search text   Advanced Search

This Article Abstract Full Text (PDF) P3Rs: Submit a response Alert me when this article is cited Alert me when P3Rs are posted Alert me if a correction is posted Citation Map Services E-mail this article to a friend Similar articles in this journal Similar articles in ISI Web of Science Similar articles in PubMed Alert me to new issues of the journal Add to My File Cabinet Download to citation manager Citing Articles Citing Articles via CrossRef Citing Articles via ISI Web of Science (3) Citing Articles via Google Scholar Google Scholar Articles by Witsaman, R. J. Articles by Smith, G. A. Search for Related Content PubMed PubMed Citation Articles by Witsaman, R. J. Articles by Smith, G. A. Related Collections Office Practice

Pediatric Fireworks-Related Injuries in the United States: 1990–2003

^a Center for Injury Research and Policy, Columbus Children's Research Institute, Children's Hospital, Columbus, Ohio
^b Department of Pediatrics, College of Medicine and Public Health, The Ohio State University, Columbus, Ohio

	ABSTRACT

TOP ABSTRACT METHODS RESULTS DISCUSSION CONCLUSIONS REFERENCES

 
OBJECTIVE. Our goal was to describe the epidemiology of pediatric fireworks-related injuries among children aged 19 years and younger by using a nationally representative sample.

DESIGN. We performed a retrospective analysis of data from the US Consumer Product Safety Commission's National Electronic Injury Surveillance System from 1990–2003.

RESULTS. An estimated 85800 pediatric fireworks-related injuries were treated in US emergency departments during the 14-year study period. Injured children had a mean age of 10.8 years, and 77.9% were male. Fireworks users accounted for 49.5% of the injuries, whereas 22.2% of the injuries were to bystanders; however, user status could not be determined in 28.3% of cases. The overall fireworks-related injury rate decreased significantly during the study period, but subgroup analysis did not indicate consistent declines among all ages and types of fireworks. Injuries were most commonly caused by firecrackers (29.6%), sparklers/novelty devices (20.5%), and aerial devices (17.6%). The most commonly injured body sites were the eyeball (20.8%), face (20.0%), and hands (19.8%), and the most common injury type was burns (60.3%). Approximately 91.6% of all children with fireworks-related injuries were treated and released from hospital emergency departments, 5.3% were admitted, and 2.3% were transferred to another institution. Bystanders accounted for 13.3% of admitted cases and 20.6% of transferred cases.

CONCLUSIONS. Consumer fireworks cause serious preventable injuries among pediatric fireworks users and bystanders in the United States. Parents should be advised to take their children to safer public fireworks displays rather than allowing consumer fireworks to be used by or near their children. A national restriction of consumer fireworks, in accordance with the policy recommendations of the American Academy of Pediatrics, should be implemented to reduce the burden of fireworks-related injuries among children.

Key Words: fireworks • pediatric • injury prevention • burns • trauma

Abbreviations: ED—emergency department • NEISS—National Electronic Injury Surveillance System • CPSC—Consumer Product Safety Commission • RR—relative risk • CI—confidence interval

Every year, Americans celebrate the Fourth of July by setting off firecrackers, bottle rockets, sparklers, and other consumer fireworks, and every year, fireworks cause serious injuries to both users and bystanders. During the 2004 fireworks season, an estimated 9600 people sought emergency department (ED) care for fireworks-related injuries.^1,2 Approximately 40% of these fireworks-related injuries occurred among children younger than 15 years.^1,2 Parents often falsely assume that close supervision of children using fireworks³ and the use of ‘‘safe and sane fireworks’’^3,4 will prevent injuries. However, previous studies have found that parental supervision was present in 54% of fireworks-related injury events.^3,4 In addition, sparklers, considered by some as one of the safer types of fireworks, have been found to cause 10% to 17% of fireworks-related injuries.^4–6

Most data on fireworks-related injuries have been presented in governmental reports^1,2,7–9 and short policy statements.⁴ Many of these are limited to the period surrounding the Fourth of July.^1,7–9 Peer-reviewed publications tend to report aggregate results, including both adults and children,^5,6,10 or to focus on specific types of injuries such as hand¹¹ or ocular injuries.^12–14 Other studies have been retrospective analyses of data from individual EDs.^3,10,11 Although several studies have been conducted outside of the United States,^6,12,14–16 it is difficult to compare results from such studies to US data because of the variability in countries' fireworks use and regulations.

Our objective with this study was to describe the epidemiology of US pediatric fireworks-related injuries by using a nationally representative database.

