Newsletters

POSTED: October 14th, 2022
POSTED IN: EM Pulse - The Official Newsletter of MOCEP, September/October 2022,

MaryBeth Bernardin MD FAAP
Assistant Professor of Pediatric Emergency Medicine, Department of Emergency Medicine, University of Missouri School of Medicine

In 2020, after decades of being the second leading cause of pediatric deaths following motor vehicle accidents, firearm injuries rose to the number one cause of death amongst American children and adolescents (ages 1-19 years). Pediatric firearm mortality had been relatively stable throughout the early 2000s but began to climb from 2015-2019. From 2019-2020, the US experienced a 30% increase in pediatric firearm deaths [1]. Multiple potential explanations have been proposed, and many barriers to firearm safety remain.

The COVID-19 pandemic had a profound effect on life across the globe, and it is difficult to ignore that the sharp increase in pediatric firearm deaths occurred simultaneously with the pandemic. Many have proposed that this increase is due at least in part to pandemic-related increases in gun purchasing. A study by Schleimer et al. estimated that 4.3 million excess firearms were purchased nationally in March-July of 2020, while at the same time, more than 4,000 additional firearm injuries occurred above what was expected based on previous trends [2]. Another study by Sokol et al. found that 10% of households with teenagers purchased a firearm during the first several months of the pandemic in 2020, including 3% that became first-time gun owners [3]. When Cohen et al. discovered a significant increase in firearm injuries amongst children during the pandemic, they proposed that pandemic-related increased gun purchasing and subsequent increased child access to guns in the home may be partially to blame [4]. They and others have hypothesized that caregivers trying to work from home concurrent with daycare and school shutdowns resulted in a lack of child supervision that has placed children at increased risk for unintentional firearm injuries [4–6]. 

It has been noted that the increase in overall firearm mortality occurring in 2020 amongst adults was driven by a 33% increase in firearm homicides [1]. Many have suggested that this firearm homicide surge was most closely related to the economic instability, social disruption and subsequent increased violent crime that occurred during the COVID-19 pandemic [5,7,8]. It has been further hypothesized that increased pandemic-related violent crime amongst adults has led to increased child exposure to community violence and consequent firearm injuries [5,8]. Martin et al. found that when evaluating the number of fatal shootings per census tract, children’s exposure to neighborhood firearm violence significantly increased during the pandemic, and this effect was most significant amongst Black children [9]. Multiple other studies have found that while pediatric firearm injury rates increased during the pandemic, it was children of color that were most likely to be victims [5,8]. Those familiar with gun violence research will not be surprised by that finding, given that it has been well established that the children most at risk for firearm injuries are Black adolescent males [10,11]. The significantly increased rate of firearm injuries amongst children of color during the pandemic is still a profoundly important discovery because it indicates that the national surge in pediatric firearm deaths has not been suffered amongst American children equally. Rather, the marginalized communities known to already be plagued by violence have again taken the brunt of some of the pandemic’s most tragic impacts.

While there are multiple proposed reasons for firearms becoming the leading cause of pediatric deaths, this feat could not have occurred without the simultaneous and consistent decrease in deaths due to motor vehicle accidents (MVAs). From 2000-2020, deaths due to MVAs dropped nearly 40% [12]: a direct result of concerted efforts in technology, research and legislation. Such efforts have included but are not limited to the implementation of car safety features, development of a comprehensive data system used to monitor MVA deaths and study the effects of new innovations, creation of a federal agency responsible for the reduction of MVA deaths, and the passing of laws requiring driver training and licensing, vehicle registration and adherence to traffic laws [13]. Comparatively, guns have become more prevalent and more lethal, the firearm industry and gun-rights organizations have succeeded in severely limiting federal funding for firearm research, and pro-gun rights legislation has limited requirements for firearm purchasing background checks, allowed for the carriage of concealed weapons without permits, as well as protected the firearm industry from many tort-liability suits/negligence claims [13].

Despite the climb in pediatric firearm deaths in recent years, the existing research on pediatric firearm injuries offers some encouragement. Several studies have established that hospital-based violence intervention programs can be successful in reducing youth reinjury and recidivism due to interpersonal violence [14–16]. Those intervention programs offering therapeutic community-based case management services have been linked to decreases in re-injury and aggression, as well as improved self-efficacy amongst marginalized, high-risk youths [17,18]. Gun safety legislation, such as Child Access Prevention laws, have also been shown to decrease child firearm injury rates [19,20]. Even during the rise in child firearm injuries that has occurred during the COVID-19 pandemic, Donnelly et al. recently found there to be fewer pediatric shootings in states with strong gun laws [21]. These findings, in addition to the steady decrease in deaths due to MVAs in recent decades, are hopeful reminders that the height of firearm mortality we have hit as a nation is a statistic that can be reversed. While the COVID-19 virus may have become a permanent part of American life, child shootings do not have to be. These injuries and deaths can be prevented with the use of the same harm reduction strategies that have proven successful against other safety threats, if we as a state and a nation commit to taking the necessary steps.

References:

[1]         Goldstick JE, Cunningham RM, Carter PM. Current Causes of Death in Children and Adolescents in the United States. N Engl J Med 2022:1955–6. https://doi.org/10.1056/nejmc2201761.

