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Objectives: To identify the frequency, spectrum and outcome of horse-related injuries in children., Design and Setting: Retrospective case series of horse-related injuries in children admitted to the Children's Hospital at Westmead (CHW) from January 1988 to December 1999, the John Hunter Children's Hospital (JHCH) from January 1991 to December 1997 and deaths reported to the New South Wales Paediatric Trauma Death (NPTD) Registry from January 1988 to December 1999., Main Outcome Measures: Circumstances of injury; helmet use; adult supervision; type and number of injuries identified., Results: 232 children were admitted with horse-related trauma, 97 to the CHW over 12 years and 135 to JHCH over seven years, with one death at each hospital. There were six deaths reported to the NPTD Registry over 12 years. The median age was 11 years (range, 1-17). Girls accounted for 65% of those injured and 75% of children were injured while riding. Falls caused the injury in 76.3% of cases. Head and upper-limb trauma accounted for 216 of the injuries (73%). Five out of six children with severe head injuries died. In the CHW group, helmet use was documented in only 24 riders (38%) and adult supervision in 22 (22.9%)., Conclusions: Horse-related trauma accounts for a considerable number of deaths and injuries in children in NSW. The use of a Standards-approved helmet for riding or horse-related activities might have decreased the severity of head injuries.