Procedural skills are integral to the practice of pediatric emergency medicine, but provider experience is limited by case rarity. Simulation-based medical education allows for the practice of rare procedures without compromising patient safety. Simulation-based procedural training improves provider confidence, knowledge, and performance, and may translate to better patient outcomes. However, optimal instructional designs for simulation-based training remain unclear, and educators have a plethora of didactic approaches and simulator characteristics to consider. This article reviews how simulation can be used for pediatric procedural skills training and maintenance, focusing on instructional design features, simulation modalities, and the use of simulation as an assessment tool in the era of competency-based medical education.