Context An increasing number of compact pickup trucks can accommodate restrained rear occupants. Rear seats in these pickup trucks are exempt from regulatory safety testing though their relative safety has not been determined. Objectives To evaluate the risk of injury to children in compact extended-cab pickup trucks compared with children in other vehicles and to determine if any unique hazards exist. Design Cross-sectional study of children aged 15 years or younger in crashes of insured vehicles, with data collected via insurance claim records and a telephone survey. Setting and Participants Probability sample of 7192 multirow vehicles involved in crashes, with 11335 child occupants, in 3 large US regions from December 1, 1998, to November 30, 2000. Main Outcome Measure Relative risk of injury, defined as concussions and more serious brain injuries, spinal cord injuries, internal organ injuries, extremity fractures, and facial lacerations, estimated by odds ratios (ORs) adjusting for age, restraint use, point of impact, vehicle weight, and crash severity. Results Injuries were reported for 1356 children, representing 1.6% of the population. Children in compact extended-cab pickup trucks were at greater risk of injury than children in other vehicles (adjusted OR, 2.96; 95% confidence interval [Cl], 1.685.21). Children in the rear seats of compact pickup trucks were at substantially greater risk of injury than rear-seated children in other vehicles (adjusted OR, 4.75; 95% Cl, 2.39-9.43). Children seated in the front seat of compact extended-cab pickup trucks were at greater risk of injury than children in the front seats of other vehicles, but this risk was not statistically significant (adjusted OR, 1.70; 95% Cl, 0.78-3.69). Conclusions Children in compact extended-cab pickup trucks are not as safe as children in other vehicles, primarily due to the increased relative risk of injury in the back seat. For families with another choice of vehicle, clinicians should advise parents against transporting children in compact pickup trucks. The current exemption for regulatory testing for occupant protection in the rear seats of compact pickup trucks should be reconsidered.; Children who sit in the back seat of a compact extended-cab pickup truck have a higher risk of injury than children who sit in other vehicles. These pickup trucks have a small back seat area, but it contains side-facing fold-down seats that are exempt from regulatory safety testing.