Pediatric Firearm-related Injuries Research Articles

Trends in pediatric firearm-related injuries and disparities in acute outcomes.

Firearm-related injuries (FRI) are an increasing cause of death and injury in children. The etiology for this rise is multifactorial and includes socioeconomic factors. Despite its prevalence and documented increase over COVID-19, there is a paucity of research on disparities and the influence of social determinants of health (SDH) in pediatric FRI. This study aims to explore the epidemiology of this vulnerable population in Atlanta, trends over time and relevant dates such as COVID-19 and a state firearm law, and disparities in clinical outcomes. Retrospective cohort of patients with FRI (0-20 years-old, x̄=9.8, Median = 11) presenting to our hospital EDs from January 2014 to April 2023 (N = 701) and eligible for the Trauma Registry. This period includes two major events, namely the COVID-19 pandemic (March 2020), and passage of state law Constitutional Carry Act (SB 319) (April 2022), allowing for permit-less concealed firearm carry. Single series interrupted time series (ITS) models were run and clinical outcome differences between race and insurance groups were calculated unadjusted and adjusted for confounders using inverse propensity treatment weights (IPTW). The primary outcome was mortality; secondary are admission and discharge. Majority of FRI involved patients who were male (76.7%), Black (74.9%), publicly insured (82.6%), ≤12 years-old (61.8%), and injured by unintentional shootings (45.6%) or assault (43.7%). During COVID-19, there was a sustained increase in FRI rate by 0.42 patients per 1,000 trauma visits per month (95% CI 0.02-0.82, p = 0.042); post-SB 319 it was 2.3 patients per 1,000 trauma visits per month (95% CI 0.23-4.31, p = 0.029). Publicly insured patients had 58% lower odds of mortality than privately insured patients (OR 0.42, 95% CI 0.18-0.99, p = 0.047). When controlled for race and mechanism of injury, among other confounding factors, this association was not significant (p = 0.652). Pediatric FRI are increasing over time, with disproportionate burdens on Black patients, at our hospitals. Disparities in mortality based on insurance necessitate further study. As social and economic repercussions of COVID-19 are still present, and state firearm law SB 319 is still in effect, assessment of ongoing trends is warranted to inform preventative strategies.

Pediatric firearm injury epidemiology at a level 1 trauma center from 2019 to 2021: including time of the COVID-19 pandemic

BackgroundFirearms are a leading cause of death in children. The demand for firearms increased following COVID-19 “stay-at home orders” in March 2020, resulting in record-breaking firearm sales and background checks. We aim to describe the changes in pediatric firearm-related injuries, demographics, and associated risk factors at a Level 1 trauma center in Houston before and during the COVID 19 pandemic.ResultsThe total number of pediatric firearm-related injury cases increased during March 15th to December 31st, 2020 and 2021 compared to the same time period in 2019 (104 verses 89 verses 78). The demographic group most affected across years were males (87% in 2019 vs 82% in 2020 and 87% in 2021) between 14 and 17 years old (83% in 2019 vs 81% in 2020 and 76% in 2021). There was an increase in firearm injuries among black youth across all years (28% in 2019 vs 41% in 2020 vs 49% in 2021). Injuries in those with mental illness (10% in 2019 vs 24% in 2020 vs 17% in 2021), and injuries where the shooter was a known family member or friend (14% in 2019 vs 18% in 2020 vs. 15% in 2021), increased from 2019 to 2020.ConclusionThe total number of pediatric firearm-related injuries increased during the COVID-19 pandemic compared to the previous year despite a decline in overall pediatric emergency department visits. Increases in pediatric firearm-related injuries in already vulnerable populations should prompt further hospital initiatives including counseling on safe firearm storage, implementation of processes to identify children at risk for firearm injuries, and continued research to mitigate the risk of injury and death associated with firearms in our community.