[2]         Schleimer JP, McCort CD, Shev AB, Pear VA, Tomsich E, De Biasi A, et al. Firearm purchasing and firearm violence during the coronavirus pandemic in the United States: a cross-sectional study. Inj Epidemiol 2021;8:1–10. https://doi.org/10.1186/s40621-021-00339-5.

[3]         Sokol RL, Zimmerman MA, Rupp L, Heinze JE, Cunningham RM, Carter PM. Firearm purchasing during the beginning of the COVID-19 pandemic in households with teens: a national study. J Behav Med 2021;44:874–82. https://doi.org/10.1007/s10865-021-00242-w.

[4]         Cohen JS, Donnelly K, Patel SJ, Badolato GM, Boyle MD, McCarter R, et al. Firearms injuries involving young children in the United States during the COVID-19 pandemic. Pediatrics 2021;148:1–8. https://doi.org/10.1542/peds.2020-042697.

[5]         Afif IN, Gobaud AN, Morrison CN, Jacoby SF, Maher Z, Dauer ED, et al. The changing epidemiology of interpersonal firearm violence during the COVID-19 pandemic in Philadelphia, PA. Prev Med (Baltim) 2022;158.

[6]         Sethuraman U, Kannikeswaran N, Singer A, Krouse CB, Cloutier D, Farooqi A, et al. Trauma Visits to a Pediatric Emergency Department During the COVID-19 Quarantine and “Stay at Home” Period. Am Surg 2021:1–9. https://doi.org/10.1177/00031348211047497.

[7]         Neufeld MY, Poulson M, Stolarski AE, Dunnington C, Burke PA, Allee L. Amplifying inequity: The compounding impact of COVID-19 and violence. J Natl Med Assoc 2021;113:528–30. https://doi.org/10.1016/j.jnma.2021.04.003.

[8]         Kegler SR, Simon TR, Zwald ML, Chen MS, Mercy JA, Jones CM, et al.  Vital Signs : Changes in Firearm Homicide and Suicide Rates — United States, 2019–2020 . MMWR Morb Mortal Wkly Rep 2022;71:656–63. https://doi.org/10.15585/mmwr.mm7119e1.

[9]         Martin R, Rajan S, Shareef F, Xie KC, Allen KA, Zimmerman M, et al. Racial Disparities in Child Exposure to Firearm Violence Before and During COVID-19. Am J Prev Med 2022:0–19. https://doi.org/10.1016/j.amepre.2022.02.007.

[10]      Cunningham RM, Walton MA, Carter PM. The major causes of death in children and adolescents in the United States. N Engl J Med 2018;379:2468–75. https://doi.org/10.1056/NEJMsr1804754.The.

[11]      Bachier-Rodriguez M, Freeman J, Feliz A. Firearm injuries in a pediatric population: African-American adolescents continue to carry the heavy burden. Am J Surg 2017;213:785–9. https://doi.org/10.1016/j.amjsurg.2016.10.004.

[12]      Centers for Disease Control and Prevention. WISQUARS n.d. https://www.cdc.gov/injury/wisqars/index.html.

[13]      Lee LK, Douglas K, Hemenway D, Ph D. Crossing Lines – A Change in the Leading Cause of Death among U.S. Children. N Engl J Med 2022;386:1485–7.

[14]      Cooper C, Eslinger DM, Stolley PD. Hospital-based violence intervention programs work. J Trauma – Inj Infect Crit Care 2006;61:534–7. https://doi.org/10.1097/01.ta.0000236576.81860.8c.

[15]      Gomez G, Simons C, St. John W, Creasser D, Hackworth J, Gupta P, et al. Project prescription for hope (RxH): Trauma surgeons and community aligned to reduce injury recidivism caused by violence. Am Surg 2012;78:1000–4. https://doi.org/10.1177/000313481207800942.

[16]      Juillard C, Cooperman L, Allen I, Pirracchio R, Henderson T, Marquez R, et al. A decade of hospital-based violence intervention: Benefits and shortcomings. J Trauma Acute Care Surg 2016;81:1156–61. https://doi.org/10.1097/TA.0000000000001261.

[17]      Zun LS, Downey LV, Rosen J. The effectiveness of an ED-based violence prevention program. Am J Emerg Med 2006;24:8–13. https://doi.org/10.1016/j.ajem.2005.05.009.

[18]      Cheng TL, Wright JL, Markakis D, Copeland-Linder N, Menvielle E. Randomized trial of a case management program for assault-injured youth: Impact on service utilization and risk for reinjury. Pediatr Emerg Care 2008;24:130–6. https://doi.org/10.1097/PEC.0b013e3181666f72.

[19]      DeSimone J, Markowitz S, Xu J. Child Access Prevention Laws and Nonfatal Gun Injuries. South Econ J 2013;80:5–25. https://doi.org/10.4284/0038-4038-2011.333.

[20]      Hamilton EC, Miller CC, Cox CS, Lally KP, Austin MT. Variability of child access prevention laws and pediatric firearm injuries. J Trauma Acute Care Surg 2018;84:613–9. https://doi.org/10.1097/TA.0000000000001786.

[21]      Donnelly MR, Grigorian A, Swentek L, Arora J, Kuza CM, Inaba K, et al. Firearm violence against children in the United States: Trends in the wake of the COVID-19 pandemic. J Trauma Acute Care Surg 2022;92:65–8. https://doi.org/10.1097/TA.0000000000003347.