REVIEW ARTICLE

Pediatric Firearm-Related Injuries in theUnited StatesKavita Parikh, MD, MSHS,a Alyssa Silver, MD,b Shilpa J. Patel, MD, MPH,c Sabah F. Iqbal, MD,c Monika Goyal, MD, MSCEc

A B S T R A C T Pediatric firearm-related deaths and injuries are a national public health crisis. In this SpecialReview Article, we characterize the epidemiology of firearm-related injuries in the United States anddiscuss public health programs, the role of pediatricians, and legislative efforts to address this healthcrisis. Firearm-related injuries are leading causes of unintentional injury deaths in children andadolescents. Children are more likely to be victims of unintentional injuries, the majority of whichoccur in the home, and adolescents are more likely to suffer from intentional injuries due to eitherassault or suicide attempts. Guns are present in 18% to 64% of US households, with significantvariability by geographic region. Almost 40% of parents erroneously believe their children areunaware of the storage location of household guns, and 22% of parents wrongly believe that theirchildren have never handled household guns. Public health interventions to increase firearm safetyhave demonstrated varying results, but the most effective programs have provided free gun safetydevices to families. Pediatricians should continue working to reduce gun violence by asking patientsand their families about firearm access, encouraging safe storage, and supporting firearm-relatedinjury prevention research. Pediatricians should also play a role in educating trainees about gunviolence. From a legislative perspective, universal background checks have been shown to decreasefirearm homicides across all ages, and child safety laws have been shown to decrease unintentionalfirearm deaths and suicide deaths in youth. A collective, data-driven public health approach is crucialto halt the epidemic of pediatric firearm-related injury.

aHospitalist Division,Children’s National HealthSystem, Washington, DC;

bDivision of PediatricHospital Medicine,Children’s Hospital

at Montefiore, Bronx,New York; and cDivisionof Emergency Medicine,

Children’s National HealthSystem, Washington, DC

www.hospitalpediatrics.orgDOI:https://doi.org/10.1542/hpeds.2016-0146Copyright © 2017 by the American Academy of Pediatrics

Address correspondence to Kavita Parikh, MD, MSHS, Hospitalist Division, Children’s National Medical Center, 111 Michigan Ave NW,Washington, DC 20010. E-mail: kparikh@childrensnational.org

HOSPITAL PEDIATRICS (ISSN Numbers: Print, 2154-1663; Online, 2154-1671).

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

FUNDING: No external funding.

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

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Firearm-related injuries and fatalities area dangerous reality for children andadolescents in the United States. Thefirearm-related fatality rate is 49 timeshigher for 15- to 24-year-olds in theUnited States than in other high-incomecountries.1 Globally, 9 out of 10 children,15 years of age killed by firearms residein the United States.1 Data from the Centersfor Disease Control and Prevention (CDC)reveal that firearm-related injuries areleading causes of injury deaths in youth.2

Homicide by firearms is the fourth leadingcause of injury death in 5- to 9-year-olds and10- to 14-year-olds and the second leadingcause in 15- to 19-year-olds. In addition,suicide by firearm ranks as the third mostcommon cause of death in children 10 to14 and 15 to 19 years of age.2 Across allages, in 2014 firearm injuries wereresponsible for the same number of deathsin the United States as motor vehiclecrashes.3

The morbidity, mortality, and financialcosts of firearm-related violencedemonstrate why guns have become apublic health issue. The rate of firearm-related injuries in the United States hasremained stable since the 1990s,whereas this rate in other countries hasdecreased during the same time period.4

Firearm-related injuries were responsiblefor .35 000 deaths (all ages, 2015 data)in the United States, and the medicalcost of treating firearm-related injuriesin children and young adults ,21 yearsold was .$330 million (2010 cost data)2

(Table 1). This review discusses theavailable evidence on the epidemiologyof firearm-related injuries in pediatricsand the public health interventions,

the role of pediatricians, and the impact oflegislation.

