Purpose <p>To evaluate clinical predictors of ventriculoperitoneal (VP) shunt malfunction in children presenting to the pediatric emergency department and to quantify cumulative imaging-related radiation exposure.</p> Methods <p>This retrospective study included 84 patients aged 0–18&#xa0;years with VP shunts who were followed between August 2014 and July 2018. A total of 123 shunt-related emergency department visits were analyzed regarding clinical presentation, physical examination findings, laboratory results, imaging utilization, and outcomes. Multivariable logistic regression was performed to identify independent clinical predictors of shunt malfunction. Model performance was assessed using receiver operating characteristic (ROC) analysis.</p> Results <p>Shunt malfunction was diagnosed in 39.8% of visits. Physical examination findings suggestive of increased intracranial pressure (<i>p</i> = 0.001) and abnormalities along the shunt tract (<i>p</i> = 0.02) were independently associated with malfunction. The prediction model demonstrated moderate discriminative ability (AUC = 0.70), with a sensitivity of 49% and a specificity of 88%. Cranial computed tomography showed high sensitivity (73%) but low specificity (35%) for detecting malfunction. The mean annual cumulative radiation exposure per patient was 16.1&#xa0;mSv.</p> Conclusion <p>Specific physical examination findings can help identify children at high risk for VP shunt malfunction and may support more selective imaging strategies. These findings may contribute to reducing unnecessary radiation exposure in this vulnerable population.</p>