Version May 2024
INTRODUCTION — Firearm injury is a major cause of morbidity and mortality in the United States and thus an important medical and public health problem. Children may be injured or killed in shootings; may lose caregivers, 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.
EPIDEMIOLOGY
Firearm injuries — Firearm injury is a major cause of morbidity and mortality in the United States and an important medical and public health problem [1-6]. In 2019, firearm injury surpassed motor vehicle crash as the leading cause of death in children and adolescents after excluding deaths due to congenital anomalies and prematurity [7-9]. Rates of firearm homicide, suicide, and unintentional firearm deaths are substantially higher in the United States than in other high-income countries (eg, 4.38 versus ≤0.67 per 100,000 for firearm homicides in 2019; 7.29 versus ≤2.51 per 100,000 for firearm suicides in 2019) [6,10-12]. The rate of firearm suicide in the United States increased to 8.1 per 100,000 in 2022 [13]. The incidence of firearm mortality in children in the United States continues to increase [14,15].
●Mortality – Firearms are the leading cause of death in children and adolescents age 0 to 19 years [7]. Black children and adolescents, particularly those who live in urban areas and areas with a high concentration of poverty, are disproportionately affected [16]. Firearm fatalities usually are classified as homicides, suicides, and unintentional, although intent is potentially misclassified [17,18]. The majority of pediatric firearm deaths are attributed to homicide in male adolescents [4,19-21].
During 2020, there were 3230 firearm fatalities in children age 0 to 18 years in the United States [21]. Among the 3146 that could be classified, there were:
•2040 firearm-related homicides (crude rate 2.65 per 100,000)
Firearms were used in 74 percent of homicides in children age 0 to 18 years.
•970 firearm-related suicides (crude rate 1.26 per 100,000); firearms were used in 45 percent of suicides in children age 0 to 18 years
•136 unintentional deaths (crude rate 0.18 per 100,000)
Among children <15 years, unintentional firearm deaths usually are self-inflicted or inflicted by other children (usually a family member); it is rare for a child shooter to kill an adult [4,18]. In a review of 229 unintentional firearm fatalities among children <15 years in the United States during 2005 to 2012, 81 percent of the victims were male, and most deaths occurred in children age 11 to 14 years [18]. Among children age two to four years, 27 of the 42 shooting deaths were self-inflicted; in all other age groups, the majority of shooting deaths were other-inflicted (usually by a brother, another family member, or friend). Approximately 10 percent of the deaths were related to hunting, of which 40 percent were self-inflicted.
●Morbidity – Nonfatal firearm injuries are two to three times more common than fatal injuries in children and youth [22,23]. Compared with other types of pediatric injuries (eg, falls, being struck by or hit against an object or person), firearm injuries are less common but more severe (eg, require hospitalization or surgery) [24-28].
Male adolescents living in urban areas with a high concentration of poverty, particularly African Americans, are at increased risk for firearm injuries [29-31]. In an observational study evaluating firearm injuries in a large city in the United States during the first two years of the COVID-19 pandemic, the rate of injuries in children <17 years old increased in low-resource neighborhoods and decreased in high-resource neighborhoods [32].
In a population-based study from Canada, the rate of assault-related firearm injury was greater in immigrant than nonimmigrant children, but the risk of unintentional injury was lower [33].
●Setting – Nearly all unintentional firearm injuries in children occur in or around the home [4,18,34,35]. Unintentional shootings typically occur when children are unsupervised [36-38] and out of school (eg, in the late afternoon, on weekends, and during the summer months and holiday seasons) [39].
In a cross-sectional study of firearm injuries in children <20 years of age in the United States, hospitalization rates for adolescents (15 through 19 years) were higher in urban than rural areas, whereas hospitalization rates for children 5 through 14 years were higher in rural areas [40].
