be early indicators of pathological metabolic changes associated with later cardiometabolic abnormalities.</p> </ItemContent> </UnorderedList></p>