The distribution of the cause, rate and nature of fatal and major non-fatal injuries in children living in Metropolitan Toronto and their trends from 1986 to 1991 were systematically reviewed from hospital discharge records and coroner's records. A total of 11,024 non-fatal injuries, of which falls were the leading cause (45%), and 133 fatal injuries, of which intentional injury (21%) was the principal cause, occurred during the six-year study period. The non-fatal injury rate dropped 23%, from 567 to 436 per 100,000 children. Mortality rates also fell during the study period. However, injuries to motor vehicle occupants and drownings increased considerably. Fractures of various kinds were the most common clinical diagnosis. Protecting children in motor vehicles by promoting the use of proper restraints and preventing injuries caused by falls and drowning should be high priorities for childhood injury prevention in Metropolitan Toronto.