PURPOSE: To report the prevalence of meibomian gland atrophy and gland tortuosity in a pediatric population. METHODS: Participants who presented with no history of dry eye disease or meibomian gland dysfunction were recruited from the Duke University Eye Center. Meibography was performed and subjective symptoms were assessed through the Standard Patient Evaluation of Eye Dryness (SPEED) questionnaire. Grading of images was assessed by a masked rater using a previously validated 5-point meiboscale (0-4) for gland atrophy and a 3-point scale for gland tortuosity (0-2). RESULTS: Ninety-nine eyes of 99 participants (50 females) aged 4 to 17 years (mean 9.6 years) were imaged. The mean meiboscore was 0.58 ± 0.80 (mean ± SD) for gland atrophy and 0.45 ± 0.64 for tortuosity. In all subjects, 42% (n = 42) had any evidence of meibomian gland atrophy (meiboscore >0) and 37% (n = 37) had any evidence of meibomian gland tortuosity. The majority of subjects had mild gland atrophy. No significant association was found between age, sex, or race and presence of gland atrophy. Males were significantly more likely to have gland tortuosity (P = 0.0124, odds ratio 3.36). CONCLUSIONS: This study reveals a relatively high level of mild meibomian gland atrophy in the pediatric population, though moderate-severe gland atrophy was also present in this young population. This calls into question our current understanding of baseline gland architecture and suggests that perhaps clinicians should be examining young patients for meibomian gland atrophy and dysfunction because it may have implications for future development of dry eye disease.