When public health crises collide: 5 years of pediatric firearm injury prevention opportunities

ObjectivesPrior publications on pediatric firearm-related injuries have emphasized significant social disparities. The pandemic has heightened a variety of these societal stresses. We sought to evaluate how we must now adapt...

Pediatric Firearm-Related Injuries: Taking Kids out of Harm's Way Begins with Targeted Prevention

Pediatric firearm injury is a leading cause of death in children in the United States and the incidence continues to rise each year; however, comprehensive and accurate data on the scope of the problem is lacking. 1 Cunningham RM Walton MA Carter PM The major causes of death in children and adolescents in the united states. N Engl J Med. 2018; (375): 379 Google Scholar National statistics on firearm violence focus almost exclusively on deaths. This information is publicly available through the National Violent Death Reporting System, a state-based resource of violence-related deaths from multiple sources that informs the CDCs Web-Based Injury Statistics and Query System (WISQARS). This database used to contain information on non–fatal firearm injuries, but since 2019 this is no longer being reported as the data was not thought to be accurate enough. Non–fatal firearm injuries are significantly more common in children than fatal injuries, and knowing the full scope of pediatric firearm violence is vital to inform effective prevention efforts. 2 Eber GB Annest JL Mercy JA Ryan GW Nonfatal and Fatal firearm-related injuries among children aged 14 years and younger: united states, 1993-2000. Pediatrics. 2004; 113: 1686-1692 Google Scholar

Pediatric Firearm-Related Injuries: Taking Kids Out of Harm's Way Begins with Targeted Prevention

Firearm-related injury is a public health crisis and remains the 3rd most common cause of death from ages 1 15 years. By evaluating events surrounding such injuries, evidence-based intervention strategies efforts may be targeted to maximize impact. A retrospective chart review was performed for firearm-related injuries in patients 15 years-old and under at an urban Pediatric Level 1 Trauma Center between January 2016 and December 2020. Age, gender, race/ethnicity, injury severity score (ISS), reported cause of injury, timing of injury around school and curfew, and mortality were evaluated. Medical Examiner data identified other deaths that occurred within the hospital's catchment area. There were 195 injuries including 14 from the Medical Examiner. Overall, 82.6% were male with median age of 14 years (range 1-15; IQR 13-15), and median ISS of 5 (IQR 1-10). African-American children comprised 74.9% of the cohort while only representing 35.9% of local schools. Intentional interpersonal injuries comprised 65.6%; 17.4% were bystanders; 7.2% were negligent discharges; and 0.5% suicide. Median age for intentional interpersonal injuries was 14 years (IQR 13-15) compared to 11 years (IQR 8-14, P=0.03) for negligent discharges. Regarding timing, 6.9% of injuries occurred during school hours; 56.4% after school or during non-school days; and 36.7% were after legal curfew. Mortality rate was 17.4%. Firearm safety education and community-based violence intervention should start in the pre-teen years. Pediatric firearm-related injury prevention strategies must be multifaceted addressing structural racism, truancy, curfew violation, extra-curricular activities, childcare options, firearm safety education, violence reduction, suicide prevention, and recidivism.

Financial burden of pediatric firearm-related injury admissions in the United States.

Pediatric firearm-related injuries pose a significant public health problem in the United States, yet the associated financial burden has not been well described. This is the first study examining national data on the cost of initial hospitalization for pediatric firearm-related injuries. In this retrospective review, the Healthcare Cost and Utilization Project Kids’ Inpatient Database from the years 2003, 2006, 2009, and 2012 was used to identify all patients 18 years of age and under who were admitted with firearm-related injuries. We compared demographic and discharge-level data including injury severity score, hospital length of stay, income quartile, injury intent, and inflation-adjusted hospital costs across age groups (0–5, 6–9, 10–15, 16–18 years). There were approximately 4,753 pediatric firearm-related admissions each year, with a median hospitalization cost of $12,984 per patient. Annual initial hospitalization costs for pediatric firearm injuries were approximately $109 million during the study period. Pediatric firearm-related injuries predominately occured among older teenagers (74%, 16–18 years), males (89%), black individuals (55%), and those from the lowest income quartile (53%). We found significant cost variation based on patient race, income quartile, injury severity score, intent, hospital length of stay, disposition, and hospital region. Inflation-adjusted hospitalization costs have increased significantly over the study period (p < 0.001). Pediatric firearm-related injuries are a large financial burden to the United States healthcare system. There are significant variations in cost based on predictable factors like hospital length of stay and injury severity score; however, there are also substantial discrepancies based on hospital region, patient race, and income quartile that require further investigation.

