Objectives: The purpose of this investigation was to determine the incidence and character of pediatric emergencies on a US-based commercial airline and to evaluate current in-flight medical kits. Methods: In-flight consultations to a major US airline by a member of our staff are recorded in an institutional database. In this observational retrospective review, the database was queried for consultations for all passengers up to 18 years old between January 1, 1995, and December 31, 2002. Consultations were reviewed for type of emergency, use of the medical kit, and unscheduled landings. Results: Two hundred twenty-two pediatric consultations were identified, representing 1 pediatric call per 20,775 flights. The mean age of patients was 6.8 years. Fifty-three emergencies were pre-flight calls, and 169 were in-flight pediatric consultations. The most common in-flight consultations concerned infectious disease (45 calls, 27%), neurological (25 calls, 15%), and respiratory tract (22 calls, 13%) emergencies. The emergency medical kit was used for 60 emergencies. Nineteen consultations (11%) resulted in flight diversions (1/240,000 flights), most commonly because of in-flight neurological (9) and respiratory tract (5) emergencies. International flights had a higher incidence than domestic flights of consultations and diversions for pediatric emergencies. Conclusions: The most common in-flight pediatric emergencies involved infectious diseases and neurological and respiratory tract problems. Emergency medical kits should be expanded to include pediatric medications.