Background Massive transfusion (MT) in pediatric trauma has been described in combat populations and other single institutions studies. We aim to define the incidence of MT in a large US civilian pediatric trauma population, identify predictive parameters of MT, and the mortality associated with MT. Methods Data from the National Trauma Databank (2010-2012), a trauma registry maintained by the American College of Surgeons, were analyzed. We included pediatric trauma patients ≤14 y that underwent MT, as defined by 40 mL/kg of blood products within the first 24 h after admission. We compared the MT group with children receiving any transfusion within the same time frame. Univariate and multivariate analysis were performed. Results Of 356,583 pediatric trauma patients, 13,523 (4%) received any transfusion in the first 24 h and 173 (0.04%) had a MT. On multivariate analysis, factors predicting MT were: older patients (5-12: OR 2.71, P = 0.006, and ≥12: OR 5.14, P < 0.001), hypothermic patients (temperature <35: OR 2.48, P < 0.025), low Glasgow Coma Scale (Glasgow Coma Scale <8: OR 2.82, P = 0.009), and Injury Severity Scores ≥25 (OR 2.01, P = 0.03). Overall mortality for the entire group, any transfusion group, and MT group were 2.5%, 13.6%, and 50.6%, respectively (P < 0.001). Conclusions MT in pediatric trauma is an uncommon event associated with a significant mortality. Patients undergoing MT are older, more likely to be hypothermic and have sustained more severe injuries as measured by traditional trauma scoring systems than transfused trauma patients.