OBJECTIVES: We evaluated spatial clustering of pediatric firearm injuries using national 9-1-1 emergency medical services (EMS) responses, locations where these events occurred, and geographic changes over time. METHODS: This was a cross-sectional study from January 1, 2012 through December 31, 2022 using 9-1-1 EMS responses for children in 50 states from the National EMS Information Systems (NEMSIS). For 37 states with continuous data over the study period, we evaluated spatial changes over time. We included children aged 0 to 17 years with a 9-1-1 EMS response including transports, nontransports, and deaths at the scene. We stratified by child (0-10 years) and adolescent (11-17 years) age groups. The outcome was firearm injury, regardless of intent or severity. RESULTS: There were 10 521 575 9-1-1 EMS responses from 30 393 incident zip codes, including 26 101 (0.25%) for firearm injuries (3679 [14.1%] in children and 22 422 [85.9%] in adolescents). Among 3679 children with firearm injuries, 2975 (80.9%) occurred in their home zip code and 1490 (40.5%) occurred in a cluster. Among 22 422 adolescents with firearm injuries, 15 635 (69.7%) occurred in their home zip code and 11 551 (51.5%) occurred in a cluster. Among 37 states (n = 6 103 297 events, n = 11 433 zip codes), 213 of 446 (47.8%) clustered zip codes for children were new in 2022 and 148 of 461 (32.1%) clustered zip codes for adolescents were new. Results were similar when using home zip codes. CONCLUSIONS: There was spatial clustering of pediatric firearm injuries, commonly in their home zip code. The number of zip codes included in pediatric firearm hotspots is increasing.