Among adolescents, retrospective reviews of national data indicate higher rates of self-inflicted firearm injury hospitalizations or deaths (suicides) in rural areas and higher rates of assault-related firearm injury hospitalizations or deaths in urban areas [6,40,41]. The presence of a firearm in the home increases the risk of adolescent suicide. (See "Suicidal behavior in children and adolescents: Epidemiology and risk factors", section on 'Firearms'.)
●School shootings – School shootings are a growing concern in the United States, with nearly 1400 incidents since 1970 [42]. The majority of firearms used in school-based shootings in the United States were obtained from the homes of the perpetrators or their friends or relatives [43].
Characteristics of school shootings in the United States were described in a cross-sectional study of 133 school shootings/attempted school shootings from 1980 to 2019 that were included in the public K-12 School Shooting Database [44,45]:
•93 percent involved a single perpetrator
•89 percent of perpetrators were <22 years of age (range 10 to 53 years)
•70 percent of perpetrators were current students; 15 percent were former students
•47 percent were targeted shootings
•69 percent involved handguns; 22 percent involved shotguns; 17 percent involved rifles; 10 percent involved assault rifles or submachine guns
•An armed guard was present at 24 percent of schools
●Gun ownership and storage practices – In the United States, firearms are present in approximately one-third of households with children [46,47]. In cross-sectional analysis of a national survey, 10 percent of gun owners were classified as new gun owners (ie, acquired all of their firearms in the previous five years and before that had lived in a home without a gun) [48]. In a nationally representative survey, the prevalence of gun ownership was similar in households with and without children at increased risk of self-harm (eg, with depression, attention deficit hyperactivity disorder, or other mental illness) [49].
Although gun storage practices vary geographically [1,2,50-52], in a nationally representative survey, only 44 percent of gun-owning caregivers of children <18 years stored the gun(s) safely (ie, locked and unloaded), and 15 percent stored guns unlocked and loaded [47]. In a cross-sectional survey, new gun owners were more likely than longstanding gun owners to store their guns safely [48]. The proportion of safely stored guns was similar in households with and without children at increased risk of self-harm.
●Gun-carrying – According to the 2017 and 2019 Youth Risk Behavior Survey, a nationwide survey of high school students, 6.8 percent of male students and 1.9 percent of female students reported carrying a gun that they did not use for hunting or a sport such as target practice at least one day in the 12 months before the survey [53]. Gun carrying was more common among students who had experienced violence (eg, threatened or injured with a weapon on school property, bullying, dating violence), suicidal ideation or attempts, or substance used than among children without these experiences. In another survey, high school students who self-reported being a victim of traditional and/or cyberbullying were more likely to report access to loaded guns than students who were not bullied [54].
Nonpowder gun injuries — Nonpowder guns (eg, ball-bearing [BB] guns, pellet guns, airsoft guns, paintball guns) are popular among adolescents. These guns can cause serious injury [55]. They can have muzzle velocities ranging from 150 to 1200 feet per second, compared with 750 to 1450 feet per second for traditional firearms [56].
Data from the Consumer Product Safety Commission suggest that there are approximately four deaths related to nonpowder guns each year [57]. In national surveillance in the United States from 1990 to 2016, an average of 13,486 children were treated each year in emergency departments for injuries related to nonpowder guns [58]. Most of the injuries were due to BB guns and occurred in males age 6 through 17 years.
The most common injuries are to the eye, usually from air guns [58-60]. Serious penetrating injuries (requiring operative management) to the head, neck, chest, abdomen, and extremities have also been reported [55,61]. An additional risk of using nonpowder guns is that they may be mistaken for traditional firearms. Children and adolescents using nonpowder guns have been mistakenly shot and injured because the nonpowder guns were assumed to be traditional firearms [62].
SOCIOECONOMIC IMPACT — The impact of firearm-related deaths and injuries to children extends beyond the pain and suffering of the victims and their families. Children who shoot someone unintentionally are at risk for subsequent mental health problems, including posttraumatic stress disorder [63].
