Aim:To identify the clinical and biochemical risk factors associated with outcome of paracetamol induced significant hepatotoxicity in children. Methods:Retrospective case notes review of those with paracetamol overdose admitted from 1992 to 2002. Patients were analysed in two groups:group I recovered after conservative treatment and group II developed progressive liver dysfunction and were listed for liver transplantation. Results:Of 51 patients (6 males,45 females,aged 0.8-16.1 years),6 (aged < 7 years) received cumulative multiple doses,and 45 a single large overdose (median 345 mg/kg,range 91-645). The median (range) interval to hospital at presentation post-ingestion was 24 hours (4-65) and 44 hours (24-96) respectively in groups I and II. Patients received standard supportive treatment including N-acetylcysteine. All children in group I survived. In group II,6/11 underwent orthotopic liver transplantation (OLT) and 2/6 survived; 5/11 died awaiting OLT. Cerebral oedema was the main cause of death. Children who presented late to hospital for treatment and those with progressive hepatotoxicity with prothrombin time >100 seconds,hypoglycaemia,serum creatinine > 200 μmol/l,acidosis (pH<7.3),and who developed encephalopathy grade III,had a poor prognosis or died. Although hepatic transaminase levels were markedly raised in both groups,there was no correlation with necessity for liver transplantation or death. Conclusion:Accidental or incidental paracetamol overdose in children may be associated with toxic liver damage leading to fulminant liver failure. Delayed presentation and/or delay in treatment,and hepatic encephalopathy ≥grade III were significant risk factors,implying poor prognosis and need for OLT. Prompt identification of high risk patients,referral to a specialised unit for management,and consideration for liver transplantation is essential. Aim: To identify the clinical and biochemical risk factors associated with outcome of paracetamol induced significant hepatotoxicity in children. Methods: Retrospective case notes review of those with paracetamol overdose admitted from 1992 to 2002. Patients were analyzed in two groups: group I recovered after conservative Treatment and group II developed progressive liver dysfunction and were listed for liver transplantation. Results: Of 51 patients (6 males, 45 females, aged 0.8-16.1 years), 6 (aged <7 years) received cumulative multiple doses, and 45 a single The median (range) interval to hospital at presentation post-ingestion was 24 hours (4-65) and 44 hours (24-96) respectively in groups I and II (median 345 mg / kg, range 91-645) . Patients received standard supportive treatment including N-acetylcysteine. All children in group I survived. In group II, 6/11 underwent orthotopic liver transplantation (OLT) and 2/6 survived; 5/11 died awaiting OLT. Cerebral oedema was the mai n cause of death. Children who presented late to hospital for treatment and those with progressive hepatotoxicity with prothrombin time> 100 seconds, hypoglycaemia, serum creatinine> 200 μmol / l, acidosis (pH <7.3), and who developed encephalopathy grade III, had a poor prognosis or died. Although hepatic transaminase levels were markedly raised in both groups, there was no correlation with necessity for liver transplantation or death. Conclusion: Accidental or incidental paracetamol overdose in children may be associated with toxic liver damage leading to fulminant liver failure . Delayed presentation and / or delay in treatment, and hepatic encephalopathy ≥ grade III were significant risk factors, implying poor prognosis and need for OLT. Prompt identification of high risk patients, referral to a specialized unit for management, and consideration for liver transplantation is essential.