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Objective This observational study examined national trends in injury fatality rates among children and adolescents in urban versus rural areas by intent (ie, unintentional, suicide, homicide/legal intervention and undetermined).Methods We used data from the 2014 to 2023 National Vital Statistics System’s Multiple Cause of Death datafile for children and adolescents aged 0–19. We conducted joinpoint regression analysis to identify changes over time for each intent type in urban and rural areas.Results Between 2014 and 2023, there were 145 125 deaths among US children and adolescents due to injuries. Approximately 60% of the injury deaths were attributed to motor vehicle traffic, firearm and drug poisoning in both urban and rural areas. Injury death rates across all intents increased by 3.0% per year on average in urban areas and by 1.7% per year on average in rural areas. In urban areas, homicide/legal intervention death rates increased significantly by 5.9% per year on average, followed by undetermined (5.5% per year), unintentional (2.5% per year) and suicide (1.5% per year) from 2014 to 2023. During that period in rural areas, homicide/legal intervention death rates increased significantly by 6.6% per year on average.Conclusions Our study identifies the patterns of injury deaths in urban and rural children and adolescents by intent type and calls for tailored approaches to injury prevention.