United States trends in healthcare charges for pediatric firearm injuries.

From 2009 to 2016, >21,000 children died and an estimated 118,000 suffered non-fatal injuries from firearms in the United States. Limited data is available on resource utilization by injury intent. We use hospital charges as a proxy for resource use and sought to: 1) estimate mean charges for initial ED and inpatient care for acute firearm injuries among children in the U.S.; 2) compare differences in charges by firearm injury intent among children; and 3) evaluate trends in charges for pediatric firearm injuries over time, including within intent subgroups. In this repeated cross-sectional analysis of the 2009-2016 Nationwide Emergency Department Sample, we identified firearm injury cases among children aged ≤19years using ICD-9-CM and ICD-10-CM external cause of injury codes (e-codes). Injury intent was categorized using e-codes as unintentional, assault-related, self-inflicted, or undetermined. Linear regressions utilizing survey weighting were used to examine associations between injury intent and healthcare charges, and to evaluate trends in mean charges over time. Among 21,951 unweighted cases representing 102,072 pediatric firearm-related injuries, mean age was 16.6years, and a majority were male (88.2%) and publicly insured (51.5%). Injuries were 53.9% assault-related, 37.7% unintentional, 1.8% self-inflicted, and 6.7% undetermined. Self-inflicted injuries had higher mean charges ($98,988) than assault-related ($52,496) and unintentional ($28,618) injuries (p<0.001). Self-inflicted injuries remained associated with higher mean charges relative to unintentional injuries, after adjusting for patient demographics, hospital characteristics, and injury severity (p=0.015). Mean charges for assault-related injuries also remained significantly higher than charges for unintentional injuries in multivariable models (p<0.001). After adjusting for inflation, mean charges for pediatric firearm-related injuries increased over time (p-trend=0.018) and were 23.1% higher in 2016 versus 2009. Mean charges increased over time among unintentional injuries (p-trend=0.002), but not among cases with assault-related or self-inflicted injuries. Self-inflicted and assault-related firearm injuries are associated with higher mean healthcare charges than unintentional firearm injuries among children. Mean charges for pediatric firearm injuries have also increased over time. These findings can help guide prevention interventions aimed at reducing the substantial burden of firearm injuries among children.

Impact of the COVID-19 Pandemic on Pediatric Firearm-Related Injuries in the USA

Impact of the COVID-19 Pandemic on Pediatric Firearm-Related Injuries in the USA

Pediatric Firearm-Related Injuries: Taking Kids out of Harm’s Way Begins with Targeted Prevention Efforts

Soult, Alexa E. MD; Tatebe, Leah C. MD, FACS; Koo, Nathaniel C. MD; Mis, Justin RN; Schlanser, Victoria DO, FACOS; Bokhari, Faran MD, FACS; Dennis, Andrew J. DO, FACOS, FACS Author Information

Guns, scalpels, and sutures: The cost of gunshot wounds in children and adolescents.

