OBJECTIVE: Pin fixation and rigid immobilization of the head is desirable in many neurosurgical procedures. However, these techniques are associated with complications in infants and young children. A simple modification of a commonly used cranial fixation system allows rigid, safe immobilization of the head in infants and children. INSTRUMENTATION: A standard Mayfield horseshoe headrest and cranial fixation system was adapted to allow simultaneous use of the headrest and three-point pin fixation. The system is compatible with most neuronavigational systems. RESULTS: The combined horseshoe and pin system was used successfully in more than 30 patients ranging in age from 6 months to 14 years. No complications were encountered. CONCLUSIONS: Rigid immobilization is achievable in the pediatric population, facilitating intracranial and frameless stereotaxy procedures.