PEDIATRIC FIREARM-RELATEDINJURIES AND HEALTH CAREUTILIZATION

In 2015, there were 4500 deaths fromfirearm violence in children and youngadults ,21 years of age.2 Firearm-relatedmortality is one of the top 4 causes of deathin American youth.2 In pediatric firearminjuries presenting to US emergencydepartments (EDs) or ambulatory carecenters from 2001 to 2010, one-third wererelated to homicide or suicide, but themajority of firearm-related injuries wereunintentional or accidental injuries.5

Younger children are more likely to beunintentionally injured, and the majority ofthese accidental shootings occur in thehome.6 Homicide and suicide by firearmsare the second and third leading causes ofdeath, respectively, for adolescents 15 to19 years of age.2

EDs are an important point of entry intothe health care system for victims offirearm-related injuries. Approximately20 000 children present for care to the EDfor firearm-related injuries every year.5

Children ,12 years of age account for 10%of all firearm-related ED visits by childrenand adolescents, and those 12 to 19 years ofage account for the remaining 90%.5 Forevery child killed, a substantially greaternumber are seriously injured, and ∼50% ofchildren hospitalized for a firearm-relatedinjury are discharged from the hospital witha disability.7

Pediatric ED evaluations andhospitalizations due to firearm-relatedinjuries are a health care and financial

burden.5 Hospitalization data from theAgency for Healthcare Research and QualityHealthcare Cost and Utilization Project Kids’Inpatient Database revealed that there were.7000 hospitalizations for firearm-relatedinjuries in US children and adolescents in2009.8 On average, 20 US children andadolescents were hospitalized each day forfirearm-related injuries. Hospitalizationsdue to injuries from assault were the mostfrequent (61.7%), whereas hospitalizationsdue to suicide attempt were infrequent(3.7%). In children ,10 years of age,hospitalization due to unintentional firearminjuries was most common (74.2%); incontrast, in adolescents (ages 15–19 years),the majority of hospitalizations were relatedto assault (66.8%).8

FIREARM ACCESS IN CHILDRENAND ADOLESCENTS

An understanding of routes of firearmaccess in the pediatric population isimportant to help guide interventions.Surveys conducted in different parts of theUnited States demonstrate significantvariability in firearm ownership amongfamilies with children.9–11 In a survey of424 parents of children 4 to 12 years of agein suburban areas by Atlanta, Georgia,.25% of parents reported having firearmsin their homes; however, ,50% reportedstoring them safely.10 In another survey of314 families with children 5 to 14 years ofage in rural Alabama, 64% reported thepresence of $1 firearm in the home.11 In alarger survey of .5000 fifth-graders andtheir caregivers from 3 different USmetropolitan areas (conducted 2004–2006),18% of surveyed families reported firearmsin their homes.9 According to that survey,

TABLE 1 Total Medical Cost and Number of Nonfatal and Fatal Firearm Injuries for Ages 0–21 in the United States, 2010

Unintentional, Cost (No.) Other Assault, Cost (No.) Self-Harm, Cost (No.) Total, Cost (No.)

ED treat and release (nonfatal) $4 893 000 (2513) $28 249 000 (9837) $63 000 (23) $34 204 000 (12 374)

Hospitalization (nonfatal) $23 312 000 (1316) $205 791 000 (9074) $25 458 000 (571) $254 561 000 (10 962)

Death (fatal) $2 152 000 (166) $33 168 000 (2894)a $6 560 000 (1218)b $41 881 000 (4 278)

Total $330 646 000

Cost expressed in 2010 US prices. Source: National Center for Injury Prevention and Control, CDC, National Center for Health Statistics, National Vital StatisticsSystem.a Includes homicide, undetermined, and legal intervention categories.b Includes suicide category.

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families with African American and Hispanicchildren had lower odds of firearmownership than families of non-Hispanicwhite children, and only 6% of families withfirearms stored firearms safely (locked,unassembled, with trigger locks, and withammunition locked up). Families of non-Hispanic white children were less likely thanfamilies with African American children toengage in safer storage practices.Protection from crime and hunting werereported as the most common reasons forownership.9

A few surveys have also reported on thebehavior of young children who encounterhousehold guns. In 1 survey, when askedwhat their child would do if he or sheencountered a gun, nearly 75% of parentsreported that the child would not touch thegun.10 However, in another observationalstudy of gun behavior among school-ageboys, the majority of the boys handled a gunafter discovering it hidden in a drawer, andalmost 50% pulled the trigger.12 In anotherstudy, 73% of children ,10 years old livingin homes with guns reported knowing thelocation of their parents’ firearms, and 36%admitted they had handled the weapons.11 Ofnote, 39% of parents from that study whoreported that their children did not knowthe storage location of household guns and22% of parents who reported that theirchildren had never handled a householdgun were contradicted by their child’sreport. These studies reinforce the need forsafe storage practices for household gunsand the need for parents to talk to theirchildren about firearms.