Firearm injuries are the second leading cause of death among US children. While injury prevention has been shown to be effective for blunt mechanisms of injury, the rising incidence of accidental gunshot wounds, school shootings, and interpersonal gun violence suggests otherwise for firearm-related injuries. The purpose of the study is to describe the incidence, injury severity, and institutional costs of pediatric gun-related injuries in Colorado. Pediatric patients (≤18 years), who sustained firearm injuries between 2008 and 2018, were identified from the trauma registries of three pediatric trauma centers in Colorado. Patients were stratified based on age: those younger than 14 years were defined as children and those 15 years to 18 years as adolescents. Our cohort (n = 308) was predominantly male (87%), with a median age of 14 years. The overall mortality rate was 11% (34/308), with significantly fewer children (5%) dying from their injuries when compared with adolescents (14%; p = 0.04). Sixty-five (21%) patients required blood product transfusions, with 23 (7.4%) patients receiving a massive transfusion. Overall, 52% (161/308) required a major operation, with 15% undergoing an exploratory laparotomy. One third (4/13) of the patients who had a thoracotomy in the emergency department survived to hospital discharge. Overall, 14.0% of patients had psychiatric follow-up at both 30 days and 1 year. The readmission rate for complications was 11.6% at 30 days and 14% at 1 year. The total cost of care for all pediatric firearm-related injuries was approximately US $26 million. The survivors of pediatric firearm injuries experience high operative and readmission rates, sustain long-term morbidities, and suffer from mental health sequelae. Combining these factors with the economic impact of these injuries highlights the immense burden of disease. This burden may be palliated by a multipronged approach, which includes the development and dissemination of injury prevention strategies and better follow-up care for these patients. Epidemiological, Level III.

4256 Association Between Injury Intent and Emergency Department and Hospital Charges for Pediatric Firearm Injuries in the United States

OBJECTIVES/GOALS: In 2016, more than 3,100 children died, and an estimated 17,000 children had non-fatal injuries, from firearms in the United States. In this study, we used hospital charges as a proxy for medical resource utilization, and compared differences in charges by intent of firearm injury among children. METHODS/STUDY POPULATION: In this cross-sectional study of the 2016 Nationwide Emergency Department Sample, we identified firearm injury cases among children aged 19 years or younger using ICD-10-CM external cause of morbidity codes. Injury intent was characterized as unintentional, assault, self-inflicted, undetermined, or due to legal intervention. We included patients treated and released from the emergency department (ED) or admitted alive to the hospital, and excluded those who were transferred or died in the ED. We used linear regressions with survey weighting to compare differences in mean healthcare charges by firearm injury intent, with and without adjustment for ED disposition. RESULTS/ANTICIPATED RESULTS: Among 12,469 cases in the weighted sample, mean age was 16.5 years, a majority were male (88.2%) and Medicaid-insured (57.8%), and 64% were discharged from the ED and 36% admitted. Injuries were 49.0% unintentional, 45.1% assault-related, and 1.8% self-inflicted. Compared to children with self-inflicted injuries (charges $115,224), children with assault-related injuries (charges $55,052; p&lt;0.007) and unintentional injuries (charges $38,643; p&lt;0.001) had lower mean charges per visit. Differences in charges were no longer significant after adjusting for ED disposition, as 85.8% of self-inflicted injuries were admitted, compared to 46.5% of assault-related and 24.3% of unintentional injuries. DISCUSSION/SIGNIFICANCE OF IMPACT: Although the majority of pediatric firearm-related injuries resulting in emergency department care are unintentional or assault-related, self-inflicted injuries result in greater per visit hospital charges, attributable to higher hospitalization rates, and likely due to more severe injuries.

Applying Behavioral Economics to Enhance Safe Firearm Storage.