	METHODS

TOP ABSTRACT METHODS RESULTS DISCUSSION CONCLUSIONS REFERENCES

 
Data Source
The National Electronic Injury Surveillance System (NEISS) of the US Consumer Product Safety Commission (CPSC) is a stratified probability sample of 98 US hospital EDs, including 8 children's hospitals.¹⁷ It is updated daily and includes information abstracted from ED medical charts, including patient demographics and specific injury information. Fireworks-related injuries among children aged 19 and younger, for the 14-year period from 1990–2003, were identified by using the NEISS consumer product code 1313.¹⁸

Variables
Firework Type
Each year, the CPSC conducts a fireworks study during the period surrounding the Fourth of July holiday (June 22 to July 22).^1,7 Firework types, abstracted from NEISS narratives, were identified by using the classification system of previous CPSC fireworks studies.^19,20 Firework types were then grouped into the following categories: firecrackers, aerial devices, Roman candles/fountains, sparklers/novelty devices, illegal fireworks, and other/unknown. Illegal fireworks consisted of large firecrackers, including M80s, M100s, and cherry bombs, as well as homemade devices. Firecrackers of an unknown size were included in the firecracker category rather than the illegal fireworks or other/unknown categories. Cases related to public displays (43 unweighted cases [1.8% of the original sample]) were excluded from analysis.

Body Site and Diagnosis
Injured body parts were grouped into the following categories: head/neck, face (including the mouth, nose, eyelids, and surrounding eye areas), upper extremities, lower extremities, trunk, 25% to 100% of the body (for burn injuries according to the NEISS coding manual),¹⁸ and other/unknown. In addition, hands, fingers, and eyeballs were kept as separate categories because of the frequency of their involvement and the clinical importance of injuries to these sites. Injury types were categorized as burns, contusions/abrasions, lacerations, entrance of a foreign body, and other/unknown.

Fireworks-User Status
A child was categorized as a fireworks user if the narrative specifically stated they were "playing with," handling, examining, or carrying fireworks or if the firework detonated in the child's hand. Children were categorized as bystanders if the narrative stated that someone else was the firework handler, the firework was thrown at or exploded near the child, the child stepped on or was hit by a firework that they were not handling, or if it was otherwise explicitly stated that the child was not the handler. All other cases were categorized as user status "uncertain."

Statistical Analysis
Data were analyzed by using SPSS 13.01 (SPSS Inc, Chicago, IL) and Stata 8.2 (Stata Corp, College Station, TX) statistical software. Statistical weights provided by the CPSC were used to calculate national injury estimates. Numbers reported in this article are national estimates unless noted otherwise. Rates of injury were calculated by using the 1990–2003 population estimates for 5-year age groups obtained from the US Census Bureau.^21,22 Statistical analysis included the calculation of relative risks (RRs) with 95% confidence intervals (CIs), using stratum and primary sampling unit variables to account for the complex survey design of the NEISS sample. Trends over time were analyzed by using linear regression. The institutional review board of Columbus Children’s Research Institute approved this study.

	RESULTS

TOP ABSTRACT METHODS RESULTS DISCUSSION CONCLUSIONS REFERENCES

 
Demographics and Fireworks Type
Between 1990 and 2003, there were nearly 85800 cases of pediatric fireworks-related injuries treated in US EDs. The mean age of injured children was 10.8 years (±4.8 years; range: 0–19 years), 62% were 10 years of age or older, and 77.9% were male (Table 1). Children were injured most often by firecrackers (29.6%), sparklers/novelty devices (20.5%), and aerial devices (17.6%) (Table 1). Nearly 9200 injuries (10.7%) were from illegal fireworks (Table 1).

View larger version (18K): [in this window] [in a new window]   FIGURE 1 Rate of pediatric fireworks-related injuries according to age group: United States, 1990–2003. Rates were calculated by using the US Census Bureau's population estimates for 5-year age groups during the years of 1990–2003.

View larger version (20K): [in this window] [in a new window]   FIGURE 2 Rate of pediatric fireworks-related injuries according to firework type: United States, 1990–2003. Rates were calculated by using the US Census Bureau's population estimates for all children aged 0–19 years during the years of 1990–2003.

Of all the children with fireworks-related injuries, 91.6% were treated and released from the hospital ED, 5.3% were admitted, 2.3% were transferred to another institution, and 0.8% resulted in other/unknown dispositions. Hospitalization was required for 14.4% of the children with illegal fireworks injuries, 5.3% of those with aerial device injuries, and 5.2% of those with firecracker injuries (Table 3). Illegal fireworks were more likely to result in hospitalization than all other fireworks types combined (RR: 3.35; 95% CI: 2.02–5.56). Among all hospitalized children with fireworks-related injuries, the hands (23.0%), face (18.6%), eyeball (15.8%), and lower extremities (15.0%) were the most common body sites injured. An estimated 6.1% of the children with aerial-device injuries were treated in the ED and then transferred to another institution (Table 3). When compared with all other fireworks categories combined, aerial-device injuries were more likely to result in transfer of the injured child (RR: 2.64; 95% CI: 1.31–5.31). Eyeball injuries made up a large proportion (40.2%) of the transferred cases.

