Pediatric thyroid disease has changed since the decline of widespread cervical irradiation. Our analysis of 32 recently resected childhood thyroid nodules showed that the incidence of malignancy (22%) is decreasing, though the incidence of nodules is stable. Risk factors for development of thyroid disease include female sex, age around puberty, family history of thyroid disease, previous or coexisting thyroid disease, and history of a medical condition that may be steroid- or endocrine-related. Age, sex, location and size of nodule, duration of symptoms, and family or patient history of thyroid disease did not distinguish between malignant and benign disease preoperatively. Of the seven children with thyroid cancer, six (86%) had unrelated concurrent medical conditions, compared with 9/25 (36%) with benign disease and 2/11 (18%) with adenoma. Fine needle biopsies provided correct preoperative diagnosis in 6/7 cases. As pediatric thyroid malignancy becomes rarer and the high-risk nodule becomes better defined, criteria for surgical versus nonsurgical modes of diagnosis and treatment should become more distinct.