OBJECTIVES: High quality economic evidence is necessary for optimizing pediatric health care allocation. The objectives were to appraise the quality of published pediatric cost utility analyses (CUA). It was hypothesized that higher quality would be associated with later publications, publication in a health economics/methods journal and prospective utility assessment. METHODS: Pediatric CUAs published in 1997-2009 were assessed.  Studies were retrieved from the Pediatric Economic Database Evaluation project (PEDE), a comprehensive database of pediatric health economic evaluations. Quality was assessed using the Pediatric Quality Appraisal Questionnaire which scores 14 domains from 0 to 1. Higher domain scores indicate better quality. Multiple linear regression was used to examine the effect of journal type, whether utility was measured prospectively in the study, and year of publication on each domain score. RESULTS: There were 305 CUAs published over the study interval. The annual number of pediatric CUAs increased over time. Most studies were undertaken in North America and Europe. Infectious diseases and their treatment and prevention was the most common therapeutic area (48%). Young children (1 to 12 years old) were studied most often (39%). Utility was measured prospectively in only 8% of studies. Quality was appraised in a random sample of 213 CUAs. Mean domain scores ranged from 0.57 (Analysis) to a high of 0.91 (Target population). Studies published in methods/economics journals demonstrated significantly higher scores for 7 domains (p<0.05). Studies that measured utility prospectively scored significantly higher on the Analysis domain. Multiple regression results showed that quality of five domains improved over time (p<0.05). CONCLUSIONS: While quality in some domains improved over time, others did not. Variability in quality of pediatric CUAs indicates that caution should be exercised when interpreting results for decision making. Challenges in conducting economic evaluations in children, such as prospective utility measurement, require further research.