Background: Pediatric colorectal cancer (CRC) is rare. Comparison with adult CRC tumors, management, and outcomes may identify opportunities for improvement in pediatric CRC care. Study Design: CRC patients in the National Cancer Data Base from 1998 to 2011, were grouped into Pediatric (≤ 21 years), early onset adult (22–50) and older adult (> 50) patients. Groups were compared with χ2 and survival analysis. Results: A total of 918 pediatric (Ped), 157,779 early onset adult (EA), and 1,304,085 older adults (OA) were identified (p < 0.01 for all comparisons). Patients ≤ 50 presented more frequently with stage 3 and 4 disease (Ped: 62.0%, EA: 49.7%, OA: 37.3%) and rectal cancer (Ped: 23.6%, EA: 27.5%, OA: 19.2%). Pediatric histology was more likely signet ring, mucinous, and poorly differentiated. Initial treatment was usually surgery, but patients ≤ 50 were more likely to have radiation (Ped: 15.1%, EA: 18.6%, and OA: 9.2%) and chemotherapy (Ped: 42.0%, EA: 38.2%, and OA: 22.7%). Children and older adults showed poorer overall survival at 5 years when compared to early onset adults. Adjusting for covariates, age ≤ 21 was a significant predictor of mortality for colon and rectal cancers (colon HR: 1.22, rectal HR: 1.69). Conclusions: This is the largest cohort of pediatric CRC patients, revealing more aggressive tumor histology and behavior in children, particularly in rectal cancer. Despite standard oncologic treatment, age ≤ 21 was a significant predictor of mortality. This is likely owing to worse tumor biology rather than treatment disparities and may signal the need for different therapeutic strategies.