Behavioral economics applies key principles from psychology and economics to address obstacles to behavior change. The important topic of pediatric firearm injuries has not yet been explored through a behavioral economic lens. Pediatric firearm-related injuries are a significant public health problem in the United States. Despite American Academy of Pediatrics guidelines advising that firearms be stored unloaded, in a locked box or with a locking device, and separate from ammunition, estimates suggest that ∼4.6 million children live in homes with at least 1 loaded and unlocked firearm. In this article, we use behavioral economic theory to identify specific cognitive biases (ie, present bias; in-group, out-group bias; and the availability heuristic) that may influence parental decision-making around firearm storage. We illustrate situations in which these biases may occur and highlight implementation prompts, in-group messengers, and increased salience as behaviorally informed strategies that may counter these biases and subsequently enhance safe firearm storage. We also describe other opportunities to leverage the behavioral economic tool kit. By better understanding the individual behavioral levers that may impact decision-making around firearm storage, behavioral scientists, pediatric providers, and public health practitioners can partner to design and test tailored interventions aimed at decreasing pediatric firearm injuries. Further empirical study is warranted to identify the presence of specific biases and heuristics and determine the most effective behavior change strategies for different subpopulations.

US Regional trends in pediatric firearm-related injuries

Introduction: Firearm-related injury (FRI) is a major cause of preventable death and disability among children in the United States. However, little is known about regional patterns in pediatric FRI and regional firearms legislation. We hypothesized that regions with more stringent firearm legislation would have a lower incidence of pediatric …

US Regional trends in pediatric firearm-related injuries

US Regional trends in pediatric firearm-related injuries

Regional Differences in Pediatric Firearm-Related Emergency Department Visits and the Association With Firearm Legislation.

The objective of this study was to describe regional and temporal trends in pediatric firearm-related emergency department (ED) visits and investigate association with regional firearm legislation. We conducted a cross-sectional analysis using the Nationwide Emergency Department Sample from 2009 to 2013 for children aged 21 years or younger. We calculated national estimates of firearm-related visits using annual census data and measured trends. We used state-level gun law scores to derive regional scores to measure strictness of firearm legislation. We used multivariable logistic and linear regression to measure regional differences in visits and their association with regional gun law scores, respectively. There were 111,839 (95% confidence interval, 101,248-122,431) ED visits for pediatric firearm-related injuries. Rates of visits varied by region, with the lowest rate in the Northeast and highest rate in the South (40.0 [34-45]; 70.8 [63.7-76.9] per 100,000 ED visits, respectively). Compared with the Northeast, odds of firearm-related ED visits were higher in the Midwest (adjusted odds ratio [aOR], 1.8; 1.4-2.3), West (aOR, 2.5; 2.0-3.2), and South (aOR, 1.9; 1.5-2.4). Firearm-related visits remained consistent over time. A higher (stricter) regional median Brady gun law score was associated with a lower rate of firearm-related visits (β = -0.8; R2 = 0.9; P = 0.03). Rates of pediatric firearm-related ED visits vary by region. Stricter regional gun laws were associated with lower rates of ED visits for pediatric firearm-related injuries. Further study of the social and cultural regional differences in gun ownership and the role of legislation in the prevention of pediatric firearm-related morbidity and mortality is warranted.

Geographic Regions with Stricter Gun Laws Have Fewer Emergency Department Visits for Pediatric Firearm-Related Injuries: A Five-Year National Study

Geographic Regions with Stricter Gun Laws Have Fewer Emergency Department Visits for Pediatric Firearm-Related Injuries: A Five-Year National Study

Pediatric Firearm-Related Injuries in the United States.

Pediatric firearm-related deaths and injuries are a national public health crisis. In this Special Review Article, we characterize the epidemiology of firearm-related injuries in the United States and discuss public health programs, the role of pediatricians, and legislative efforts to address this health crisis. Firearm-related injuries are leading causes of unintentional injury deaths in children and adolescents. Children are more likely to be victims of unintentional injuries, the majority of which occur in the home, and adolescents are more likely to suffer from intentional injuries due to either assault or suicide attempts. Guns are present in 18% to 64% of US households, with significant variability by geographic region. Almost 40% of parents erroneously believe their children are unaware of the storage location of household guns, and 22% of parents wrongly believe that their children have never handled household guns. Public health interventions to increase firearm safety have demonstrated varying results, but the most effective programs have provided free gun safety devices to families. Pediatricians should continue working to reduce gun violence by asking patients and their families about firearm access, encouraging safe storage, and supporting firearm-related injury prevention research. Pediatricians should also play a role in educating trainees about gun violence. From a legislative perspective, universal background checks have been shown to decrease firearm homicides across all ages, and child safety laws have been shown to decrease unintentional firearm deaths and suicide deaths in youth. A collective, data-driven public health approach is crucial to halt the epidemic of pediatric firearm-related injury.

