Firearm injuries in children: Prevention
- Anne C Gill, DrPH, MS, RN
Anne C Gill, DrPH, MS, RN
- Associate Professor of Pediatrics and Medical Ethics
- Baylor College of Medicine
- David E Wesson, MD
David E Wesson, MD
- Professor of Surgery
- Baylor College of Medicine
Firearm injury is a major cause of morbidity and mortality in the United States and an important medical and public health problem. Children may be injured or killed in shootings; may lose parents, siblings, or other relatives in shootings; or may be adversely affected by witnessing shootings. (See "Intimate partner violence: Childhood exposure".)
Pediatric health professionals can provide leadership for improved gun safety through education of patients and families, advocacy for legislation that protects children from firearm injuries, or becoming informed spokespersons for firearm safety.
This topic review will describe the epidemiology of pediatric firearm injury and review strategies for prevention of firearm injuries in children. The primary focus will be on unintentional injuries. Intentional violence is discussed separately. (See "Peer violence and violence prevention" and "Suicidal behavior in children and adolescents: Epidemiology and risk factors".)
Societal issues associated with access to firearms, such as Second Amendment rights and individual freedoms and responsibilities, exceed the scope of this topic review.
Firearm injury is a major cause of morbidity and mortality in the United States and an important medical and public health problem [1-3].
- Dowd MD, Sege RD, Council on Injury, Violence, and Poison Prevention Executive Committee, American Academy of Pediatrics. Firearm-related injuries affecting the pediatric population. Pediatrics 2012; 130:e1416.
- Butkus R, Doherty R, Daniel H, Health and Public Policy Committee of the American College of Physicians. Reducing firearm-related injuries and deaths in the United States: executive summary of a policy position paper from the American College of Physicians. Ann Intern Med 2014; 160:858.
- Fowler KA, Dahlberg LL, Haileyesus T, Annest JL. Firearm injuries in the United States. Prev Med 2015; 79:5.
- Schaechter J, Duran I, De Marchena J, et al. Are "accidental" gun deaths as rare as they seem? A comparison of medical examiner manner of death coding with an intent-based classification approach. Pediatrics 2003; 111:741.
- Hemenway D, Solnick SJ. Children and unintentional firearm death. Inj Epidemiol 2015; 2:26.
- Centers for Disease Control and Prevention. Injury Prevention & Control: Data and Statistics (Web-based Injury Statistics Query and Reporting System [WISQARS]). Fatal Injury Data. https://www.cdc.gov/injury/wisqars/fatal.html (Accessed on January 18, 2017).
- Senger C, Keijzer R, Smith G, Muensterer OJ. Pediatric firearm injuries: a 10-year single-center experience of 194 patients. J Pediatr Surg 2011; 46:927.
- Veenstra M, Patel V, Donoghue L, Langenburg S. Trends in pediatric firearm-related injuries over the past 10 years at an urban pediatric hospital. J Pediatr Surg 2015; 50:1184.
- Centers for Disease Control and Prevention. Injury Prevention & Control: Data and Statistics (Web-based Injury Statistics Query and Reporting System [WISQARS]). Nonfatal Injury Data. https://www.cdc.gov/injury/wisqars/nonfatal.html (Accessed on January 18, 2017).
- Leventhal JM, Gaither JR, Sege R. Hospitalizations due to firearm injuries in children and adolescents. Pediatrics 2014; 133:219.
- Srinivasan S, Mannix R, Lee LK. Epidemiology of paediatric firearm injuries in the USA, 2001-2010. Arch Dis Child 2014; 99:331.
- Newgard CD, Kuppermann N, Holmes JF, et al. Gunshot injuries in children served by emergency services. Pediatrics 2013; 132:862.
- Perkins C, Scannell B, Brighton B, et al. Orthopaedic firearm injuries in children and adolescents: An eight-year experience at a major urban trauma center. Injury 2016; 47:173.
- Faulkenberry JG, Schaechter J. Reporting on pediatric unintentional firearm injury--who's responsible. J Trauma Acute Care Surg 2015; 79:S2.
- Lyons BH, Fowler KA, Jack SP, et al. Surveillance for Violent Deaths - National Violent Death Reporting System, 17 States, 2013. MMWR Surveill Summ 2016; 65:1.
- Wintemute GJ, Teret SP, Kraus JF, et al. When children shoot children. 88 unintended deaths in California. JAMA 1987; 257:3107.
- Smith DR, Cohen J, Lautman B. Child's play: A study of 266 unintentional handgun shootings of children. Center to Prevent Handgun Violence, Washington DC, 1992.
