IMPORTANCE: Recent reports have shown that the indications for pediatric tracheostomy have evolved over time. OBJECTIVE: To review the indications for pediatric tracheostomy over the last 30 years. DESIGN: Retrospective chart review. SETTING: Tertiary referral children’s hospital. PARTICIPANTS: Patients who underwent tracheostomy. INTERVENTION: Surgical tracheostomy placement. MAIN OUTCOMES AND MEASURES: Medical records for patients who underwent surgical tracheostomy over the 30-year study period (1984-2014) were reviewed. Patient characteristics including age, gender, birth-weight, gestational age and death were collected and compared with the primary indication for tracheostomy using bivariable analysis. RESULTS: Five hundred and one patients met inclusion criteria. The most common primary indications for tracheostomy were cardiopulmonary disease (34%) and neurological impairment (32%), followed by airway obstruction (19%), craniofacial (11%), and traumatic injury (4%). Over the last five years (2010-14) cardiopulmonary disease became the most common indication for tracheostomy. CONCLUSIONS: and RELEVANCE: The indications for pediatric tracheostomy have evolved over the past 30 years. Infectious causes of airway obstruction and tracheostomy have almost disappeared. Tracheostomy is now most commonly performed in very premature patients with cardiopulmonary or neurological impairment who require prolonged ventilator support.