Abstract Background The efficiency of medical care in the United States has become intensely scrutinized with expectations from patients, families, payors, lawmakers, and, currently, the President. The most effective vehicle to bring more efficient care is the employment of evidence-based medicine whenever possible. Evidence-based medicine is dependent on best evidence, and best evidence is generated from prospective trials. To evaluate current state of evidence based practice in pediatric surgery we reviewed the literature for trials conducted in our field the past 10 years. Methods All randomized controlled trials from January 1999 through December 2009 published in the English literature were identified through a literature search using PubMed (www.pubmed.com). We included only those in pediatric general surgery excluding transplant, oncology, and the other nongeneral subspecialties. Results The search criteria produced 56 manuscripts, of which 51 described appropriate randomization techniques. A definitive trial design with a sample size calculation was utilized in only 19 studies (34%). A statistically significant difference between treatment arms was identified in 29 of the 56 (52%) trials. There were 26 different journals of publication, with the Journal of Pediatric Surgery being most common (20) followed by Pediatric Surgery International (7). The combined total publications from January 1999 through December 2009 for the 26 journals these randomized trials represent 0.04% of all publications. Appendicitis was the most common condition that was studied (n = 10) followed by pyloric stenosis (n = 4). Trials originated in 19 different countries led by the United States (28%), United Kingdom (14%), and Turkey (12%). There was a generally progressive increase in published trials from 1999 to 2009, however, the percentage of prospective articles published in pediatric surgery was similar to a previous review published in 1999. Conclusions The current state of evidence-based surgery in pediatric surgery has remained stable in the first decade of the 21st century. Randomized controlled trials represent less than 0.05% of all publications involving pediatric surgery. Some of the hurdles to evidence based surgery are identified and reviewed.