Firearm injuries put a burden on the health care and criminal justice systems and reduce the work force due to deaths and disabilities. In 2010, the total cost (ie, direct medical costs and lost productivity) of firearm-related assaults, homicides, suicides, and self-inflicted firearm injuries for children age ≤18 years in the United States was estimated to exceed 3.6 billion dollars [64].
The hidden costs of firearm injuries are reflected in the fear and worry that permeate urban neighborhoods with populations living below the poverty threshold. A meta-analysis of 114 studies concluded that community violence, which included firearm injury, was a predictor for the development of posttraumatic stress disorder in children and adolescents [65].
FRAMEWORK FOR PREVENTION — The Haddon Injury Control Model provides a framework for identification of strategies to prevent firearm injuries (table 1). Combining several strategies is more effective than choosing a single strategy. (See "Pediatric injury prevention: Epidemiology, history, and application", section on 'Principles of injury prevention and control'.)
Most of the strategies to prevent firearm injury discussed in this topic can be applied anywhere in the world. Those that focus on legislation and/or regulation are specific to the United States.
PRE-EVENT STRATEGIES — Pre-event strategies focus on preventing children from shooting firearms. Because of the high potential for mortality in firearm injuries, pre-event strategies are preferred to event or post-event strategies. Pre-event strategies focus on the behavior of the child or family, the environment of the firearm, the manufacture of firearms with safety features, and regulatory/legislative changes.
Family counseling — In agreement with multiple professional societies and other experts [1,5,66-70], we encourage pediatric health care providers to provide counseling to prevent firearm injuries in the context of standard injury prevention counseling (eg, car seat safety, bicycle helmet use, etc) (table 2). It is important to ask about access to guns at regular intervals; each year in the United States, approximately 1 million people become new gun owners [48]. Asking about access to guns (not just the presence of a firearm in the home) identifies patients at increased risk of firearm injury who may benefit from education and safety counseling [71,72]. It is especially important to discuss access to guns with caregivers of adolescents who have depression. Although education and safety counseling have not been definitively proven to decrease firearm injury or death, they do not cause harm [73-75].
Anticipatory guidance regarding guns is recommended by the American Academy of Pediatrics (AAP), the American Academy of Family Physicians (AAFP), the American College of Physicians, the Society for Adolescent Health and Medicine, and the American Pediatric Surgical Association, among others [1,5,66,69,70,76]. Clinicians who counsel families about firearm safety may want to use the firearm safety tips provided by Safe Kids Worldwide or display information related to gun safety that is available on the AAP website.
Federal and state statutes permit asking about firearms when such information is relevant to the health of the patient or others [74]. This is true even in the state of Florida. Although the 2011 Privacy of Firearms Owners Act restricted clinicians from asking patients and their families about firearms and intentionally entering firearm information into medical records, it included an exception for health care practitioners who, in good faith, believed that the information was relevant to the patient's medical care or safety or the safety of others [77]. In 2017, the United States Court of Appeals for the 11th Circuit struck down the Privacy of Firearms Owners Act [78-80].
The AAP/Bright Futures guidelines for health supervision suggest firearm injury prevention counseling throughout childhood and adolescence (table 2) [81].
Components of the counseling include:
●Education about the dangers of firearms in the home – The absence of guns from the home is the most effective means of prevention of firearm injuries in children [1]. Houses and apartments are the most common sites of unintentional firearm injuries and fatalities. In national surveillance for 2018, 76 percent of all unintentional firearm fatalities took place in a house or an apartment [35].
Caregivers may not realize the risk that a gun in the home poses to them or their children; may underestimate their child's or adolescent's ability to gain access to a gun or to pull the trigger; and may overestimate their child's ability to distinguish between a toy and real gun, make good judgments about handling a gun, and consistently follow rules about gun safety [82-92].
