The 2024 update of the North American consensus guidelines for pediatric administered radiopharmaceutical activities (NAGL) is presented. Under the auspices of the Image Gently Alliance, a working group of 19 pediatric nuclear medicine experts, including clinicians, technologists, and physicists, worked for 2 y to update the 2016 NAGL, its most recent version. Building on previous success, the current recommendations regarding pediatric diagnostic nuclear medicine were reviewed systematically regarding their continued pertinence, the need for modification, and whether any recent protocols should be added. The working group reviewed and approved the 2024 update of the NAGL, and the update was subsequently approved by the Image Gently Alliance in the spring of 2024. None of the 23 protocols listed in the 2016 NAGL were removed; however, 9 were modified, and 6 new protocols (13N-NH3 and 83Rb for cardiac imaging; 18F-DOPA, 68Ga-DOTATATE, 68Ga-DOTATOC, and Na123I for thyroid cancer imaging) were added. Five of 6 new protocols involve PET imaging, reflecting an increase in the routine use of PET in children in the past decade. This 2024 update addresses the impact of advances in imaging equipment, reconstruction, image processing, and clinical practice and the introduction of new radiopharmaceutical agents into the practice of pediatric nuclear medicine.