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BACKGROUND To describe the demographic characteristics and burden of pediatric suicides by firearm in the U.S. using a large all-payer, pediatric inpatient care database. METHODS Children and young adults (<21 years old) were identified with an ICD-9 diagnosis of suicide and self-inflicted injury with a firearm (SIF) in the Kids' Inpatient Database for the study years of 2006, 2009, and 2012. National estimates were obtained using case weighting. Multivariable logistic regression was performed to examine the association between SIF and risk factors while adjusting for various sociodemographic characteristics using separate models incorporating mental health diagnoses. RESULTS There were a total of 613 hospitalizations for SIF during the years under study. Almost four hospitalizations per week occurred, and in-hospital mortality was 39.1%. The mean age of the study population was 17.3 years, and this population was predominantly male (87.5%), white (62.4%), resided in an urban area (43.8%), lived in the South (51.3%), and within the lowest income quartile (33.8%). Mental health (38.3%) and mood disorders (28.3%) were common. Males had a markedly increased likelihood of hospitalization for SIF (aOR 7.56, 95% CI: 5.54-10.30). Children and adolescents from rural environments and those in the South were more likely to have a hospitalization for SIF than respective comparison groups. Using separate regression models, a diagnosis of any mental health disorder increased the likelihood of hospitalization for a SIF (aOR 11.9, 95% CI: 9.51-14.9), mood disorders (aOR 17.2, 95% CI: 13.3-22.3), and depression (aOR 21.3, 95% CI: 16.1-28.3). CONCLUSIONS Pediatric hospitalizations for SIF are a common occurrence with high associated mortality. The prevalence of mental health disorders and their impact on this population highlight the need for early identification and intervention for individuals at risk. LEVEL OF EVIDENCE 3, retrospective.