An increasing number of children are being diagnosed with thyroid cancer, the most common form being papillary, followed by follicular and then medullary. Most patients have an excellent prognosis, and the goal of treatment is to optimize outcomes while reducing complications. As our understanding of the disease process continues to evolve, it is worth revisiting certain practice patterns in the treatment of pediatric thyroid cancer. Is a total thyroidectomy always necessary? What is the added benefit of a prophylactic central neck dissection? In these complex patients, the optimal treatment requires a nuanced discussion between the patient, their family, and all providers involved. We have presented some considerations when discussing the appropriate treatment.