Background Gastrostomy tubes (GTs) provide life‐saving enteral access for children. Although upper gastrointestinal (UGI) series and impedance studies (ISs) detect gastroesophageal reflux disease (GERD) or malrotation, their benefit for preoperative evaluation of asymptomatic patients requiring GT placement is controversial. This study investigated the value of routine preoperative testing and whether specific patient characteristics could guide the selective use of these studies. Methods The charts of children who underwent GT placement from 2003 to 2019 were reviewed retrospectively. Demographics, preoperative evaluation, and postoperative course were evaluated. Results Three hundred forty‐three patients underwent GT placement, 61% with preoperative testing. Seven of 190 UGI (4%) series demonstrated malrotation, and 39 of 141 (28%) ISs revealed severe GERD. Although all malrotations were surgically addressed, only 59% (23/39) of IS‐proven GERD cases prompted simultaneous fundoplication. Age <1 year was associated with a positive UGI series (6.7% positive vs 1.0%; P < 0.05), but no other patient characteristics were associated with either positive UGI series or IS. Elimination of the 96% of UGI series that did not alter care represented a cost savings of $89,487–$229,665 and avoided the radiation exposure from testing; elimination of the 84% of ISs that did not alter eventual treatment would have saved $127,776–$266,563. Conclusion Routine preoperative evaluation with UGI series and IS can increase healthcare costs without substantially altering care. The only patients potentially benefiting from routine UGI series were <1 year old. Instead, a targeted, symptom‐based preoperative evaluation may streamline the process by decreasing preoperative testing and minimizing cost and radiation exposure.