The 2011 National Youth Risk BehaviorSurveillance reported that ∼5% of studentsin grades 9 through 12 had carried a gun inthe past month.13 Furthermore, a recentsurvey of .3000 high school seniors foundthat 65% reported having $1 gun in theirhousehold. The likelihood of gun ownershipwas higher among white men and boys, andgun access was not associated with mentalhealth status.14 There have been few studiesevaluating screening practices and firearmaccess among adolescents in the healthcare setting. One study of pediatricresidents from various residency programsfound that only 50% reported screening for

firearm access during routine adolescenthealth visits.15 An ED-based survey thatenrolled 300 adolescents presenting forcare regardless of presenting complaintfound that 16% reported having a gun intheir home, and 28% stated they couldaccess a loaded gun within 3 hours.16

Furthermore, .50% of adolescentsscreened for firearm access stated that theyhad a friend or relative who owned a gun,and almost 50% reported that they knewsomeone who had previously been shot.16

Interestingly, a study evaluating differencesin firearm accessibility between patients inthe ED who presented for violence-relatedinjuries and non–violence-related concernsfound no difference in access to firearmsbetween the 2 groups.17 Given the highprevalence of firearm access amongadolescents, universal screening for accessto firearms in adolescents may be abeneficial strategy.

INTERVENTIONS TO IMPROVEFIREARM SAFETY

Firearms are common in US householdswith children, and some studies have shownthat counseling parents can improve gunsafety in the home.18,19 Most families arewilling to discuss gun safety with healthcare providers,20 and counseling by healthcare providers results in safer storagepractices in the home.21 Interventionstargeting counseling can take place in theED, outpatient, or inpatient settings, andTables 2 and 3 describe interventionsfocused on improving gun safety. Table 2describes 6 studies with positive impact onincreased gun safety in the home, andTable 3 describes 7 studies with nullfindings. Of note, 3 of the 6 interventionswith positive findings provided free gunsafety devices (locks or cabinets) tofamilies, whereas the null studies involvedinterventions focused on verbal and writtencounseling for firearm safety.

Many ED-based public health interventionshave capitalized on the notion of a“teachable moment,” or an event thatmotivates people to adopt risk-reducingbehaviors. In a random sample ofemergency physicians, the majoritysurveyed did not believe that their patientswould be receptive to firearm safety

counseling.22 However, studies demonstratethat parents who are advised by EDclinicians or mental health clinicians torestrict access to firearms after a childpresents with a mental health concern aremore likely to do so than parents who arenot advised to restrict access.23,24

Furthermore, several ED and inpatient-instituted youth violence intervention andcounseling programs have been successfulin decreasing the frequency of violentaggression and criminal justiceinvolvement.25–27

Community and clinic-based interventionshave also been successful at improvingfirearm safety. Table 2, adapted from asystematic review that analyzed communityand clinic-based studies examining safefirearm storage interventions,28 describes afew of these studies. Barkin et al21

conducted a large cluster randomizedcontrolled multicenter study via thePediatric Research in Office Settingsnetwork to analyze the efficacy of office-based counseling focused on violenceprevention, specifically media use, corporalpunishment, and firearm access. Theseauthors highlighted health care clinicians’struggles with their role in addressingviolence prevention, specifically lack of time,inadequate training, and uncertainty ofimpact. In response, the investigatorsconducted a study to compare a bundle ofinterventions focusing on violenceprevention with usual care. Theinterventions included the use of a previsitsummary by parents to assess behaviorsand concerns about media use, disciplinestrategies, and children’s exposure tofirearms; brief motivational interviewing byclinicians; the provision of tangible tools forparents (ie, gun cable locks); and referral tolocal agencies for behavioral or aggressionconcerns.21 The authors reported that theodds of storing all firearms with a gun lockin the intervention group was twice that ofthe nonintervention group.21 In addition,investigations by Carbone et al29 andGrossman et al30 reported increased gunsafety after family education and provisionof gun safety devices. Interventions in high-risk populations (eg, children with mentalhealth disorders or families who own guns)by Kruesi et al,23 Albright and Burge,31 and

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TABLE2

StudiedInterventions

With

PositiveFindings

(ie,Improved

GunSafety)

FirstAuthor,Year

StudyDesign

StudySetting

StudyPopulation

InterventionGroup

Results

Limitations

KeyConclusions

Kruesi,19992

3Quasiexperimental

MidwestruralED,

Illinois

Parentsof6-to

19-y-old

patientsseen

inthe

EDforamental

health

assessment

Means

restrictionverbal

counselingto

limitaccess

tolethal

weapons

targetingparentsof

youth

atrisk

forsuicide(n5

41)

Increasedlikelihoodof

lockingup

ordisposing

offirearmsinthosewho

hadguns

inthehome

Notrandom

ized,small

samplesize,self-

reported

data

Means

restrictioncounseling

delivered

toparentsof

childrenseen

formental

health

assessmentin

anED

may

increase

likelihoodof

decreasing

access

tofirearms.

