Children tend to have higher alanine aminotransferase (ALT) levels early in life. The risk of hepatocellular carcinoma (HCC) is related to the duration of infection, the degree of histologic injury, and the replicative state of the virus (HBV DNA levels). The risk is higher in patients who are HBeAg-positive for extended periods or have basal core promoter mutants, and this risk is increased further in the presence of cirrhosis. Hepatocellular carcinoma in children with HBV infection has been described in both Asian4 and Western5 populations. Importantly, HCC has been described in children who had undergone early HBeAg seroconversion, indicating that there is still a risk for HCC even after viral replication decreases.