Background: Prior to enactment of the Affordable Care Act in 2010 few states had pediatric palliative care. Literature suggests that adult palliative care services result in cost savings, but little literature provides evidence about the effect of pediatric palliative care on cost, and no literature as yet compares costs in states with and without pediatric palliative care programs. Objective: To investigate differences in hospitalization characteristics between states with and without pediatric palliative care programs. Design: I used the 2009 Healthcare Cost and Utilization Project Kids' Inpatient Database (Agency for Healthcare Research and Quality) to determine total hospital charges, length of stay, and number of procedures associated with all in-hospital pediatric deaths. I compared median values of states with and without pediatric palliative care and regressed presence of palliative care on all variables to examine total hospital charges. I further adjusted the model for length of stay and number of procedures and I repeated the analysis with an adjustment for the presence of a Diagnosis Related Group for neuromuscular disorder, one of the most common diagnoses in pediatric palliative care programs. Results: I found that patients who died in hospital in states with pediatric palliative care programs had higher hospital charges, longer hospital stays, and more procedures during their hospitalization. The difference in charges closed dramatically for patients with neuromuscular disorders. Conclusion: States with pediatric palliative care programs have higher hospital-based health care utilization over all, but state palliative care programs are in their infancy, and in states with such programs, costs associated with conditions amenable to palliative care do not significantly differ from median costs. These findings suggest that implementing palliative care programs may not cause significantly higher costs for patients who most commonly receive palliative care, and it is possible that the early effect of pediatric palliative care programs on hospital charges varies by diagnosis.