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Pediatric patients with cerebrospinal fluid shunts frequently present to the emergency department for evaluation of possible shunt malfunction. Most shunt studies appear in the neurosurgical literature. To our knowledge, none have reviewed presenting signs and symptoms of shunt malfunction in patients who present to the pediatric emergency department. The study objective was to evaluate the medical record of children with cerebrospinal fluid shunts who presented to a pediatric emergency department to determine if any signs and/or symptoms were predictive of shunt malfunction.A retrospective chart review was conducted on 352 pediatric patients aged 0 to 18 years, who presented to the pediatric emergency department between January 1, 1998, and December 31, 2002, with signs and/or symptoms that prompted an evaluation for possible shunt malfunction.Univariate analysis of all signs and symptoms revealed lethargy (odds ratio, 1.99; 95% confidence interval, 1.15-3.42; P = 0.02) and shunt site swelling (odds ratio, 2.56, 95% confidence interval, 1.08-6.07, P = 0.03) to be significantly predictive of shunt malfunction. Logistic regression analysis continued to show significance for lethargy (odds ratio, 2.20; bias-corrected 95% confidence interval, 1.11-3.63) and shunt site swelling (odds ratio, 3.10; bias-corrected 95% confidence interval, 1.38-9.05), but found no other study variable to be significant. Bootstrap resampling validated the importance of the significant variables identified in the regression analysis.In this study, lethargy and shunt site swelling were predictive of shunt malfunction. Other signs and symptoms studied did not reach statistical significance; however, one must maintain a high index of suspicion when evaluating children with an intracranial shunt because the presentation of malfunction is widely varied. A missed diagnosis can result in permanent neurological sequelae or even death.