The ASA Physical Status Grading System is widely used as a preoperative assessment tool in adults, but whether it is suitable for children is still a question. We present the history of the ASA physical status and review the literature on its applicability to adults. We also review the literature on the reliability of it in children and analyse the reasons why it is low in pediatric practice. New pediatric risk assessments are introduced as well. A new grading system developed specifically for use in pediatrics, or modification for pediatrics of the existing adult physical status grading system is needed in the future.