Although families that keep firearms in the home often cite the need for personal protection, keeping guns in the home is associated with an increased risk of homicide by a family member or intimate acquaintance and of completed suicide [93-95]. In a 2014 meta-analysis of six observational studies, the risk of becoming a victim of homicide was greater among adults with access to firearms than those without access (pooled odds ratio [OR] 2.0, 95% CI 1.6-3.0) [93]. In a 2014 meta-analysis of 14 studies (four in adolescents, 10 in adults), the risk of completed suicide was three times greater among individuals with access to firearms than those without (OR 3.2, 95% CI 2.4-4.4) [93]. Approximately 55 percent of suicides among male adolescents (14 to 18years) and 23 percent of suicides among female adolescents are associated with firearms [21]. (See "Suicidal behavior in children and adolescents: Epidemiology and risk factors", section on 'Firearms'.)
●Children cannot be relied upon to avoid guns – Even if they have been taught to avoid guns and can repeat what they have learned (eg, that they should not touch the gun, should get away, and should tell an adult), children cannot be relied upon to avoid guns in real-life situations [82,83,96,97].
In a randomized trial, 70 children age 4 to 7 years were assigned to a week-long firearm safety program or to a control intervention, after which pairs of children were observed in a structured setting in which they had access to an unloaded semiautomatic pistol [83]. Gun play behavior was not influenced by gun safety training. More than one-half of the pairs played with the gun. In another study, a convenience sample of 29 8- to 12-year-old males and one or two of their siblings or playmates were observed through a one-way mirror in a room where two water pistols and an unloaded handgun were concealed in separate drawers [82]. Twenty-one of the groups discovered the handgun (approximately one-half of these children thought that it was a toy or were unsure whether it was real); 16 groups handled it; and one or more of the children in 10 of the groups pulled the trigger with enough force to discharge the firearm. Nearly all of the children who handled the gun reported that they had received some sort of gun safety instruction in the past.
●Keep guns away from children and children away from guns – Removal of guns from homes with children and the homes where children visit or play is recommended as one of the most effective means of preventing firearm injuries in children [1,71]. Most guns that are involved in self-inflicted or unintentional injuries come from the home of the victim or the home of a friend or relative of the victim [18,98]. Access to firearms may be particularly dangerous for children and adolescents with mood disorders, substance use problems, or a history of suicide attempt or other risk factors for suicide [99,100]. (See "Suicidal behavior in children and adolescents: Epidemiology and risk factors", section on 'Firearms' and "Peer violence and violence prevention", section on 'Access to firearms and weapon carrying'.)
The Asking Saves Kids Campaign is a collaboration between the Brady Campaign to Prevent Gun Violence and the AAP that teaches caregivers to ask, "Is there an unlocked gun in your house?" before allowing their children to play in another person's home. This is particularly true for children ≥11 years of age [18]. In a review of 229 unintentional firearm fatalities among children <15 years in the United States, only one child age ≤10 years was killed by a firearm at a friend's house, whereas 39 percent of unintentional firearm fatalities among children age 11 to 14 occurred at the home of a friend [18].
In another review of 277 unintentional firearm injuries involving children <19 years of age, 52 percent occurred while playing with or handling a firearm [34]. Among incidents in which the shooter was known, nearly 40 percent were caused by children shooting themselves. Among incidents in which the age of the shooter was known, 65 percent of the shooters were younger than 18 years (16 percent were younger than 6 years; 12 percent between 6 and 12 years, and 37 percent between 12 and 18 years).
●Safer storage – Firearms that are kept in the home should be stored unloaded and locked, with the ammunition stored securely in a separate location. Storage in a gun safe is ideal. Children are often able to find firearms that are stored out of sight or out of reach. Safe Kids reports that three out of four children living in a house know where the gun is, even when their caregivers think they do not know [101]. More than 10 percent of a nationally representative sample of adults living with children in the United States who own and store firearms in the home reported that their child is able to access the firearm without assistance [102]. For caregivers who own firearms primarily for protection, a rapid access fingerprint safe may be an option.
