Paediatric acute liver failure (PALF) is a rare but devasting condition with high mortality. Unlike acute liver failure (ALF) in adults, the aetiology of PALF varies according to age; identifiable causes include metabolic causes in neonates and infants, whereas autoimmune liver disease, infections and drug overdose predominate in older children [1]. Since the 1990s, liver transplantation (LT) has drastically changed the outcome of PALF, but it is associated with short-and long-term side effects. Therefore, every effort is made to promote spontaneous liver recovery, avoiding the need for LT. The rate of spontaneous recovery has gradually increased from 28% in the pre-transplantation era to almost 73.4% recently [2]. The rate of spontaneous survival is aetiology dependent: the chances of spontaneous recovery are greatest in paracetamol overdose, and lowest in cases with an undetermined aetiology [3]. Understanding and targeting the underlying aetiology and pathophysiology of PALF, as outlined below, is the key to improved outcomes.