Objective Both gastroesophageal reflux (GER) scintigraphy and radionuclide salivagram are commonly used in the detection of pulmonary aspiration in pediatric patients. This investigation is to compare the diagnostic value of these 2 imaging methods. Methods This retrospective study included 4186 pediatric patients (aged 1 week to 16 years; mean age, 28 months) who underwent a GER scintigraphy and/or radionuclide salivagram. Detection rate of pulmonary aspiration by the 2 imaging techniques was compared. Results The detection rate for pulmonary aspiration in patients undergoing both procedures was 1.9% (5 of 266) for GER scintigraphy and 22.2% (59 of 266) for radionuclide salivagram. Fifty-six of 59 patients with proven aspiration on radionuclide salivagram demonstrated no such findings on GER scintigraphy, whereas 2 of 5 patients with proven aspiration on GER scintigraphy demonstrated no such findings on radionuclide salivagram. In patients who underwent only 1 procedure (either GER scintigraphy or salivagram), the detection rate for pulmonary aspiration was 0.4% (15 of 3551) for GER scintigraphy and 20.3% (75 of 369) for radionuclide salivagram. Conclusions Radionuclide salivagram showed a much higher detection rate for pulmonary aspiration compared with GER scintigraphy. However, this may be related to a significantly higher prevalence of antegrade versus retrograde aspiration in our study population. Our results also suggest that not all episodes of retrograde aspiration can be detected by a radionuclide salivagram, and the requested scan should be tailored to the type of suspected aspiration.