Background Sparse data are available on prehospital care by Helicopter Emergency Medical Service (HEMS) for pediatric patients with traumatic brain injury (TBI). This study focusses on prehospital interventions, neurosurgical interventions and mortality in this group. Methods We performed a retrospective analysis of pediatric (0–18 years of age) patients with TBI treated by Rotterdam HEMS. Results From January 2012 to December 2017 415 pediatric (<18 years of age) patients with TBI were included. Intubation was required in in 92 of 111 patients with GCS ≤ 8, 92 (82.9%), compared to 12 of 77 (15.6%) with GCS 9–12, and 7 of 199 (3.5%) with GCS 13–15. Hyperosmolar therapy (HSS) was started in 73 patients, 10 with a GCS ≤8. Decompressive surgery was required in 16 (5.8%), nine patients (56.3%) of these received HSS from HEMS. Follow-up data was available in 277 patients. A total of 107 (38.6%) patients were admitted to a (P)ICU. Overall mortality rate was 6.3%(n = 25) all with GCS ≤8, 15 (60.0%) died within 24 hours and 24 (96.0%) within a week. Patients with neurosurgical interventions (N = 16) showed a higher mortality rate (18.0%). Conclusions The Dutch HEMS provides essential emergency care for pediatric TBI patients, by performing medical procedures outside of regular EMS protocol. Mortality was highest in patients with severe TBI (n = 111) (GCS≤8) and in those who required neurosurgical interventions. Despite a relatively good initial GCS (>8) score, there were patients who required prehospital intubation and HSS. This group will require further investigation to optimize care in the future.