0of

7control,5of

8intervention(P

,.05)

Albright,20033

1Quasiexperimental

(3-arm

)Family

practiceclinic,

urbancommunity-

based,university

affiliatedteaching

clinic,Texas

Adultpatientsor

families

ofchildren

attendingclinicvisits

(mostly

femaleand

Hispanic);restricted

togunow

ners

Group1:survey

andverbal

counseling(n

536)

Madesafe

changes:31%

control,64%

group1,

58%

group2(P

5.02)

Notrandom

ized,small

samplesize

Office-based

verbal

counseling

with

orwithoutwritten

materialsimproved

safe

firearm

storagehabits.

Group2:survey,verbal

counseling,andwritten

counseling(n

552)

Madean

unsafechange:

31%control,22%group

1,31%group2(P

5.09)

Carbone,2005

29Quasiexperimental

Pediatricclinic,

urbancommunity

health

center,

Arizona

Families

atclinicvisits

(mostly

Hispanic);

restricted

togun

owners

Physician-delivered

1-to

2-minverbalcounseling,gun

safety

brochure,and

free

gunlock

(n5

73families)

Improvem

entin

gunsafety

practices:27%

control,

62%

intervention

(P,

.001)

Timeseries

design,

smallsamplesize,

self-reported

data,

social

desirability

bias

Office-based

safe

storage

counselingwith

written

materialsandafree

gun

lock

ledto

significant

improvem

ents

insafe

gun

storagebehaviors(but

not

removal

offirearmsfrom

home).

Improvem

entingunsafe

storage:12%control,51%

intervention(P

,.001)

Barkin,20082

1Random

ized

controlledtrial

Pediatricclinicsin

41US

states,

Canada,and

Puerto

Rico

participatingin

practice-based

research

network

oftheAAP

Families

ofchildren

2–11

yoldforwell

child

visit

Physician-delivered

counselingusing

motivationalinterviewing

with

provisionof

free

cablelocks(n

568

practices,470

families)

Usingfirearm

cablelocks

at1mo:59%

control,

64%

intervention

(P5

.006)

Self-reported

data

Office-based

counselingwith

provisionoffree

cablefirearm

lockssignificantlyincreased

safe

firearm

storagein

firearm-owning

families.

Safe

firearm

outcom

esonly

analyzed

bygun

owners

Usingfirearm

cablelocks

at6mo:54%

control,

68%

intervention

(P,

.001)

Grossm

an,201230

Random

ized

controlledtrial

6villagesin

2regions,Alaska

Gun-ow

ning

households

with

nooperational

gunsafe

forstorage

Steppedwedge

design

in2phases

(earlyvs

late),

installationof

afree

metal

guncabinetwith

verbal

andwritten

instructions

onuse,andsafety

message

aboutsafe

storageof

guns

and

ammunition

(early

n5

129,late

5126)

Report

both

gunand

ammunition

unlocked

at12

and18

mo:23%

control,78%intervention

(P,

.001)

Lack

ofgeneralizability

oftheintervention

andresults

toother

settings

and

populations

Community-based

interventionto

installgun

cabinetsalongwith

verbal

andwritten

safety

messagesincreasedsafe

firearm

storagepractices.

Zatzick,2014

32Random

ized

controlledtrial

Inpatient

settingin

alevel1trauma

center,W

ashington

Inpatient

adolescents

(12–18

yold)

hospitalized

forboth

intentionaland

unintentional

injuries

Steppedcollaborativecare

interventionincluding

motivationalinterviewing

targetingrisk

behavior

andsubstanceabuse,and

cognitive–behavioral

therapytargetingPTSD

anddepression

(n5

59)

Collaborativecare

intervention:Patients

hadreducedweapon

carrying

at1y

Primaryoutcom

ewas

notspecificto

carrying

weapons,

butthestudydid

includeweapon

carrying

at1yas

asecondaryoutcom

e;sm

allsample.

Steppedcollaborativecare

interventionforassault-

injuredteensreduced

likelihoodof

carrying

aweaponat

1y.