Keeping firearms locked, unloaded, and separate from ammunition has the potential to substantially reduce firearm-related unintentional injuries and suicide/self-harm [103]. Observational studies suggest that safer storage of firearms is associated with decreased risk of intentional and unintentional firearm injury [34,104-106]. Although it is uncertain whether counseling about safer storage of firearms reduces firearm injury or fatalities, observational studies and a systematic review suggest that safety counseling is associated with safer firearm storage practices [107-110]. Provision of a safety device (eg, a trigger lock, gun storage cabinet) at the time of counseling is associated with improved firearm storage practices [73,111,112].
●Nonpowder gun safety – Safety precautions for nonpowder guns (eg, air guns, pellet guns) include [113]:
•Adult supervision at all times
•Use of eye and face protection
•Always treating the gun as if it is loaded (ie, not pointing it at others, not looking down the barrel)
•Keeping the finger off the trigger until ready to fire
•Not taking the gun out in public (where it may be mistaken as a traditional firearm)
●Use of toy guns – Toy guns include nonfiring replicas of traditional firearms, pop guns, cap guns, water pistols, and guns that fire foam projectiles. We generally advise caregivers to limit toy gun play [114] but acknowledge that opinions vary and that this advice may be difficult to follow. Many of the questions regarding toy gun play remain unanswered (eg, whether limiting access to toy guns in the home increases the chance of playing with a toy gun – or real gun – outside the home, whether toy gun play is directly related to intentional or unintentional gun injury) [115]. Nonetheless, we discourage toy gun play because toy guns may be mistaken for traditional firearms (and vice versa), some toy guns (eg, cap guns) may be loud enough to damage hearing, and toy gun play may be associated with aggressive behavior [82,115,116].
●Limit television and media viewing – We counsel our patients to limit television and screen media use (not related to school work) to one to two hours per day, in agreement with the AAP policy statement on media use in school-age children and adolescents [117]. In television and other forms of media, the use of guns is often portrayed as a socially acceptable means of conflict resolution or may not appear to have serious consequences. (See "Television and media violence".)
Gun safety programs — Gun safety programs focus on gun avoidance or the safer handling and storage of firearms. Gun safety programs usually are targeted to specific age groups.
●Gun avoidance – Educational programs that teach gun avoidance appear to work better when they also include a skills training program [118,119]. Nonetheless, even after participation in gun avoidance programs, children should not be relied upon to follow advice concerning guns. Skills demonstrated during such educational programs do not always generalize to real-life settings [82,83,120]. (See 'Family counseling' above.)
In a randomized trial, 45 children were randomly assigned to one of three groups: 1) the Eddie Eagle Gun Safety Program (which teaches children that if they see a gun they should, "Stop! Don't touch. Run away. Tell a grown-up."); 2) a behavioral skills training program that augmented the educational message with modeling of desired behavior, rehearsal, and feedback; and 3) a control group [119]. Children in both intervention groups learned to verbalize the safety message, but those in the behavioral skills group were more likely to demonstrate the skills in role-playing and in situ (ie, real-life situations) assessments.
●Safer handling and storage of firearms – Programs that describe the safer handling and storage of firearms are beyond the scope of this review but are provided by Project ChildSafe.
Gun safety features — Strategies that prevent unintentional firing of firearms may be more effective in preventing pediatric firearm injuries than education about gun avoidance because children – even those who have received gun avoidance training – are likely to handle guns and pull the trigger [82,83]. Observational studies suggest that approximately one-third of unintentional shootings could be prevented if guns were required to have safety features to prevent unintentional firing [121,122].
