CONTEXT: Endotracheal intubation (ETI) is widely used for airway management of children in the out-of-hospital setting, despite a lack of controlled trials demonstrating a positive effect on survival or neurological outcome. OBJECTIVE: To compare the survival and neurological outcomes of pediatric patients treated with bag-valve-mask ventilation (BVM) with those of patients treated with BVM followed by ETI. DESIGN: Controlled clinical trial, in which patients were assigned to interventions by calendar day from March 15, 1994, through January 1, 1997. SETTING: Two large, urban, rapid-transport emergency medical services (EMS) systems. PARTICIPANTS: A total of 830 consecutive patients aged 12 years or younger or estimated to weigh less than 40 kg who required airway management; 820 were available for follow-up. INTERVENTIONS: Patients were assigned to receive either BVM (odd days; n = 410) or BVM followed by ETI (even days; n = 420). MAIN OUTCOME MEASURES: Survival to hospital discharge and neurological status at discharge from an acute care hospital compared by treatment group. RESULTS: There was no significant difference in survival between the BVM group (123/404 [30%]) and the ETI group (110/416 [26%]) (odds ratio [OR], 0.82; 95% confidence interval [CI], 0.61-1.11) or in the rate of achieving a good neurological outcome (BVM, 92/404 [23%] vs ETI, 85/416 [20%]) (OR, 0.87; 95% CI, 0.62-1.22). CONCLUSION: These results indicate that the addition of out-of-hospital ETI to a paramedic scope of practice that already includes BVM did not improve survival or neurological outcome of pediatric patients treated in an urban EMS system.