21%control,7%

intervention,

odds

ratio

50.31

(95%

confidence

interval,0.11–0.9)

Tableadaptedfrom

Rowhani-Rahbaret

al28andRoszko

etal.61

AAP,Am

erican

Academ

yof

Pediatrics;PTSD,

posttraumaticstress

disorder.

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TABLE3

StudiedInterventions

With

NullFindings

(ie,DidNotImproveGunSafety)

FirstAuthor,Year

StudyDesign

StudySetting

StudyPopulation

InterventionGroup

Results

Limitations

KeyConclusions

Oatis,19996

2Quasiexperimental

Midwesturban

pediatricclinic,O

hio

Parentsof

pediatric

patients(m

edianage2y,

range0–17

y)seen

for

annual

school

physical

clinicvisit

Clinician-delivered

verbal

andwritten

counselingon

firearm

safety(n

51617,381

with

completefollow-up

data)

Nochange

inprevalence

ofguns

inthehome,guns

stored

unlocked

orguns

loaded

Self-reported,low

follow-uprate,

underpow

ered

Office-based

clinician-

delivered

verbal

and

written

counselingon

firearm

safetydidnot

improvesafestorageof

firearms.

Brent,2000

63Quasiexperimental

Psychiatry

clinic,

Pennsylvania

Parentsandfamilies

ofadolescentswith

diagnosisof

major

depression

Repeated

firm

recommendations

byprovider

toremove

guns

forparents

reportingfirearms

inthehome(n

529)

Nodifferencein

families

ofdepressedteens

who

removed

guns

from

home

Smallsamplesize,

post

hocanalysis,

notstandardized

intervention,

self-report,social

desirabilitybias

Inahigh-riskgroupof

parentsof

teens

receiving

psychotherapyfor

depression,the

majority

didnotcom

ply

with

office-based

provider’sverbal

recommendations

toremovefirearmsfrom

thehome.

Grossm

an,20006

4Random

ized

controlledtrial

9urbanandsuburban

family

medicineand

pediatricpractices,

Washington

Families

ofchildren

2mo–18

yoldforwell

child

visit

Practitioner-delivered

verbal

andwritten

gunsafety

counseling,with

couponsfor

obtainingdiscounted

triggerlocksand

lockboxesfor

firearm-owning

families

(n5

309),

counselingto

not

acquireagunfor

non–gun-ow

ning

families

Nodifferencein

firearm

acquisition

betweengroups,

ratesof

firearm

removal,orratesof

purchase

offirearm

safetyequipm

ent

amongfirearm

owners

Difficulty

assessing

whether

intervention

was

delivered,self-

reported

outcom

es,

notavalidated

questionnaire

Office-based

practitioner’s

verbal

andwritten

counselingalongwith

couponsforsafety

devicesdidnotimprove

safe

storageor

removal

offirearms

from

homes.

Stevens,2002

65Random

ized

controlledtrial

12pediatricclinics,

mostly

ruralNew

England

Gun-ow

ning

andnon–gun-

owning

families

offifth

-andsixth-graders

seen

forwellchild

visits

Practitioner-delivered

counselingon

safety,

includinggunsafety,

clinicsupport,and

written

materials

(n5

6practices)

Nodifferencein

safe

storageof

guns

at12,24,or

36mo

Multiple-injury

prevention

intervention,self-

reported

outcom

es,

lowbaselinereport

rate

ofgun

ownership

Office-based

counseling

with

long-term

reinforcem

entdidnot

improvesafestorageof

guns.

Johnston,20026

6Random

ized

controlledtrial

Urbanlevel1trauma

center

pediatricED

PacificNW

,Washington

12-to

20-y-old

medically

stableandcognitively

ablepatientspresenting

with

aninjury

20-min

behavior

change

counseling

byatrained

therapistregarding

injury

risk

behaviors

(n5

318)

Nodifferencein

likelihoodto

carrya

weaponat

3and

6mo

Interventiontargeting

multiplerisky

behaviors,low

baselinerates,

secondaryoutcom

eself-reported

data

ED-based

behavior

change

counselingfor

adolescentsseen

for

injury

onoverallinjury

risk

reductiondoes

not

reduce

thelikelihoodof

carrying

aweapon.

