Purpose <p>This study aims to analyze the use of programmable shunts in the treatment of hydrocephalus in pediatric patients, with particular emphasis on indications and treatment outcomes.</p> Methods <p>A retrospective analysis was conducted of pediatric patients who underwent implantation of Medtronic™ Strata II programmable shunts for hydrocephalus between 2013 and 2023. Patients with tumor-related hydrocephalus were excluded.</p> Results <p>The study population comprised 54 patients (22 girls and 32 boys) with a median age at programmable shunt implantation of 3.3&#xa0;years (range 0.2–17.4&#xa0;years) and a mean follow-up of 6.2&#xa0;years (SD ± 2.9&#xa0;years). Adjustable valves were implanted de novo in 22 patients (40.74%) and secondarily in 32 (59.26%). De novo implantation was primarily indicated for a significantly enlarged ventricular system (<i>n</i> = 17, 77.27%), while secondary implantation was mainly performed for overdrainage syndrome (<i>n</i> = 15, 46.88%). Reprogramming of opening-pressure settings was required in 44.44% of children (<i>n</i> = 24). Shunt revisions were performed in 24.07% of cases (<i>n</i> = 13), with all multiple revisions observed exclusively in patients with posthemorrhagic hydrocephalus (<i>n</i> = 7). At 10&#xa0;years after shunt implantation, 90.9% of patients in the de novo group remained free from revision, compared with 59.9% in the secondary group (log-rank test, <i>p</i> = 0.023).</p> Conclusions <p>The analysis substantiated that programmable shunt implantation is an effective treatment for pediatric hydrocephalus. In most cases, initial valve settings were sufficient without the need for subsequent adjustments. Secondary implantation of a shunt and posthemorrhagic hydrocephalus etiology were associated with a higher risk of revision.</p>