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Objective: To describe the changes to routine pediatric surgical care over the past 2 decades for children living in urban and rural environments. Background: A knowledge gaps exists regarding trends in the location where routine pediatric surgical care is provided to children from urban and rural environments over time. Methods: Children (age 0--18) undergoing 7 common surgeries were identified using State Inpatient Databases (SID, 2002--2017). Rural- Urban Commuting Area codes were used to classify patient and hospital zip codes. Multivariable regression models for distance traveled > 60 miles and transfer status were used to compare rural and urban populations, adjusting for year, age, sex, race, and insurance status. Results: Among 143,467 children, 13% lived in rural zip codes. The distance traveled for care increased for both rural and urban children for all procedures but significantly more for the rural cohort (eg, 102% vs 30%, P< 0.001, cholecystectomy). Transfers also increased for rural children (eg, transfers for appendectomy increased from 1% in 2002 to 23% in 2017, P< 0.001). Factors associated with the need to travel >60 miles included year [adjusted odds ratio (aOR)= 2.18, 95% CI: 1.94--2.46: 2017 vs 2002], rural residence (aOR= 6.55, 95% CI: 6.11--7.01), age less than 5 years (aOR=2.17, 95% CI: 1.92--2.46), and Medicaid insurance (aOR= 1.35, 95% CI: 1.26--1.45). Factors associated with transfer included year (aOR=5.77, 95% CI: 5.26--6.33: 2017 vs 2002), rural residence (aOR=1.47, 95% CI: 1.39--1.56), age less than 10 years (aOR=2.34, 95% CI: 2.15--2.54), and Medicaid insurance (aOR=1.49, 95% CI: 1.42--1.46). Conclusion: Rural children, younger age, and those on Medicaid disproportionately traveled greater distances and were more frequently transferred for common pediatric surgical procedures. [ABSTRACT FROM AUTHOR]