Acute liver failure (ALF) is a syndrome defined by the ra­pid decline of hepatic function, jaundice, coagulopathy (INR>1.5) and hepatic encephalopathy in patients with no evi­dence of previous liver disease. In children, the etiology of ALF is different, depending on age, and is associated with a high mortality, despite optimal medical therapy. The treat­ment for children with ALF will be directed to maintain vital functions, to prevent and treat the complications or against the etiologic agent when it is known. The the­ra­peu­tic measures consist in stabilizing the child by the administration or adjustment of liquids, vasoactive me­di­ca­tion or respiratory support if necessary, the treatment of encephalopathy through measures to reduce the am­monia in the blood, correction of hypoglycemia or hydroelectrolytic imbalances, the treatment of hemorrhage and coagulopathy. Specific treatment can be life-saving if the etiology is known, and includes administering anti­dots in toxic ALF, antivirals or antibacterial medication in infectious causes, immunosuppressive therapy in au­to­im­mune hepatitis, cooper chelators in Wilson disease, or specific diets in metabolic disorders. In severe ALF in chil­dren, extracorporeal methods (hemodiafiltration, plas­ma exchange or hepatic dialysis) may be used, but the only therapeutic option remains emergency liver trans­plan­ta­tion. The management of these cases requires a multi­dis­ci­pli­na­ry team, involving pediatric hepatologist, critical care spe­cia­list, nephrologist, or liver transplant surgeon.