Radiation therapy plays an important role in the combined modality treatment of Hodgkin lymphoma (HL) in pediatric patients. Given the excellent oncologic outcomes following therapy, late toxicities from radiation therapy, such as cardiovascular disease and second malignancy, are a major concern. Deep Inspiratory Breath Hold (DIBH) has been used in adult patients to minimize normal tissue radiation exposure. Our institution has developed a pathway to use DIBH in pediatric patients with HL involving the mediastinum and hilum in an effort to reduce dose to nearby tissues and organs at risk (OARs). From 12/2016-11/2018, 19 consecutive pediatric patients with HL received pencil beam scanning proton therapy to the mediastinum and other subsites. All patients first underwent DIBH and 5-point mask education with a nurse navigator prior to consultation, met with child life specialists prior to DIBH training and 5-point mask creation, and then underwent actual DIBH CT simulation. Patients who underwent DIBH CT simulation had treatment volumes and OARs contoured on a breath hold scan for treatment planning and on a free breathing 4D scan (FBS) for volumetric comparative analysis. All 19 patients were successfully simulated with DIBH; no patient was unable to tolerate simulation with 5-point mask and DIBH. The median age was 17 (range 9-21). Male: female ratio was 8:11. Patients had Stage II (n = 9), III (5), and IV (5) nodular sclerosing HL. Sites of treatment included neck (N), supraclavicular fossa (Sc), and mediastinum (M) in 9, Sc, M, and hila (H) in 3, Sc, M, and axilla (A) in 3, Sc and M in 2, and Sc, M, N, H, and A in 2. Sixteen patients received a total dose of 21Gy, the remaining three patients received 30Gy for residual FDG avid disease. All but 2 patients completed their radiation course using daily DIBH. One patient stopped treatment early due to disease progression, and the other patient was unable to tolerate DIBH during daily treatment. Compared to volumes on FBS, ITV volumes were an average of 242cm3 smaller using DIBH (p = 0.02). There was less ITV volume intersecting the left anterior descending artery (14.2cm3 vs 24.5 cm3, p = 0.02), left ventricle (32.1cm3 vs 54.5 cm3, p = 0.02), aorta (12.2cm3 vs 29.5 cm3, p = 0.02), and lung (67.2cm3 vs 98.5 cm3, p = 0.02) using DIBH compared to FBS. DIBH is feasible in a pediatric patient population with support of multidisciplinary education and coaching, and has the potential to optimize the therapeutic ratio in patients with Hodgkin lymphoma. Reductions in dose to OARs may allow for reduced long term toxicity risk following radiation therapy, and this approach should be considered for select pediatric patients receiving radiation therapy to the mediastinum.