In a recently published consensus statement on management of acute liver failure, the authors have recommended the use of N-acetylcysteine in the treatment of children with non-acetaminophen pediatric acute liver failure [1]. Intravenous N-acetyleysteine (NAC) was incorporated into the general management of acute liver failure following a small uncontrolled study suggesting improved cardiovascular hemodynamics and oxygen transport in liver failure in adults [2]. In pediatric population, NAC became popular after a retrospective single-center review from Kortsalioudaki, et al. [3] which affirmed its beneficial effect in acute liver failure. Based on these data, the consensus among pediatric hepatologists over the years has been to use this inexpensive medication in liver failure.

However, a recently published, decade long, multi-centric, randomized placebo controlled study to test the widespread assumption of usefulness of intravenous NAC in non-acetaminophen pediatric liver failure by Squires, et al. [4] does not support broad use of NAC in this condition. The study by Squires, et al. in itself is unique with regard to its design and the results and perhaps is the only prospective study in children which tries to give an insight to the role of NAC in non- acetaminophen pediatric liver failure. More prospective studies are still warranted before we can establish the role of NAC in treatment of non-acetaminophen pediatric acute liver failure.

1. Bhatia V, Bavdekar A, Yachha SK. Management of acute liver failure in infants and children: Consensus Statement of the Pediatric Gastroenterology Chapter, Indian Academy of Pediatrics. Indian Pediatr. 2013;50;477-82.

2. Harrison PM, Wendon JA, Gimson AE, Alexander GJ, Williams R. Improvement by acetylcysteine of hemodynamics and oxygen transportin fulminant hepatic failure. N Engl J Med. 1991;324:1852-7.

3. Kortsalioudaki C, Taylor RM, Cheeseman P, Bansal S, Mieli-Vergani G, Dhawan A. Safety and efficacy of N-acetylcysteine in children with nonacetaminophen- induced acute liver failure. Liver Transpl. 2008;14:25-30.