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Injuries and deaths due to firearms in children and young adults is a public health crisis in the United States. Pediatric clinicians are powerful advocates to reduce harm due to firearms. By forming coalitions with legislators on a bipartisan basis, working with government relations teams in the hospitals, and partnering with community allies and stakeholders, pediatric clinicians can work to enact legislation and influence policies at the individual, state, and national levels. This can include advocacy for strengthening Child Access Prevention Laws and firearm safer storage campaigns., Competing Interests: Disclosure Dr L.K. Lee receives royalties as an editor for the book, “Pediatric Firearm Injuries and Fatalities: The Clinician’s Guide to Policies and Approaches to Firearm Harm Prevention.”, (Copyright © 2022 Elsevier Inc. All rights reserved.)

Importance: Firearm fatality rates in the United States have reached a 28-year high. Describing the evolution of firearm fatality rates across intents, demographics, and geography over time may highlight high-risk groups and inform interventions for firearm injury prevention., Objective: To understand variations in rates of firearm fatalities stratified by intent, demographics, and geography in the US., Design, Setting, and Participants: This cross-sectional study analyzed firearm fatalities in the US from 1990 to 2021 using data from the Centers for Disease Control and Prevention. Heat maps, maximum and mean fatality rate graphs, and choropleth maps of county-level rates were created to examine trends in firearm fatality rates by intent over time by age, sex, race, ethnicity, and urbanicity of individuals who died from firearms. Data were analyzed from December 2018 through September 2022., Main Outcomes and Measures: Rates of firearm fatalities by age, sex, race, ethnicity, urbanicity, and county of individuals killed stratified by specific intent (suicide or homicide) per 100 000 persons per year., Results: There were a total of 1 110 421 firearm fatalities from 1990 to 2021 (952 984 among males [85.8%] and 157 165 among females [14.2%]; 286 075 among Black non-Hispanic individuals [25.8%], 115 616 among Hispanic individuals [10.4%], and 672 132 among White non-Hispanic individuals [60.5%]). All-intents total firearm fatality rates per 100 000 persons declined to a low of 10.1 fatalities in 2004, then increased to 14.7 fatalities (45.5% increase) by 2021. From 2014 to 2021, male and female firearm homicide rates per 100 000 persons per year increased from 5.9 to 10.9 fatalities (84.7% increase) and 1.1 to 2.0 fatalities (87.0% increase), respectively. Firearm suicide rates were highest among White non-Hispanic men aged 80 to 84 years (up to 46.8 fatalities/100 000 persons in 2021). By 2021, maximum rates of firearm homicide were up to 22.5 times higher among Black non-Hispanic men (up to 141.8 fatalities/100 000 persons aged 20-24 years) and up to 3.6 times higher among Hispanic men (up to 22.8 fatalities/100 000 persons aged 20-24 years) compared with White non-Hispanic men (up to 6.3 fatalities/100 000 persons aged 30-34 years). Males had higher rates of suicide (14.1 fatalities vs 2.0 fatalities per 100 000 persons in 2021) and homicide (10.9 fatalities vs. 2.0 fatalities per 100 000 persons in 2021) compared with females. Metropolitan areas had higher homicide rates than nonmetropolitan areas (6.6 fatalities vs 4.8 fatalities per 100 000 persons in 2021). Firearm fatalities by county level increased over time, spreading from the West to the South. From 1999 to 2011 until 2014 to 2016, fatalities per 100 000 persons per year decreased from 10.6 to 10.5 fatalities in Western states and increased from 12.8 to 13.9 fatalities in Southern states., Conclusions and Relevance: This study found marked disparities in firearm fatality rates by demographic group, which increased over the past decade. These findings suggest that public health approaches to reduce firearm violence should consider underlying demographic and geographic trends and differences by intent.

Competing Interests: LKL receives royalties from Springer Nature as an editor and author for the book, Pediatric Firearm Injuries and Fatalities; grant funding from the National Institute on Alcohol Abuse and Alcoholism (NIAA); and honoraria for speaking engagements from the American Academy of Pediatrics, Golisano Children's Hospital, the Medical College of Wisconsin, and the Milwaukee Medical Society; and has leadership roles in the American Academy of Pediatrics, Council on Injury, Violence, and Poison Prevention, and the Injury Free Coalition for Kids. EWF receives royalties from Springer Nature as an editor and author for the book, Pediatric Firearm Injuries and Fatalities. AK receives grant funding from the NIAA and National Institute of Child Health and Human Development and honoraria for speaking engagements from the Destiny Hill Church and Greater Mt Calvary Baptist Church; and has leadership roles in the American Academy of Pediatrics, Council on Injury, Violence, and Poison Prevention, and Fraser. All other authors declare no competing interests.

