Chronic hepatitis C virus (HCV) infection is a major global health problem. The incidence of transfusion-related HCV infection has markedly decreased, and perinatal transmission has become the most important route of viral spread in children. Perinatally acquired HCV infection is generally a benign condition, but severe liver disease can occur. Little is known about the risk factors for the progression of liver disease in children, and few well-designed pediatric clinical trials have been conducted. Therefore, the decision to treat (or not) children with this viral pathogen is currently a contentious endeavor. Herein, we describe the virus and its life cycle and summarize our current understanding of the epidemiology and natural history of perinatally acquired infection and review current and future therapy of HCV infection in children.