Background/Objectives: As congenital syphilis incidence continues to increase yearly in the United States (US), recommendations from government and professional organizations aim to inform effective clinical practice, although it is unclear how closely these recommendations are followed. This study surveyed US pediatric specialists regarding their approach to congenital syphilis diagnosis and treatment to examine decision-making relative to practice guidelines and subspecialty. Methods: US pediatric physicians recruited from subspecialty directories were sent an online survey conducted in March–April 2024. The case-based survey elicited diagnostic and treatment decisions for different case definitions of congenital syphilis (proven or highly probable, possible, and less likely). Results: Among 442 respondents (56.8% women, 74.2% age 40–69, 57.7% 15+ years since training completion), 94.1% chose to evaluate and manage proven or highly probable congenital syphilis as recommended whereas only 45.8% did so for congenital syphilis considered less likely. Diagnostic and treatment decisions by infectious disease specialists and other subspecialists differed across case definitions. Conclusions: Physicians’ approaches to congenital syphilis workup and management, including the decision to treat, varied with case presentation where decision-making seemed to diverge from published recommendations and between subspecialists as infection became less likely by case definition.