Objective: To identify contributing factors associated with rapid spikes and declines in Chicago youth homicide from 2009 to 2018., Setting: City of Chicago, Illinois, US 2009-2018., Participants: Homicide count data come from the National Violent Death Reporting System. The study included information on 2271 homicide decedents between the ages of 15 and 24 who died between 1 January 2009 and 31 December 2018. Of these decedents, 92.9% were male; 79.1% were non-Hispanic black; and 94.9% died from a firearm injury. PRIMARY AND SECONDARY OUTCOME MEASURES: (A) Temporal shifts in monthly homicide rates and (B) temporal associations between social, environmental and economic conditions/events and fluctuations in homicides., Results: We found statistically significant shifts in homicide rates over time: a 77% rise in monthly youth homicide rates per 100 000 persons from 2015 to 2016 (4.3 vs 7.5); dropping back to pre-2015 rates (4.3) by mid-2017. There was a temporal co-occurrence between the rapid rise in youth homicides and absence of a state budget. Conversely, we found a temporal co-occurrence of the sharp decline in homicides with the reinstatement of a state budget. Adjusting for seasonality, we found death rates were greater in the months without a budget compared with months with a budget (1.48, 95% CI 1.29 to 1.70)., Conclusions: Our findings suggest that state funding may be a potential protective factor against youth homicide., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Importance: Firearms caused more than 500 pediatric fatalities in 2017-a 50% increase from 2009. Laws regulating firearms are one approach to reducing pediatric firearm fatalities., Objective: To evaluate the association between state child access prevention (CAP) firearm laws and pediatric firearm fatalities., Design, Setting, and Participants: A state-level, cross-sectional study of CAP firearm laws throughout the United States, 1991-2016, was conducted using negative binomial regression to analyze differences in state fatality rates in children aged 0 to 14 years. Data analysis was performed from November 21, 2018, to October 18, 2019., Exposures: Implementation of 2 categories of state CAP firearm laws: recklessness laws, which pertain to providing a firearm to a child, and negligence laws, which pertain to accessibility of a firearm within the home., Main Outcomes and Measures: Rates of firearm fatalities across all intents and by specific intent (homicide, suicide, and unintentional) per 100 000 children aged 0 to 14 years., Results: Twenty-five states passed CAP laws between 1989 and 2000. Between 1991 and 2016, 13 697 firearm fatalities occurred in children aged 0 to 14 years. Recklessness laws were not associated with changes in pediatric firearm fatality rates. Negligence laws overall were associated with significant reductions in firearm fatalities in children aged 0 to 14 years, with a 13% relative reduction in all firearm fatalities (95% CI, -18% to -7%), a 15% relative reduction in firearm homicides (95% CI, -22% to -7%), a 12% relative reduction in firearm suicides (95% CI, -20% to -2%), and a 13% relative reduction in unintentional firearm fatalities (95% CI, -24% to -1%). The most stringent negligence laws were associated with unintentional firearm fatality reductions of 59% (95% CI, -68% to -49%). A total of 3929 deaths (29% of all firearm deaths) were associated with states not having passed the most stringent form of negligence CAP laws., Conclusions and Relevance: In this study, negligence laws were associated with relative reductions in firearm fatality rates in children aged 0 to 14 years. The most stringent negligence laws were associated with the largest reductions in unintentional firearm fatalities. Recklessness laws were not associated with reduced firearm fatality rates. The passage of negligence CAP laws may have the potential to reduce firearm fatalities in children.

School shootings comprise a small proportion of childhood deaths from firearms; however, these shootings receive a disproportionately large share of media attention. We conducted a root cause analysis of 2 recent school shootings in the United States using lay press reports. We reviewed 1760 and analyzed 282 articles from the 10 most trusted news sources. We identified 356 factors associated with the school shootings. Policy-level factors, including a paucity of adequate legislation controlling firearm purchase and ownership, were the most common contributing factors to school shootings. Mental illness was a commonly cited person-level factor, and access to firearms in the home and availability of large-capacity firearms were commonly cited environmental factors. Novel approaches, including root cause analyses using lay media, can identify factors contributing to mass shootings. The policy, person, and environmental factors associated with these school shootings should be addressed as part of a multipronged effort to prevent future mass shootings.

