Abstract Incidence and significance of respiratory failure after trauma in children was the subject of this study. One thousand nine hundred eighty-nine pediatric trauma patients (aged 18 years or less) were treated at the authors' level I trauma center between 1985 and 1993. Of these, 364 (18%) were intubated. Their mechanisms of injury were: motor vehicle accidents in 93 (25%), pedestrians struck by vehicles in 93 (25%), motorcycle or bicycle accidents in 55 (15%), gunshot and stab wounds in 43 (12%), major burns (>20% BSA) in 31 (9%), 14 of whom also had smoke inhalation, falls in 25 (7%), sport-related injuries in 9 (2%), and child abuse in 8 (2%). Average injury severity score of intubated patients was 27.0 ± 21.4. Average trauma score was 11.7 ± 4.1. Of the intubated patients, 248 (68%) had head injuries, 153 (42%) chest injuries, and 114 (31%) abdominal and pelvic injuries. Ninety-three (25%) of intubated patients died within 5 days of injury: 70 of head injury, 23 of multiple major organ injury. Intubation was required for more than 5 days in 77 patients (21%); 50 (14%) of these patients met criteria for respiratory distress syndrome (RDS): 12 (24% of RDS patients) died. Two of the deaths were multiply traumatized patients, and 10 were patients with burns and smoke inhalation. The authors conclude that RDS is uncommonly the cause of death in pediatric trauma patients. Burned patients with RDS are an exceptional group, with significant mortality.