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Zatzick et al32 showed increased gun safetythrough verbal or written counseling alone.Although the heterogeneity of these studiesmakes some conclusions difficult, 3 of thesestudies provided free safe firearm storagedevices to participants. This findingsuggests that combining both counselinginterventions with provision of free safestorage devices may be a successful methodby which to increase the safe storage offirearms.28 Table 3 describes interventionsthat focused on verbal and writtencounseling and 1 that provided coupons fordiscounts on gun safety devices; none ofthese studies demonstrated significantchanges in gun safety practices. Morestudies in this area are necessary to betterunderstand why some interventions work incertain settings and others fail to improvefirearm safety in the homes with children.

The interventions above targeted parentsand caregivers rather than the childrenthemselves. Although programs designed toeducate children and adolescents onfirearm safety exist, these programs havefailed to demonstrate a reduction in riskybehaviors.33,34 One explanation for the lack ofefficacy is that these programs focus on gunsafety instruction but not behavioral skills.The National Rifle Association sponsored aprogram to instruct children on gun safety;however, a 2004 study showed that althoughchildren in this program were able to talkabout gun safety, they failed to demonstrategun safety in a simulation exercise.33 Therisk of these programs is that by relying ona child’s verbal report of gun safetyknowledge, parents may overestimate theirchild’s understanding of gun safety inpractice.

Although the previously mentioned studieswere conducted mainly in ED, outpatient, orcommunity settings, to our knowledgeinterventions related to firearm safety haveyet to be studied in the inpatient setting. Aswith other educational initiatives in theinpatient setting, such as smokingcessation,35,36 hospitalists often havedifferent availability of time and resourcesto engage patients and caregivers on topicssuch as gun safety. Given the results ofstudies conducted in the outpatient setting,an effective inpatient intervention would

include verbal and written counselingcoupled with the provision of safe storagedevices.

ROLE OF PEDIATRICIANS INCURTAILING FIREARM-RELATEDINJURIES

The American Academy of Pediatrics (AAP)strongly supports the prevention of firearm-related injuries with an emphasis on safetycounseling during routine healthmaintenance visits, reduced access, safestorage, and stronger regulations on thesale and purchase of firearms.37

Educating Physicians and Trainees

The AAP encourages the education ofphysicians on gun violence prevention,including gun safety and strategies foranticipatory guidance with patients andfamilies.37 However, a recent systematicreview found that students and traineesrarely receive training on firearm-relatedinjury prevention and firearm safety.38

Although there are limited studies onpediatric resident perspectives, 1 studyreported that the likelihood of residentsasking parents about guns and providingcounseling relates to level of comfort andprevious education on the topic.15

Pediatricians have an opportunity toeducate trainees about gun safetystrategies and model ways to speak withpatients and families about firearm safety.One study found that a Web-based gunviolence curriculum for pediatric residentssuccessfully increased feelings of self-efficacy in providing firearm injuryprevention guidance.39 Given thatincreased confidence on the topicincreases the likelihood that residents willprovide gun safety counseling,40

incorporating such curricula for pediatricresidents at the national level may be apromising strategy to improve counselingfor families.

Discussing Anticipatory GuidanceWith Families

The lack of training on firearm safety inmedical education has affected practice.In the audio recordings of .170 well childvisits with pediatric residents, firearmswere not discussed in a single encounter.41

Pediatricians discuss a variety of safety and

injury prevention topics at routine visits,including risks of lead paint exposure,bicycle helmet safety, and substance abuse,but discussion of firearm safety remainsnonexistent, a surprising finding given themagnitude of the public health threat posedby gun violence. In addition to educationabout safe storage, several advocacygroups, including the AAP,37 recommendencouraging parents to ask about guns inthe homes of others when their childrenspend time in someone else’s home.Encouraging parents not only helps ensurethe safety of their own child but alsopromotes community dialogue surroundinggun safety.

The AAP also recommends that physiciansscreen for access to firearms in all patientswith mood disorders, substance abuse, orhistory of suicide attempts.37 Several states,including Florida, Montana, Missouri, andMinnesota, enacted legislation limiting howand when patients can be asked about gunownership or limiting how much they are todocument in the medical record. However,they do allow physicians to ask if medicallynecessary and if a patient is at risk.42

Access to firearms is an obvious risk factorfor suicide completion.43 Legislation thatrestricts a physician’s ability to counselcould prevent a physician from obtaininglife-saving information from a depressedadolescent who has access to firearms inhis or her home. Restrictive legislation hasbeen challenged in several state courts, andin Florida it has also involved the federalcourts. The issue remains dynamic, andfederal involvement may affect futurelegislation in other states. It is important toconsider the context from which thislegislation and cases evolved. In Florida, ina well-publicized case, a pediatriciandischarged a family from his practice afterthe mother refused to answer questionsabout access to firearms. This case alongwith other complaints led to the passage ofFlorida’s physician gag law.19,44,45, The Floridachapters of the AAP, the American Academyof Family Physicians, and the AmericanCollege of Physicians challenged the law. Asthis issue continues to evolve, pediatriciansmust remain involved and aware of anylegislation that restricts their ability to keepchildren safe.

