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GlideScope® video laryngoscope (GVL) has been proposed to be useful for airway management, but its efficacy for difficult airways has not been confirmed in pediatric patients. In this study, we evaluated the usefulness of the GVL for improving the laryngoscopic view in patients whose Cormack and Lehane grade (C&L grade) was ≥3 under direct laryngoscopy. We also assessed the effect of GVL blade size on the laryngoscopic view.This randomized open trial was conducted in a tertiary pediatric center. Patients whose previous C&L grade was ≥3, or who were anticipated to have a difficult airway, were enrolled. The initial modified C&L grade was scored using a direct laryngoscope (DL). If the patient’s C&L grade was ≥3, the laryngoscopic view was scored again using GVLw (selected based on weight) and GVLs (1 size smaller than GVLw) in random order by a single experienced anesthesiologist. All laryngoscopic views were graded both with and without the backward, upward, and right lateral displacement of the thyroid cartilage (BURP) maneuver. The primary outcome was the difference in the C&L grade between DL and GVLw, and the secondary outcome was that between GVLw and GVLs. For statistical analysis, the modified C&L grade was converted to an ordinal scale.Data from 23 pediatric patients were analyzed. When compared with DL, improvement of laryngoscopic view with the GVLw wa not obvious (98.3% confidence interval [CI] for differences of ordinal scale, 0–1 without BURP, P = 0.15 and 0–1 with BURP, P = 0.11). However, GVLs improved the laryngoscopic view in comparison with both DL (98.3% CI for differences, 3.5–5.0 without BURP, P = 0.00007 and 3.5–4.5 with BURP, P = 0.0001) and GVLw (98.3% CI for differences, 3.0–4.5 without BURP, P = 0.00007 and 2.5–4.0 with BURP, P = 0.0001). There was no adverse outcome during this study.In patients with C&L grade ≥3 under direct laryngoscopy, GVLs significantly improved the laryngoscopic view when compared with DL or GVLw. The GVLs is recommended for improving the laryngoscopic view in patients with a difficult airway.