Difficulty with pill-swallowing ability (PSA) is common in children, yet formal evaluation is rare. The objective of this study was to prospectively evaluate and compare PSA of inpatient and outpatient children using the Pediatric Oral Medications Screener. We identified children aged 3 to 17 years admitted to a general or subspecialty pediatric service at a university hospital or outpatient clinic. Using the Pediatric Oral Medications Screener, patients were observed swallowing 3 different-sized placebo pills (5 mm tablet, 10 mm tablet, and 22 mm capsule), and subjective measures were assessed from parents and children. We analyzed 47 inpatients and 62 outpatients. Sixteen percent of patients could not swallow any pill, 11% only swallowed the small pill, 14% swallowed up to the medium pill, and 60% swallowed all formulations. After controlling for multiple factors, inpatients had superior PSA compared with outpatients ( P = .004). These results suggest targeted inpatient screening and widespread outpatient screening would likely identify children with reduced PSA.