In India, acute respiratory illnesses (ARIs), including pneumonia, are the leading cause of early childhood death. Emergency medical services (EMS) in India have been shown to be a critical component in the public health infrastructure; however, literature on the prehospital care of pediatric patients in low- and middle-income countries (LMICs) is severely limited. This study describes the demographic, environmental, and clinical characteristics associated with 30-day mortality among pediatric patients transported via EMS in India with an acute respiratory complaint. We conducted a prospective observational study of patients <18 years using EMS for “shortness of breath” or a primary chief complaint of “fever” with a secondary complaint of “difficulty breathing” or “cough” across 7 Indian states from June 20 to September 2, 2016. The primary outcome was 2, 7, and 30-day mortality. Baseline descriptive characteristics are provided as numbers and percents. Multivariate modeling, owing to predictors of increased mortality at 7 and 30 days, was constructed. A total of 1443 pediatric patients <18 years of age were enrolled during the study period: 981 (68.5%) were collected from the field, and 452 (31.5%) were interfacility transports (IFTs). Response rates were 87.0%, 85.8%, and 83.4% (N=1222) at 2, 7, and 30 days, respectively. The median age of all patients was 2 years (IQR: 0.17-10); 93.9% (N=1347) of patients lived on family incomes below the poverty level; and 54.1% (N=706) were male. The majority of calls were to rural or tribal areas (N=1122; 78.2%), with an average length of transport from initial call to health facility of 72 mins (IQR: 47-105). Overall cumulative mortality at 2, 7, and 30-days was 5.2%, 7.1%, and 7.7%, respectively, with a total of 94 deaths by 30-days. Stratified by age, the largest burden of mortality fell to neonates (0-28 days) with a mortality of 17.0% at 30-days, while under-5 mortality (U5M) was 9.8% during the same follow-up period. IFT patients carried an almost 3-fold risk of death as compared to field transports (14% versus 5%, p value<0.0001). In multivariate modeling evidence of an oxygen saturation <95% in the prehospital setting (OR: 3.18 CI: 1.77-5.71), respiratory distress (OR: 3.72 CI: 2.17-6.36) and familial use of an open cook stove (OR: 2.61 CI: 1.59-4.29), were the strongest predictors of mortality at 30 days among all patients. This is the first known study to detail the out-of-hospital clinical predictors of death among pediatric patients with shortness of breath in a LMIC. EMS rapidly connects critically ill children to needed care in India. Despite this, U5M remains high. While national case fatality rates (CFRs) for India are not widely published, U5M from ARIs remains higher than various previously published hospital-based studies (CFR range: 3.8%-8.1%) and significantly more than published CFRs for developed countries (range: 0.4%-4.8%). The risk of death remains particularly acute for those patients transported as IFTs and among those with respiratory distress, or hypoxia. Early recognition of critically ill children, targeted out-of-hospital interventions, and diversion to higher level of care may help to mitigate the burden of mortality in this population.