Background: This paper presents our experience in paediatric tracheostomy in a tertiary children’s hospital and to describe the unique multi-racial and multi-ethnic social demographics involved. Moreover, we would like to highlight an unusual social concern in the state of Sabah, Malaysia and its challenges when treating illegal immigrant children.Methods: A retrospective case note review was conducted for all paediatric patients who underwent tracheostomy between January 2014 to December 2018.Results: Seventy-six patients were recruited. Among them thirteen (17.1%) were illegal immigrant children. The commonest indication for tracheostomy was for prolonged assisted ventilation (60.5%), followed by upper airway obstruction (38.2%) and bronchial toileting (1.3%).Conclusions: This study reflects the current trend in regards to the indication for paediatric tracheostomy. The challenges in treating illegal immigrant children need to be considered on a case by case basis encompassing the family’s economic situation, hospital policies and the child well-being.