The accuracy of signs and symptoms as predictors of the presence and severity of esophageal injury was evaluated in 378 children admitted to three pediatric hospitals between 1970 and 1980. The signs and symptoms analyzed included nausea, vomiting, dysphagia, refusal to drink, abdominal pain, increased salivation, oropharyngeal burns, and abdominal tenderness. The severity of lesions found at esophagoscopy in 378 children was graded from grade 0, no lesion, to grade 3, perforation. Of the 298 patients demonstrating signs or symptoms, 243 (82%) had a grade 0 or 1 lesion, 55 (18%) had a grade 2 lesion, none had a grade 3 lesion, and five (2%) developed a stricture of the esophagus. Among the 80 patients without signs or symptoms, 70 (88%) had a grade 0 or 1 lesion, ten (12%) had a grade 2 lesion, none had a grade 3 lesion, and one (1%) developed a stricture of the esophagus. When individual signs or symptoms were correlated with the severity of esophageal lesion, vomiting (33%) followed by dysphagia (25%), excessive salivation (24%), and abdominal pain (24%) were most frequently associated with a grade 2 or 3 esophageal lesion. A similar percentage of a grade 0 or 1 (82% v 85%), a grade 2 (18% v 15%), and a grade 3 (0%) esophageal lesion followed the ingestion, respectively, of an alkali (324 patients) or an acid (54 patients). In six patients (2%) stricture occurred only following an alkali ingestion. These data demonstrate that signs and/or symptoms do not adequately predict the presence or severity of an esophageal lesion following the ingestion of a caustic substance.