OBJECTIVE: To describe the incidence, injury severity, resource use, mortality, and costs for children with gunshot injuries, compared with other injury mechanisms. METHODS: This was a population-based, retrospective cohort study (January 1, 2006-December 31, 2008) including all injured children age #19 years with a 9-1-1 response from 47 emergency medical services agencies transporting to 93 hospitals in 5 regions of the western United States. Outcomes included population-adjusted incidence, injury severity score $16, major surgery, blood transfusion, mortality, and average per-patient acute care costs. RESULTS: A total of 49 983 injured children had a 9-1-1 emergency medical services response, including 505 (1.0%) with gunshot injuries (83.2% age 15-19 years, 84.5% male). The population-adjusted annual incidence of gunshot injuries was 7.5 cases/100 000 children, which varied 16-fold between regions. Compared with children who had other mechanisms of injury, those injured by gunshot had the highest proportion of serious injuries (23%, 95% confidence interval [CI] 17.6-28.4), major surgery (32%, 95% CI 26.1-38.5), in-hospital mortality (8.0%, 95% CI 4.7-11.4), and costs ($28 510 per patient, 95% CI 22 193-34 827). CONCLUSIONS: Despite being less common than other injury mechanisms, gunshot injuries cause a disproportionate burden of adverse outcomes in children, particularly among older adolescent males. Public health, injury prevention, and health policy solutions are needed to reduce gunshot injuries in children. Pediatrics 2013;132:862-870. Copyright © 2013 by the American Academy of Pediatrics.