Dolutegravir (DTG) is recommended as first-line antiretroviral therapy for children because of its high efficacy and favorable safety profile. However, pediatric real-world data remain scarce in Chad. This study evaluated clinical, nutritional and virological outcomes among children and adolescents receiving DTG-based regimens at the University Hospital of Mother and Child in N’Djamena. A retrospective before–after cohort study included patients aged <18 years who received DTG for ≥6 months. Sociodemographic, clinical, anthropometric and biological data were extracted from records. Outcomes included changes in weight, BMI, WHO stage and viral load at 12 months. Paired t-tests and chi-square tests were used. Factors associated with undetectable viral load (<50 copies/mL) were analyzed through bivariate methods. A total of 113 participants were included (mean age 13.4 years; 53.1% male). After 12 months, median weight gain was +4 kg and normal BMI increased from 46.0% to 92.9%. WHO stages I–II rose from 80.1% to 96.4%. High viral load decreased from 75.2% to 9.7%, while undetectable viral load rose from 9.7% to 77.8% (p < 0.001). DTG was well tolerated, with 86.7% reporting no adverse effects. Clinical evolution was favorable in 78.8%, although mortality remained notable (9.7%). No factor was significantly associated with viral suppression. DTG-based regimens led to substantial clinical and virological improvements among children and adolescents in routine care. These findings support DTG as an effective first-line option in pediatric HIV programs. Strengthening adherence and follow-up may further improve outcomes.