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Leading Research Efforts to StudyFirearm-Related Injury Prevention

Progress in firearm injury prevention hasbeen limited in the United States by a lack ofscientific inquiry, knowledge, andpublications on this topic, primarily becauseof lack of funding. According to a2013 report published by the Institute ofMedicine, “the scarcity of research onfirearm-related violence limitspolicymakers’ ability to propose evidence-based policies that reduce injuries anddeath and maximize safety.”46 In the 1980s,the CDC launched efforts to promotescientific inquiries about firearm-relatedinjuries; however, in 1996 Congressrestricted the agency from funding work “toadvocate or promote gun control.”46 Anexecutive order in 2013 by President Obamasought to increase firearm-related fundingto the CDC, but Congress did not give fullsupport. Journal publications are thecornerstone of dissemination of scientificknowledge and can provide evidence forintervention development and policymaking.However, given the dearth of funding in thisarea, publications on this topic haveplateaued. Between 1985 and 1999, theannual number of publications about gunviolence increased markedly, but then theyplateaued through 2012 at about 90 articlesannually.46 When researchers accounted forthe growth of scientific literature as a wholeover the time period, publications onfirearm-related injury prevention declined64% in 2012, compared with an increase infirearm-related publications between1985 and 1999; in addition, there are fewactive career researchers in this area.46

Adding scientific inquiry and evidence inthis area can help promote change at thelocal level, with more interventions orprogram development, and at the nationallevel, providing policymakers with evidence.A more nuanced understanding of pediatricfirearm-related injury through rigorous,well-conducted research will inform thework of public health agencies,policymakers, and pediatricians toeffectively intervene legislate and counsel.

FIREARM LEGISLATION

There are .300 federal gun laws in theUnited States that regulate the sale and

possession of firearms and ammunition.However, because of different state andlocal laws, there is tremendous variation inthe implementation of these federal laws atthe local level.47,48 A 2016 study evaluatingindividual laws (through 2009) comparedtheir effectiveness in reducing firearm-related mortality.49 Only 3 laws were foundto be strongly associated with reduceddeaths from firearms in this study:universal background checks before thepurchase of guns, universal backgroundchecks before the purchase of ammunition,and firearm identification (microstampingor ballistic fingerprinting) requirements.49

More recently, in a 2017 systematic reviewfocusing on firearm homicide, US firearmlaws were divided into 5 categories: thosethat curb gun trafficking, strengthenbackground checks, improve child safety,ban military-style assault weapons, andrestrict firearms in public places.50 Theseresearchers found that laws that strengthenbackground checks and that require apermit to purchase a firearm areassociated with decreased firearmhomicide rates across all ages. However,specific laws directed to improve childsafety were not associated with decreasesin firearm homicide rates.50 These findingsare in contrast to other studies that focuson unintentional shooting deaths or suicidedeaths (not only firearm homicides), whichshow a reduction in firearm-related death inchildren when laws aimed to improve childsafety are associated with felonyprosecution or broader firearm legislationto promote responsible ownership.51–53

The Brady Handgun Violence Prevention Actof 1993 (Brady Act) is one of the mostsignificant pieces of legislation that exists tocontrol firearm access by strengtheningbackground checks. The Brady Actmandates that federally licensed firearmdealers perform federal backgroundchecks. The original legislation instituted a5-day waiting period for all peoplepurchasing a handgun; however, thisrequirement ended in 1998, and currentlythere is no federally mandated waitingperiod. Once the background check iscomplete, the gun can be transferred to thepurchaser. Although a federally licensedfirearm dealer is required to wait

3 business days to complete the backgroundcheck, a gap in the law allows unlicensedsellers, perhaps online or at gun tradeshows, to sell firearms without backgroundchecks. Background checks blocked almost2.8 million prohibited people frompurchasing or receiving a permit topurchase or carry a firearm between1994 and 2014.54 It is important to note thatunless local or state laws exist to regulateprivate sales, only federally licensed firearmdealers are required to conduct backgroundchecks before sales. This variability infirearm regulation at the state and locallevel makes evaluating the effectiveness ofdifferent categories of firearm legislationdifficult.