Safety devices that may prevent the unintentional firing of handguns include [123-127]:
●Loaded chamber indicators, which let the gun handler know when there is a bullet in the pistol chamber
●Magazine disconnect devices, which physically prevent the gun from firing if the magazine or clip has been removed from the handle of a pistol (in the event that a bullet remains in the chamber)
●Grip safety devices, which are levers located on the grip of a handgun that must be compressed to permit firing and are designed to be difficult for a child to operate
●Firing pin blocks, which prevent discharge if the gun is dropped on its hammer
●Childproof (personalized, "smart") handguns, which can be fired only by authorized users (eg, by fingerprint recognition, a personal identification number, radio frequency identification)
There is evidence to suggest public support for gun safety features that permit firing only by authorized users. In a nationally representative survey conducted in 2015, 59 percent of 3949 respondents reported that they were willing to purchase a childproof handgun, 18 percent were unwilling, and 23 percent were undecided [127]. Among gun-owning respondents, 43 percent were willing to purchase a childproof handgun and 33 percent were undecided.
Legislation — The Bipartisan Safer Communities Act (Public Law Number 117-159) was passed in 2022 [128]. It enhances the review process for firearm purchasers <21 years of age; adds persons convicted of domestic abuse in dating relationships to the National Instant Criminal Background Check System; enables criminal prosecution of "straw purchasing" and gun trafficking; provides funding for state "red flag laws" and crisis intervention services; and provides financial support for children's mental health services, school safety, and community-based violence prevention initiatives [129].
Previous federal legislative efforts to regulate handguns (eg, in 2005, in 2015) were largely unsuccessful. Multiple attempts to bring handguns and ammunition under the jurisdiction of the Consumer Product Safety Commission have met with failure. Information about federal and state firearm regulations and congressional firearm legislation efforts is available from the Law Center to Prevent Gun Violence.
Legislation limiting access to handguns may be more effective in preventing handgun injury than other types of legislation (eg, banning specific types of weapons, limiting bulk purchases, child safety laws) [130-134]. In a 2017 systematic review of observational studies, stricter gun laws (eg, requiring background checks and permit-to-purchase, requiring a waiting period) were associated with decreased firearm homicide rates [131]. In subsequent observational studies, stricter gun laws have also been associated with decreased pediatric firearm-related pediatric mortality rates [135], suicide rates [136,137] and decreased likelihood of weapon carrying or being threatened with a weapon at high school [138].
Some states, such as Massachusetts and California, have passed regulations that require a safety feature to prevent firing by children for all commercially sold handguns. Other states have laws that make gun owners criminally liable if someone is injured because a child gains unsupervised access to a gun. The Protection of Lawful Commerce in Arms Act (2005) shields gun manufacturers from civil claims made by victims of firearm injury and limits the ability of local municipalities or individuals to bring lawsuits against gun manufactures for safety design failures.
Evidence regarding the effectiveness of laws related to child safety (eg, requiring gun safety features, age restrictions for purchasing guns, increasing owner liability for injuries related to improper storage) in preventing firearm injuries is inconclusive [131,139]. In a 2017 systematic review of nine studies, there was no association between laws related to child safety and decreased firearm homicides [131]. However, observational studies suggest that most states with child access prevention laws have lower rates of unintentional shootings in children 0 to 14 years and lower rates of adolescent suicide [140-143].
Regulations regarding the minimum age for hunting vary from state to state. Updated information is available from the state (eg, from the game commission, department of fish and wildlife, department of natural resources).
Regulations regarding nonpowder guns vary from state to state. Approximately one-half of states regulate nonpowder guns to some degree and approximately one-fourth restrict sales to a child (with the definition of child ranging from <12 years to <18 years) [144,145].
EVENT STRATEGIES — Event strategies are designed to modulate the transfer of energy from the agent (ie, bullet) to the child. Event strategies to prevent firearm injuries in children include:
●Minimize the discharge of firearms in the environments of children (eg, limit firearm practice to practice ranges).
