BACKGROUND: Besides care for injured US military personnel, doctrine also requires life-, limb-, and eyesight-saving care to all injured casualties, including children. This study's objective was to evaluate the burden and epidemiology of pediatric medical care during the past decade of military operations in Iraq and Afghanistan. METHODS: Retrospective review of two military registries of all patients admitted to combat support hospitals and forward surgical teams from 2001 through 2011 was conducted. Pediatric (PED) patients were defined as younger than 18 years. Adult patients were divided into local civilian/noncoalition military (LOCAL) and coalition (COALITION) soldiers. RESULTS: A total of 7,505 PED patients, 25,459 LOCAL adults, and 95,618 COALITION soldiers were analyzed in the primary registry. Children represented 5.8% of all admissions (11% bed days), LOCAL adults represented 20% (36% bed days), and COALITION soldiers represented 74% (53% bed days). PED median (interquartile range) length of stay was 3 days (1-7 days), longer than LOCAL with 2 days (1-6 days), and COALITION with 1 day (1-2 days) (p < 0.001). PED Injury Severity Score (ISS) was 9 (4-16), similar to LOCAL with 9 (4-16) but higher than COALITION with 5 (2-10) (p < 0.001). Mortality in trauma patients was highest in PED (8.5%) compared with LOCAL (7.1%) and COALITION (3%) (p < 0.01). Mechanisms of injury for PED trauma were blast (37%), penetrating (27%), blunt (23%), and burn (13%). Factors independently associated with PED mortality included ISS (odds ratio, 95% confidence interval) (1.08, 1.06-1.09), Glasgow Coma Scale (GCS) score (0.85, 0.82-0.88), base excess (0.87, 0.85-0.90), female sex (1.73, 1.18-2.52), age less than 8 years (1.43, 1.00-2.04), and burns (3.17, 1.89-5.32). CONCLUSION: Deployed medical facilities not staffed or equipped to typical civilian standards have a high burden of pediatric casualties requiring care. The cause of increased mortality in pediatric versus adult populations despite similar severity of injury is potentially multifactorial. Military medical planners need to consider pediatric resources and training to improve outcomes for children injured during combat. LEVEL OF EVIDENCE: Epidemiologic study, level III.