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To assess the use and complications of transpyloric enteral nutrition (TEN) in the critically ill child we evaluated prospectively all children who received TEN in a pediatric intensive care unit (PICU) of a tertiary university hospital. The type of nutrition used, its duration, medication administered, tolerance, gastrointestinal complications (vomiting, abdominal distension or excessive gastric residue, diarrhea, and pulmonary aspiration), nongastrointestinal complications, and mortality were assessed. A comparative analysis was made between the first 2 years of the study and the remaining period. Over a period of 4.5 years, 152 patients between the ages of 3 days and 17 years received TEN for a duration of 19 ± 32.3 days (range 1–240 days). Forty-one patients received TEN during the first 2 years; 100 patients received TEN in the postoperative period after cardiac surgery (66%). One hundred seventeen patients (77%) received sedation and 65 (43%) received muscle relaxants, presenting no extra complications. Twenty-four patients (15.8%) presented with gastrointestinal complications: abdominal distension and/or excessive gastric residue in 17 and diarrhea in 11. Gastrointestinal intolerance was associated with pulmonary infection (p < 0.05), altered hepatic function (p < 0.001), and hypokalemia or hypocalcemia (p < 0.05). Diarrhea was more frequent in patients with shock (p < 0.05), altered hepatic function (p < 0.05), excessive gastric residue (p < 0.001), and hypokalemia or hypocalcemia (p < 0.05). In the second study period, the number of patients on TEN and the doses of sedatives, muscle relaxants, and vasoactives were higher (p < 0.05), with no increase in the incidence of complications. TEN is a useful method of nutrition with few complications in the critically ill child.