●Limit the number of bullets that a gun can discharge (based on the premise that discharge of fewer bullets results in decreased morbidity and mortality); this is the rationale for assault weapons bans in several states. The federal Violent Crime Control and Law Enforcement Act of 1994 prohibited the manufacture, transfer, and possession of semiautomatic assault weapons and ammunition magazines that hold more than 10 rounds of ammunition (except for law enforcement officials) [146] but expired in 2004. In a 2017 systematic review of four studies, this federal assault weapons ban was not associated with a decrease in firearm homicides [131]. The only study that evaluated the effect on nonfatal injuries also found no evidence of a reduction but raised caution regarding the methodologic limitations related to short duration of follow-up [147]. However, in a subsequent review of 69 high-fatality mass shootings from 1990 to 2017, state-level bans on large-capacity magazines were associated with fewer high-fatality shootings and fewer deaths in high-fatality shootings [148].
Few strategies are available once the bullet is discharged from the gun. Efforts to develop "safer bullets" (eg, low velocity or plastic bullets) have been unsuccessful [149,150]. The use of bulletproof vests has been effective for police officers and military personnel but is impractical for children.
POST-EVENT STRATEGIES — Post-event strategies are designed to prevent morbidity and mortality in the injured child (the classic medical response model). Post-event strategies to prevent firearm injuries in children include:
●Ongoing efforts to improve the children's emergency medical system and rehabilitation. (See "Prehospital pediatrics and emergency medical services (EMS)".)
●Preparing pediatric trauma centers and pediatric surgeons to manage children who present with penetrating trauma. Given that blunt trauma in children historically accounts for the majority of trauma in children, blunt trauma has been the focus of pediatric trauma center education and management.
●The "Stop the bleed" program, which is administered by the American College of Surgeons Committee on Trauma, trains bystanders to provide bleeding control measures when there are shooting victims with injuries that are rapidly bleeding [151].
●Improved frequency of provision of firearm safety education after gunshot wounds [152].
●Documentation of the firearm injury for surveillance to identify risk factors, causes, and possible prevention strategies for the future [153,154]; full, accurate documentation of injury events, including the "who, what, when, where, why, and how" of the injury occurrence and whether protective equipment (eg, a safety device) was used, is essential [155].
RESOURCES
Firearm safety — The following resources may be helpful to pediatric health care providers in counseling their patients and patients' families about firearm safety:
●American Academy of Family Physicians: Prevention of Gun Violence
●American Academy of Pediatrics
●Brady Campaign to Prevent Gun Violence
●Harborview Injury Prevention and Research Center
●Harvard TH Chan School of Public Health, Harvard Injury Control Research Center: Firearms Research
●Johns Hopkins Center for Gun Policy Research
●Giffords Law Center to Prevent Gun Violence
Counseling after school shootings — The following resource may be helpful to pediatric health care providers in counseling their patients and patients' families after a school shooting:
●The American Academy of Pediatrics
●The National Association of School Psychologists
●The National Child Traumatic Stress Network
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or email these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient education" and the keyword(s) of interest.)
●Basics topic (see "Patient education: Gun safety for families (The Basics)")
SUMMARY
●Epidemiology – Firearm injuries and deaths among children are common in the United States. Most unintentional firearm deaths occur in or around the home. When young children are unintentionally injured or killed by a firearm, the injury is usually self-inflicted or inflicted by another child, typically a family member. (See 'Epidemiology' above.)
●Framework for prevention – Strategies to prevent firearm injuries in children can be categorized according to their time of implementation: pre-event, event, or post-event (table 1). (See 'Framework for prevention' above.)
●Pre-event strategies – Pre-event strategies, which focus on preventing children from shooting firearms, are preferred to event or post-event strategies. Pre-event strategies include family counseling about gun avoidance and safer handling and storage of firearms (table 2), gun safety features, and legislation. (See 'Pre-event strategies' above.)
●Family counseling – We encourage pediatric health care clinicians to provide anticipatory guidance about the dangers of firearms in the home. Caregivers who possess guns, particularly handguns, should be encouraged to either remove them from the home or to store them safely (unloaded and locked, with ammunition stored securely in a separate location). (See 'Family counseling' above.)
ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges David E Wesson, MD, who contributed to an earlier version of this topic review.
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