OBJECTIVE Tracheostomy in the pediatric population is associated with significant morbidity and mortality compared to adult practice. This study highlights evolving experience from a UK children's hospital. METHODS All children undergoing tracheostomy between 1995 and 2004 were identified. Indications, complications, and outcomes were evaluated. RESULTS Complete case records were reviewed for 112 children (age range, newborn-18 years). Indications included congenital birth defects--craniofacial disorders, esophageal atresia, laryngeal cleft, cystic hygroma, vascular malformations. Acquired upper airway pathology (15.5%) and malacia (12.1%) were additional criteria. Tracheostomy was also required for long-term ventilation in patients with neuromuscular disorders (12.1%) or ventilator dependency (26.7 %). Fifty-eight (50%) tracheostomies were created in infants <1 year. One hundred and nine were elective procedures with only 7 (6%) for emergency airway management. Morbidity included wound problems (14, 14.4%), tube displacement or obstruction (14, 14.4%), tracheocutaneous fistula (6, 6.2%), and pneumothorax (4, 4.1%). There were no acute hemorrhagic complications. Two children died after accidental tube displacement/obstruction. CONCLUSIONS Tracheostomy at this UK center is largely undertaken as an elective procedure. Children less than 1 year form an increasing patient group. Complications may be minimized by meticulous surgical technique and ensuring a comprehensive tracheostomy care program.