Background Urban environment impacts on child injury deaths are not well understood in low and middle-income cities.

Methods Vital registration ICD-10 codes identified 179,432 child injury deaths (2010–2016) in 366 Latin American cities of ≥100,000 population (SALURBAL https://drexel.edu/lac/salurbal/overview/). City-level exposures included population (e.g., population density), landscape (e.g., isolation), street design (e.g., intersection density), and social environment (e.g., education, utility connections). Associations were estimated in multilevel negative binomial models (robust variance, population offset) by age-sex groups (<1, 1–4, 5–9, 10–14, 15–19 years) and injury type (transport, non-transport unintentional, suicide, homicide) comparing high to low standardized exposure values.

Results The most frequent child injury deaths were firearm homicides (N=63,296); by age: unintentional suffocation (<1 years), drowning (1–4 years), transport (5–9 years, 10–14 years), and firearm homicide (15–19 years). Child injury death rate types were 5% lower in cities with higher proportion of household water/sewage connections, 10% lower in cities with higher intersection density. Rates were higher in cities with higher isolated urban development. Transport deaths were 15% lower in cities with higher population density, homicide rates were 16% lower in cities with more greenspace, non-transport unintentional death rates were 3% higher in cities with bodies of water, and suicides were 31% lower in cities with higher female secondary education completion.

Conclusion Cities with more sustainable development and favorable socioeconomic characteristics may create safer environments for urban children.

Learning Outcomes 1) City-level urban environment characteristics are important determinants of children’s injury death risk; 2) Sustainable city policies can help prevent child injury deaths.