Pragmatic Firearm Advocacy for Pediatricians.

The review article “Pediatric Firearm-Related Injuries in the United States” in this issue of Hospital Pediatrics serves as a timely reminder for all health care providers that we cannot afford to be silent about gun violence. An average of 7 children and teens ages 1 to 19 are killed by guns every day in the United States.1 Pediatric hospitalists are on the front lines of this public health crisis. To uphold our duty as pediatricians to protect and improve the health of children, we must educate ourselves about gun violence and become vocal advocates for sensible, effective solutions. Although firearm safety has been highly politicized, we as physicians know that this is first and foremost a public health issue. Many analogies can be drawn from history. When motor vehicle collisions became a leading cause of mortality, auto manufacturers blamed collisions on the drivers. When evidence emerged regarding the health threat of tobacco, tobacco companies denied the association of cigarette smoke with disease. After hard-fought battles with these industries, regulations were put in place that dramatically decreased morbidity and mortality from these public health threats.2 It is clearly time to do the same for firearms. As with automobile and tobacco regulations, our advocacy must be a pragmatic one. Pediatricians must understand patient and family values and concerns regarding gun ownership. Pediatricians must be able to communicate the risks of firearm ownership to families and children, address controversies and myths, and understand which interventions have been demonstrated by existing data to be most effective in decreasing injury and death. We must understand federal law and the laws in states where we practice. In this commentary, we present a guideline for pragmatic firearm advocacy for pediatricians: key firearm facts that all pediatricians should know, common myths about firearms, interventions that have …

Pediatric Firearm Injuries: Do Database Analyses Tell the Whole Story?

Firearm injuries cause significant morbidity and mortality in the pediatric population and a large economic burden to our health care system. Recent events have increased awareness in the public and in turn for those in the medical field. Many local and national studies have evaluated various aspects of firearm-related injuries across the United States in an effort to identify an intervention that may assist with prevention or management of firearm-related injuries or death in this vulnerable population. In the 1990s, there was a significant decrease in pediatric firearm-related injuries and mortality. The reason for this decline remains unknown with many theories including improved laws, increased awareness, and increased prevention efforts. However, this trend did not continue into the 21st century, and firearms remain one of the leading causes of death in the pediatric population.

Trends in pediatric firearm-related injuries over the past 10 years at an urban pediatric hospital

PurposeFirearm injuries are the second most common cause of trauma deaths in American children. We reviewed gunshot wounds treated at an urban children’s hospital to determine the most likely time for injuries to occur over 10years. MethodsA retrospective chart review was completed for patients with a firearm injury from January 2003 to December 2012. Patients were excluded if over 17years or readmitted. Demographics, injury circumstances, interventions, and outcomes were reviewed for 289 patients. Chi square and ANOVA analyses were completed. Alpha was chosen as p<0.05. ResultsMean age was 12years, 74% were male and 80% African American. Unintentional injuries occurred in 26% and violence related in 72%. The most common months of injury were August and June, the least common November and October. Unintentional injuries were more likely to occur during the day and violence related injuries were more likely at night (p=0.01). The incidence was lowest 2008–2010 and highest in 2006 and 2011. Mortality was 3.5%. ConclusionsWe noted an increasing incidence of pediatric firearm related injuries in the last two years of the study with over half requiring operative intervention. Most injuries were violence related and occurred in a large city during summer months.