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Selective neck exploration and computed tomography angiography (CTA) in penetrating neck trauma have been well described in adults. However, data in the pediatric population are sparse. The extent to which these practices have been adopted in pediatric patients is unknown.Retrospective, single-center cohort study of pediatric penetrating neck trauma for the years 2001 to 2014 in a dedicated children's hospital/Level 1 pediatric trauma center. Clinical data, sensitivity and specificity of hard signs (active hemorrhage, airway compromise, expanding hematoma, crepitus, and so on) and soft signs of injury (bruit, voice change, stridor, laceration less than 2 cm, nonexpanding hematoma, and so on), and trends in imaging were examined.A total of 44 patients were identified with penetrating neck trauma. The majority of these patients were male (55%) aged 8 months to 18 years and a median of 7.3 years. Sixteen patients underwent neck exploration with 13 major injuries identified in 10 patients. Nineteen patients had associated injuries. Ten patients had at least one hard sign of injury, and 16 patients had only soft signs of injury. The sensitivity and specificity of hard signs of injury were 100% (95% confidence interval [CI], 59–100%) and 94.4% (95% CI, 79–99%), respectively. Soft signs only had a sensitivity and specificity of 100% (95% CI, 39–100%) and 75.5% (95% CI, 60–86%), respectively. Positive and negative predictive values were 4.8% and 100%, respectively, for both hard and soft signs. The number of CTA studies increased over time but was not statistically significant. Forty (90%) patients were discharged home and two patients died.These results suggest that management of penetrating neck trauma in children includes selective neck exploration based on physical examination and the use of CTA in stable patients, similar to current adult recommendations. We did not observe evidence of missed injuries over the study period.Therapeutic/care management, level IV.