- Center to Prevent Handgun Violence. The killing seasons: A study of when unintentional handgun shootings among children occur. Center to Prevent Handgun Violence, Washington, DC 1989.
- Li G, Baker SP, DiScala C, et al. Factors associated with the intent of firearm-related injuries in pediatric trauma patients. Arch Pediatr Adolesc Med 1996; 150:1160.
- Nance ML, Carr BG, Kallan MJ, et al. Variation in pediatric and adolescent firearm mortality rates in rural and urban US counties. Pediatrics 2010; 125:1112.
- Johnson RM, Coyne-Beasley T, Runyan CW. Firearm ownership and storage practices, U.S. households, 1992-2002. A systematic review. Am J Prev Med 2004; 27:173.
- Johnson RM, Miller M, Vriniotis M, et al. Are household firearms stored less safely in homes with adolescents?: Analysis of a national random sample of parents. Arch Pediatr Adolesc Med 2006; 160:788.
- Connor SM. The association between presence of children in the home and firearm-ownership and -storage practices. Pediatrics 2005; 115:e38.
- Schwebel DC, Lewis T, Simon TR, et al. Prevalence and Correlates of Firearm Ownership in the Homes of Fifth Graders: Birmingham, AL, Houston, TX, and Los Angeles, CA. Health Educ Behav 2014; 41:299.
- Okoro CA, Nelson DE, Mercy JA, et al. Prevalence of household firearms and firearm-storage practices in the 50 states and the District of Columbia: findings from the Behavioral Risk Factor Surveillance System, 2002. Pediatrics 2005; 116:e370.
- Powell KE, Jacklin BC, Nelson DE, Bland S. State estimates of household exposure to firearms, loaded firearms, and handguns, 1991 through 1995. Am J Public Health 1998; 88:969.
- Schuster MA, Franke TM, Bastian AM, et al. Firearm storage patterns in US homes with children. Am J Public Health 2000; 90:588.
- Kann L, McManus T, Harris WA, et al. Youth Risk Behavior Surveillance - United States, 2015. MMWR Surveill Summ 2016; 65:1.
- McNabb SJ, Farley TA, Powell KE, et al. Correlates of gun-carrying among adolescents in south Louisiana. Am J Prev Med 1996; 12:96.
- In the Line of Fire: Youth, Guns, and Violence in Urban America, Aldine Transaction, New York 1995.
- Connorton E, Miller M, Perry MJ, Hemenway D. Mental health and unintentional injurers: results from the national co-morbidity survey replication. Inj Prev 2011; 17:171.
- WISQARS: Cost of Injury Reports. https://wisqars.cdc.gov:8443/costT/ (Accessed on December 16, 2015).
- Fowler PJ, Tompsett CJ, Braciszewski JM, et al. Community violence: a meta-analysis on the effect of exposure and mental health outcomes of children and adolescents. Dev Psychopathol 2009; 21:227.
- American Academy of Family Physicians. Firearms and Safety Issues. www.aafp.org/about/policies/all/weapons-laws.html (Accessed on December 15, 2015).
- Duke N, Resnick MD, Borowsky IW. Adolescent firearm violence: position paper of the Society for Adolescent Medicine. J Adolesc Health 2005; 37:171.
- Nance ML, Krummel TM, Oldham KT, Trauma Committee of American Pediatric Surgical Association. Firearm injuries and children: a policy statement of the American Pediatric Surgical Association. J Am Coll Surg 2013; 217:940.
- Ikeda RM, Dahlberg LL, Kresnow MJ, et al. Studying "exposure" to firearms: household ownership v access. Inj Prev 2003; 9:53.
- Crossen EJ, Lewis B, Hoffman BD. Preventing gun injuries in children. Pediatr Rev 2015; 36:43.
- Rowhani-Rahbar A, Simonetti JA, Rivara FP. Effectiveness of Interventions to Promote Safe Firearm Storage. Epidemiol Rev 2016; 38:111.
- Wintemute GJ, Betz ME, Ranney ML. Yes, You Can: Physicians, Patients, and Firearms. Ann Intern Med 2016; 165:205.
- Roszko PJ, Ameli J, Carter PM, et al. Clinician Attitudes, Screening Practices, and Interventions to Reduce Firearm-Related Injury. Epidemiol Rev 2016; 38:87.
- The Florida Senate. 2011 Florida Statutes. 790.338 Medical privacy concerning firearms; prohibitions; penalties; exception. https://www.flsenate.gov/laws/statutes/2011/790.338 (Accessed on March 04, 2017).