Child safety laws include requiring the saleof guns with mechanical trigger locks andmandating age restrictions for gunpurchases. Child access prevention lawsregulate the safe storage of firearms toprevent access by minors and imposecriminal liability on adults who allowchildren unsupervised access tofirearms.50,51,55 No federal child accessprevention law exists, and as of 2013, only27 states and the District of Columbia haveenacted child access prevention laws.56

Whereas Lee et al50 concluded in theirsystematic review that the overall evidencefrom the 9 studies related to laws improvingchild safety does not support theeffectiveness of child protection laws inreducing firearm homicide deaths, otherstudies have shown that stronger firearmlegislation and child safety laws areassociated with safer firearm storage infamilies with preschool-aged children57 andthat child safety laws are effective inreducing unintentional firearm and suicidedeaths among children.51–53 For example,1 study evaluated the impact of the childaccess prevention laws in 12 states andfound that unintentional firearm deaths fellby 23% from 1990 to 1994 for children,15 years of age, but only in the subgroupof 3 states in which violation of the law wasa felony.51 Other studies noted that childaccess prevention laws were associatedwith an 8.3% decrease in suicide among14- to 17-year-olds52 and a decrease inunintentional pediatric firearm-relatedinjuries in states with very aggressive,

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felony prosecution for violators (eg, Floridaand California).53 Overall, child safety lawshave shown reductions in unintentionalfirearm deaths and suicide deaths in youth,and their role in overall firearm homicide byage group may warrant more study.

Other available research examines theoverall strictness of firearm regulationbased on state-based legislation in relationto firearm-related injury or mortality. TheBrady Campaign to Prevent Gun Violenceand the Law Center to Prevent Gun Violenceannually assess and compare each state’slegislation on gun laws and assign a scorebased on various policy points includingstrength of background checks, limitation ofmilitary-style assault weapons, andlimitation on firearms in public places.47

Although it is not a validated score, studieshave used the Brady score to account forvariability in state-based firearm legislationwhen studying firearm-related injuries. Astudy that examined gun laws and firearm-related injuries across 18 states revealedthat states with the strictest gun laws hadthe lowest numbers of hospital visits fornonfatal firearm-related injuries.58 Inparticular, among children, stricter statesalso had lower rates of hospital admissionsand visits for firearm-related injuries thanstates with less strict firearm legislation.58

Additionally, in a national sample, meanfirearm-related injury rates among traumapatients were higher in states with lessstrict firearm legislation than in states withstrict firearm legislation.48 Stricter firearmlaws have also been associated with fewerhigh school students reporting firearmcarriage in the past 30 days.59

Although the data suggest that individualreview of gun laws is sufficient to evaluatetheir effectiveness, important interactionsbetween laws must not be overlooked.There are hundreds of state-level laws thatregulate firearms. Attention should befocused on supporting the laws, orcombination of laws, that have been shownto be effective.

CONCLUSIONS

Firearm-related injuries are a pediatricpublic health crisis with significantmorbidity and mortality in the UnitedStates. Of 20 000 firearm-related pediatric

injuries every year, injury in youngerchildren is generally caused by accidentalaccess, whereas adolescent injury is mostoften intentional, from suicide attemptsand violence. Legislation to combatfirearm-related injuries has existed sincethe signing of the Brady Act in 1993. Sincethen, research has emerged clearlydemonstrating that universal backgroundchecks and firearm identification arethe most effective pieces of legislationto prevent firearm injuries.49,50 Childaccess prevention laws with felonyprosecution of violators may also playan important role in the legislativeenvironment.

Rigorous investigations, with the use ofvalidated scoring systems, largecomprehensive databases, and accuratedetailed reporting and surveillance offirearm access and related injury, areurgently needed. Firearm research by theCDC has been limited by constant threatsby Congress to reduce funding, and recentefforts to increase funding have beenunsuccessful.60 A collective, data-drivenpublic health approach is crucial to haltthe epidemic of pediatric firearm-relatedinjury.

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DOI: 10.1542/hpeds.2016-0146 originally published online May 23, 2017; 2017;7;303Hospital Pediatrics 

Kavita Parikh, Alyssa Silver, Shilpa J. Patel, Sabah F. Iqbal and Monika GoyalPediatric Firearm-Related Injuries in the United States

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