Purpose Pediatric hepatocellular carcinoma (pHCC) is a rare and aggressive liver malignancy. This study aimed to analyze the clinical outcomes, pathological characteristics, and identify prognostic risk factors for pHCC patients. Methods A retrospective review of 50 pediatric patients diagnosed with pHCC between 1990 and June 2023 was performed at Asan Medical Center. The clinical outcomes, pathological features, and prognostic factors were analyzed. Results Of the 50 patients, 45 had conventional HCC and 5 had HCN-NOS. Hepatitis B virus-related HCC (38%) was significantly associated with worse survival. High serum alpha-fetoprotein (AFP) levels (>1000 ng/mL), portal vein invasion, metastases, and resectability were strongly correlated with survival outcomes. HCN-NOS showed rapid progression and poor prognosis, emphasizing the need for multidisciplinary diagnostic and therapeutic approaches. Conclusion Early detection and aggressive management are critical for improving survival outcomes in pediatric hepatocellular carcinoma. Further studies are needed to develop more effective risk stratification models for pHCC.