Although thyroid surgery is mainly based on the malignancy risk, determination of cases with thyroid malignancy among the patients with enlarged thyroid is a controversial issue in children. To find out whether thyroid enlargements have any predictive clinical or laboratory characteristic for thyroid malignancy, a retrospective clinical study was scheduled. A total of 137 patients who had undergone surgery for thyroid enlargement in a 15-year period were evaluated. The series was composed of 90 (65.7%) cases with uninodular goiter, 40 (29.2%) cases with multinodular goiter and seven (5.1%) cases with diffuse goiter. Histopathologic examination showed nine (6.6%) patients with differentiated thyroid carcinoma. All the remaining patients had benign thyroid enlargements. Analysis of results showed no ideal or near-ideal predictive one for thyroid malignancies among clinical or laboratory characteristics consisting of age, sex, presumptive symptoms, previous irradiation, type of nodularity, nodule localization and size, lymphadenopathy, thyroid function tests, ultrasonography and thyroid scan. No characteristic studied had a simultaneous high level of positive and negative predictive value. Only two physical characteristics including nodule size less than 2.5 cm in diameter and lymphadenopathy had simultaneous high levels of sensitivity and specificity above 50%. Therefore new guidelines with higher predictivity should be sought for surgical evaluation of the childhood thyroid enlargements. Fine-needle aspiration biopsy that is extensively used in adults may also be an alternative approach despite some restrictive aspects in children.