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

Importance: Firearm homicide is a leading cause of injury death in the United States, and there is considerable debate over the effectiveness of firearm policies. An analysis of the effectiveness of firearm laws on firearm homicide is important to understand optimal policies to decrease firearm homicide in the United States., Objective: To evaluate the association between firearm laws and preventing firearm homicides in the United States., Evidence Review: We evaluated peer-reviewed articles from 1970 to 2016 focusing on the association between US firearm laws and firearm homicide. We searched PubMed, CINAHL, Lexis/Nexis, Sociological Abstracts, Academic Search Premier, the Index to Legal Periodicals and Books, and the references from the assembled articles. We divided laws into 5 categories: those that (1) curb gun trafficking, (2) strengthen background checks, (3) improve child safety, (4) ban military-style assault weapons, and (5) restrict firearms in public places and leniency in firearm carrying. The articles were assessed using the standardized Guide to Community Preventive Services data collection instrument and 5 additional quality metrics: (1) appropriate data source(s) and outcome measure(s) were used for the study, (2) the time frame studied was adequate, (3) appropriate statistical tests were used, (4) the analytic results were robust, and (5) the disaggregated results of control variables were consistent with the literature., Findings: In the aggregate, stronger gun policies were associated with decreased rates of firearm homicide, even after adjusting for demographic and sociologic factors. Laws that strengthen background checks and permit-to-purchase seemed to decrease firearm homicide rates. Specific laws directed at firearm trafficking, improving child safety, or the banning of military-style assault weapons were not associated with changes in firearm homicide rates. The evidence for laws restricting guns in public places and leniency in gun carrying was mixed., Conclusions and Relevance: The strength of firearm legislation in general, and laws related to strengthening background checks and permit-to-purchase in particular, is associated with decreased firearm homicide rates. High-quality research is important to further evaluate the effectiveness of these laws. Legislation is just 1 part of a multipronged approach that will be necessary to decrease firearm homicides in the United States.

Objective: Firearm injuries among children are a major clinical and public health concern and one of the leading causes of pediatric fatalities. Our objective was to investigate differences in predictors and clinical outcomes between self-inflicted, violent, and unintentional pediatric firearm injuries for patients who present to pediatric emergency departments (EDs)., Methods: We conducted a retrospective study of patients 0 to 21 years old treated in 37 pediatric academic EDs from 2004 to 2014. Patients were classified into the injury intent categories of self-inflicted, violent, and unintentional firearm injury using the International Classification of Diseases, 9th edition, Clinical Modification (ICD-9-CM) diagnoses and external causes of injury codes. Multivariable multinomial regression models compared groups., Results: We identified 9,628 firearm injuries from 2004 to 2014: 109 (1%) self-inflicted, 2,394 (25%) violent, and 7,125 (74%) unintentional. Male sex, increasing age, nonwhite race, public insurance, residing in an urban zip code, and lower zip code-level median household income were all independently associated with violent firearm injuries, relative to self-inflicted and unintentional injuries. Self-inflicted injuries were at the highest risk for hospital admission, death, intensive care unit services, surgical services, and increased length of stay, followed by violent injuries with intermediate risk and unintentional injuries at the lowest risk, Conclusions: Self-inflicted, violent, and unintentional firearm injuries in children had distinct demographic risk factors and clinical and utilization outcomes. Targeted prevention and intervention efforts should be developed to reduce the incidence and severity of these injuries., (© 2016 by the Society for Academic Emergency Medicine.)

Objectives: Firearm injuries to children and adolescents remain an important cause of morbidity and mortality in the USA. The objectives of this study were to describe the prevalence of and epidemiologic risk factors associated with firearm injuries to children and adolescents evaluated in a nationally representative sample of US emergency departments and ambulatory care centres., Study Design: We performed a retrospective cross-sectional analysis of data from the National Hospital Ambulatory Medical Care Survey from 2001 to 2010. Firearm injury-related visits in patients 0-19 years old were identified using the International Classification of Diseases, Ninth Revision, Clinical Modification firearm injury codes. The primary outcome was the prevalence of firearm-related injuries. We used multivariate logistic regression to analyse demographic risk factors associated with these injuries., Results: From 2001 to 2010, there were a total of 322 730 927 (95% CI 287 462 091 to 357 999 763) paediatric US outpatient visits; 198 969 visits (0.06%, 95% CI 120 727 to 277 211) were for firearm injuries. Fatal firearm injuries accounted for 2% of these visits; 36% were intentionally inflicted. There were increased odds of firearm injuries to men (OR 10.2, 95% CI 5.1 to 20.5), black children and adolescents (0-19 years) (OR 3.2, 95% CI 1.5 to 6.7) and adolescents 12-19 years old (all races) (OR 16.6, 95% CI 6.3 to 44.3) on multivariable analysis., Conclusions: Firearm injuries continue to be a substantial problem for US children and adolescents, with non-fatal rates 24% higher than previously reported. Increased odds for firearm-related visits were found in men, black children and those 12-19 years old.