Objective To investigate the clinical characteristics of hepatitis?associated aplastic anemia （HAAA） in pediatric patients. Methods A retrospective study was conducted on 212 children with aplastic anemia （AA） who were hospitalized at Henan Children's Hospital from September 2014 to February 2023. The patients were categorized into two groups based on etiology： the HAAA group and the non?HAAA group. The study group consisted of 23 patients in the HAAA group， while a control group of 115 children without HAAA was matched in a 1∶5 ratio based on age， sex， and severity of aplastic anemia. The clinical characteristics， treatment regimens， and outcomes of the 23 patients with HAAA were analyzed and compared with those of the control group comprising 115 patients. Results Among the 23 children with HAAA， there were 11 males and 12 females， with a median age of 6 years and 3 months （ranging from 1 year and 4 months to 12 years old）. The onset of aplastic anemia in all HAAA children occurred after the initial presentation of acute hepatitis. Following gradual improvement in liver function， peripheral blood images showed a progressive decline by two or three lines， including platelets. Among these cases， very severe aplastic anemia was observed in 14 patients （60.9%）， severe aplastic anemia in 7 patients （30.4%）， and non?severe aplastic anemia in 2 patients （8.7%）. The median interval between hepatitis onset and diagnosis of aplastic anemia was found to be 56 days （range：10 ~ 157 days）. All 23 pediatric patients with HAAA presented with acute icteric hepatitis， accounting for 100% of the cohort. One patient （4.3%） was genetically diagnosed with X?linked lymphoproliferative disease type 2， while liver biopsy revealed drug?induced hepatitis/chemical liver injury in five patients （21.7%）. Compared to the control group， HAAA patients exhibited significantly lower levels of CD4⁺ cells ［（1.2 ± 0.3） vs. （1.5 ± 0.1）］ and CD4⁺/CD8⁺ ratios ［（-0.2 ± 0.4） vs. （0.1 ± 0.2）］ （P < 0.05）. Three patients received immunosuppressive therapy （IST）， 18 underwent hematopoietic stem cell transplantation （HSCT）， and two non?severe cases were treated with methylprednisolone sodium succinate and compound Zapoan pill； all patients survived. Conclusions Children with HAAA present a critical condition and exhibit a poor prognosis， predominantly manifesting as severe or extremely severe aplastic anemia during the recovery phase of hepatitis. Reduction in CD4⁺ cell count and inversion of CD4⁺/CD8⁺ ratio may serve as early warning indicators for HAAA. Effective improvement in prognosis can be achieved through immunosuppressive therapy and hematopoietic stem cell transplantation.