- Dr. Bernd Wollschlaeger et al versus Governor, State of Florida, et al. Appeal from the United States District Court for the Southern District of Florida. February 16, 2017. media.ca11.uscourts.gov/opinions/pub/files/201214009.enbc.pdf (Accessed on March 04, 2017).
- Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, 3rd, Hagan JF, Shaw JS, Duncan PM (Eds), American Academy of Pediatrics, Elk Grove Village, IL 2008.
- Jackman GA, Farah MM, Kellermann AL, Simon HK. Seeing is believing: what do boys do when they find a real gun? Pediatrics 2001; 107:1247.
- Hardy MS. Teaching firearm safety to children: failure of a program. J Dev Behav Pediatr 2002; 23:71.
- Laraque D, Spivak H, Bull M. Serious firearm injury prevention does make sense. Pediatrics 2001; 107:408.
- Azrael D, Miller M, Hemenway D. Are household firearms stored safely? It depends on whom you ask. Pediatrics 2000; 106:E31.
- Farah MM, Simon HK, Kellermann AL. Firearms in the home: parental perceptions. Pediatrics 1999; 104:1059.
- Stennies G, Ikeda R, Leadbetter S, et al. Firearm storage practices and children in the home, United States, 1994. Arch Pediatr Adolesc Med 1999; 153:586.
- Connor SM, Wesolowski KL. "They're too smart for that": predicting what children would do in the presence of guns. Pediatrics 2003; 111:E109.
- Baxley F, Miller M. Parental misperceptions about children and firearms. Arch Pediatr Adolesc Med 2006; 160:542.
- Anglemyer A, Horvath T, Rutherford G. The accessibility of firearms and risk for suicide and homicide victimization among household members: a systematic review and meta-analysis. Ann Intern Med 2014; 160:101.
- Miller M, Azrael D, Hemenway D. Firearm availability and unintentional firearm deaths, suicide, and homicide among 5-14 year olds. J Trauma 2002; 52:267.
- Siegel M, Rothman EF. Firearm Ownership and Suicide Rates Among US Men and Women, 1981-2013. Am J Public Health 2016; 106:1316.
- Centers for Disease Control and Prevention (CDC). Source of firearms used by students in school-associated violent deaths--United States, 1992-1999. MMWR Morb Mortal Wkly Rep 2003; 52:169.
- Kachur SP, Stennies GM, Powell KE, et al. School-associated violent deaths in the United States, 1992 to 1994. JAMA 1996; 275:1729.
- Grossman DC, Reay DT, Baker SA. Self-inflicted and unintentional firearm injuries among children and adolescents: the source of the firearm. Arch Pediatr Adolesc Med 1999; 153:875.
- Grossman DC, Mueller BA, Riedy C, et al. Gun storage practices and risk of youth suicide and unintentional firearm injuries. JAMA 2005; 293:707.
- Miller M, Azrael D, Hemenway D, Vriniotis M. Firearm storage practices and rates of unintentional firearm deaths in the United States. Accid Anal Prev 2005; 37:661.
- Kendrick D, Barlow J, Hampshire A, et al. Parenting interventions and the prevention of unintentional injuries in childhood: systematic review and meta-analysis. Child Care Health Dev 2008; 34:682.
- Albright TL, Burge SK. Improving firearm storage habits: impact of brief office counseling by family physicians. J Am Board Fam Pract 2003; 16:40.
- Grossman DC, Cummings P, Koepsell TD, et al. Firearm safety counseling in primary care pediatrics: a randomized, controlled trial. Pediatrics 2000; 106:22.
- Barkin SL, Finch SA, Ip EH, et al. Is office-based counseling about media use, timeouts, and firearm storage effective? Results from a cluster-randomized, controlled trial. Pediatrics 2008; 122:e15.
- Coyne-Beasley T, Schoenbach VJ, Johnson RM. "Love our kids, lock your guns": a community-based firearm safety counseling and gun lock distribution program. Arch Pediatr Adolesc Med 2001; 155:659.
- Grossman DC, Stafford HA, Koepsell TD, et al. Improving firearm storage in Alaska native villages: a randomized trial of household gun cabinets. Am J Public Health 2012; 102 Suppl 2:S291.
- COUNCIL ON COMMUNICATIONS AND MEDIA. Media Use in School-Aged Children and Adolescents. Pediatrics 2016; 138.
- Himle MB, Miltenberger RG, Gatheridge BJ, Flessner CA. An evaluation of two procedures for training skills to prevent gun play in children. Pediatrics 2004; 113:70.
