In this month’s issue of JAMA Pediatrics, Chang et al1 use longitudinal data from a nationally representative, multicenter registry to demonstrate that the Pediatric End-stage Liver Disease (PELD) score significantly underestimates waitlist mortality compared with the original models on which it was based. Using a cohort of more than 4000 children listed between 2002 and 2014 and allowing for 2 years of follow-up for each child after listing, the authors have published the first validation of the PELD score in nearly 2 decades. In this updated analysis, the authors found that the calculated PELD score and mortality were concordant, with a C-statistic greater than 0.80, establishing that PELD scores accurately order children from most sick to least sick. The absolute difference between actual and previously predicted values of waitlist mortality was increased, a finding that indicates a clear underestimation of actual mortality in children by as much as 17% in all disease categories. Furthermore, these findings hold true with a broadly defined pediatric cohort of more than 4000 patients, as well as with a more narrowly defined subgroup of 2421 patients who received deceased donor liver transplants based on their natural PELD score.