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Objective: To study the causes of head injuries among the paediatric population in Singapore, and the association between causes and mortality, as well as the need for airway or neurosurgical intervention., Design: This is a prospective observational study utilising data from the trauma surveillance system from January 2011 to March 2015., Setting: Paediatric emergency departments (EDs) of KK Women's and Children's Hospital and the National University Health System., Participants: We included children aged <16 years presenting to the paediatric EDs with head injuries who required a CT scan, admission for monitoring of persistent symptoms, or who died from the head injury. We excluded children who presented with minor mechanisms and those whose symptoms had spontaneously resolved., Primary and Secondary Outcome Measures: Primary composite outcome was defined as death or the need for intubation or neurosurgical intervention. Secondary outcomes included length of hospital stay and type of neurosurgical intervention., Results: We analysed 1049 children who met the inclusion criteria. The mean age was 6.7 (SD 5.2) years. 260 (24.8%) had a positive finding on CT. 17 (1.6%) children died, 52 (5.0%) required emergency intubation in the ED and 58 (5.5%) underwent neurosurgery. The main causes associated with severe outcomes were motor vehicle crashes (OR 7.2, 95% CI 4.3 to 12.0) and non-accidental trauma (OR 5.8, 95% CI 1.8 to 18.6). This remained statistically significant when we stratified to children aged <2 years and performed a multivariable analysis adjusting for age and location of injury. For motor vehicle crashes, less than half of the children were using restraints., Conclusions: Motor vehicle crashes and non-accidental trauma causes are particularly associated with poor outcomes among children with paediatric head injury. Continued vigilance and compliance with injury prevention initiatives and legislature are vital., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)