- Gatheridge BJ, Miltenberger RG, Huneke DF, et al. Comparison of two programs to teach firearm injury prevention skills to 6- and 7-year-old children. Pediatrics 2004; 114:e294.
- Miltenberger RG. Teaching safety skills to children: prevention of firearm injury as an exemplar of best practice in assessment, training, and generalization of safety skills. Behav Anal Pract 2008; 1:30.
- Ismach RB, Reza A, Ary R, et al. Unintended shootings in a large metropolitan area: an incident-based analysis. Ann Emerg Med 2003; 41:10.
- United States General Accounting Office. Accidental shootings: Many deaths and injuries caused by firearms could be prevented. US General Accounting Office; Washington, DC, 1991.
- Milne JS, Hargarten SW, Kellermann AL, Wintemute GJ. Effect of current federal regulations on handgun safety features. Ann Emerg Med 2003; 41:1.
- Vernick JS, Meisel ZF, Teret SP, et al. "I didn't know the gun was loaded": an examination of two safety devices that can reduce the risk of unintentional firearm injuries. J Public Health Policy 1999; 20:427.
- Teret SP, Lewin NL. Policy and technology for safer guns: an update. Ann Emerg Med 2003; 41:32.
- Teret SP, Culross PL. Product-oriented approaches to reducing youth gun violence. Future Child 2002; 12:118.
- Wolfson JA, Teret SP, Frattaroli S, et al. The US Public's Preference for Safer Guns. Am J Public Health 2016; 106:411.
- Safavi A, Rhee P, Pandit V, et al. Children are safer in states with strict firearm laws: a National Inpatient Sample study. J Trauma Acute Care Surg 2014; 76:146.
- Lee LK, Fleegler EW, Farrell C, et al. Firearm Laws and Firearm Homicides: A Systematic Review. JAMA Intern Med 2017; 177:106.
- Santaella-Tenorio J, Cerdá M, Villaveces A, Galea S. What Do We Know About the Association Between Firearm Legislation and Firearm-Related Injuries? Epidemiol Rev 2016; 38:140.
- Anestis MD, Anestis JC, Butterworth SE. Handgun Legislation and Changes in Statewide Overall Suicide Rates. Am J Public Health 2017; 107:579.
- Hahn RA, Bilukha OO, Crosby A, et al. First reports evaluating the effectiveness of strategies for preventing violence: firearms laws. Findings from the Task Force on Community Preventive Services. MMWR Recomm Rep 2003; 52:11.
- Hepburn L, Azrael D, Miller M, Hemenway D. The effect of child access prevention laws on unintentional child firearm fatalities, 1979-2000. J Trauma 2006; 61:423.
- Webster DW, Vernick JS, Vittes K, et al. The Case for Gun Policy Reforms in America. Johns Hopkins Center for Gun Policy and Research, Johns Hopkins Bloomberg School of Public Health. October 2012. www.jhsph.edu/research/centers-and-institutes/johns-hopkins-center-for-gun-policy-and-research/publications/WhitePaper020514_CaseforGunPolicyReforms.pdf (Accessed on December 15, 2015).
- Webster DW, Vernick JS, Zeoli AM, Manganello JA. Association between youth-focused firearm laws and youth suicides. JAMA 2004; 292:594.
- HR3355 - Violent Crime Control and Law Enforcement Act of 1994. https://www.congress.gov/bill/103rd-congress/house-bill/3355 (Accessed on January 26, 2017).
- Koper CS, Roth JA. The impact of the 1994 Federal Assault Weapon Ban on gun violence outcomes: An assessment of multiple outcome measure sand some lessons for policy evaluation. J Quant Criminol 2001; 17:33.
- Mahajna A, Aboud N, Harbaji I, et al. Blunt and penetrating injuries caused by rubber bullets during the Israeli-Arab conflict in October, 2000: a retrospective study. Lancet 2002; 359:1795.
- Hiss J, Hellman FN, Kahana T. Rubber and plastic ammunition lethal injuries: the Israeli experience. Med Sci Law 1997; 37:139.
- Rosenberg ML, Hammond WR. Surveillance the key to firearm injury prevention. Am J Prev Med 1998; 15:1.
- Frattaroli S, Teret SP. Why firearm injury surveillance? Am J Prev Med 1998; 15:2.
- Katcher ML, Agran P, Laraque D, et al. The hospital record of the injured child and the need for external cause-of-injury codes. American Academy of Pediatrics. Committee on Injury and Poison Prevention, 1998-1999. Pediatrics 1999; 103:524.