Injuries to Users and Bystanders
Among the injured children, 49.5% were using fireworks, whereas 22.2% were bystanders (Table 1). User status could not be ascertained from the ED-chart narratives of the other 28.3% of cases (Table 1). Among bystanders, injuries were most often caused by firecrackers (25.6%), sparklers/novelty devices (24.0%), and aerial devices (13.0%) (Table 4). Fireworks users were also most frequently injured by firecrackers (31.9%), sparkler/novelty devices (21.2%), and aerial devices (14.1%) (Table 4). In 14.6% of sparkler injuries, the child stepped on a discarded sparkler. The most commonly injured body sites among bystanders were the lower extremities (25.5%), face (22.7%), and eyeball (22.5%), whereas the most commonly injured body sites among fireworks users were the hands (33.3%), fingers (18.6%), and eyeball (14.6%) (Table 4). Bystanders accounted for 13.3% of admissions (3.2% of bystanders), and fireworks users accounted for 66.9% of admissions (7.2% of users). Among transferred children, bystanders comprised 20.6% of the case subjects (2.4% of bystanders), and fireworks users comprised 34.3% of case subjects (1.8% of users).

	DISCUSSION

TOP ABSTRACT METHODS RESULTS DISCUSSION CONCLUSIONS REFERENCES

Consistent with previous results, we found that fireworks-related injuries occur most frequently among boys^1,5,7,16 and children 10 to 14 years of age.^1,5,7,16 The largest proportion of injuries was caused by firecrackers^2,3,5; the most frequently injured body sites were the face, hands, and eyeball^2,4,5; and burns were the most common type of injury.^1,3,5,7 In addition, our results showed that at least 20% of injured children were bystanders, which is comparable with earlier findings of Smith et al.³

Sparklers/novelty devices were associated with large proportions of injuries among children younger than 10 years, analogous to previous results.^1,3,7 The prevalence of injuries from these types of fireworks among young children dispels the common misconception that these are "safe" fireworks that are appropriate for use by these children.⁴ Sparklers burn at temperatures >1000°F⁴; thus, it is not surprising that >70% of sparklers/novelty-device injuries were burns. Discarded sparklers also pose an injury risk to children, who can sustain burns or lacerations from stepping on sparkler wires.

In contrast with previous studies,^5,13,23 we found that Roman candles/fountains, rather than aerial devices (specifically, bottle rockets), were responsible for a higher proportion of eye injuries. One explanation for this difference may be the categorization of body sites by the NEISS (ie, the area surrounding the eye is categorized as the face, whereas the eyeball is a separate entity).¹⁸ Most aerial-device injuries were to the face, possibly injuring the area surrounding the eye. Despite this discrepancy, aerial-device injuries were severe, responsible for 900 transfers to another hospital. These results confirm previous findings of the severity of aerial-device injuries^3,5,12–14 while indicating that previously ignored Roman candles/fountains are also sources of serious eye injuries.

The overall decline in fireworks-related injury rates found during this 14-year study period is consistent with CPSC reports,^1,7 yet both our study and the CPSC reports indicate that rates have remained essentially unchanged after large declines before 1996.^1,7 Furthermore, our results demonstrated that secular trends varied by age and firework type and were usually not significant. The cause of the overall decline in injury rates remains unclear, and the variability of subgroup-specific rates suggests that additional prevention efforts are needed to continue to decrease fireworks-related injury rates.

Nearly 19100 bystanders (22.2%) were injured by fireworks, sustaining injuries at vulnerable body sites such as the face and eyes. The consequences of these injuries can be severe, because they can result in reduced visual acuity and permanent blindness.¹³ In addition, bystanders accounted for substantial proportions of the admitted (13.3%) and transferred (20.6%) children, indicating the severity of injuries to bystanders. Sundelin and Norrsell¹⁴ found that there was no correlation between the seriousness of the injury and fireworks-user status. These results demonstrate that refraining from personal firework use does not protect against the risk of serious injury if merely being near anyone using fireworks places an individual at risk of injury.

Prevention and Policy
The results of this article, particularly in light of our findings regarding to injuries among bystanders, demonstrate the need for fireworks-related injury prevention throughout the United States. Prevention efforts for decreasing fireworks-related injury rates have traditionally fallen into 2 categories: (1) community education and intervention and (2) legislation or local ordinances restricting use and sales to private consumers. There have been few reports of evaluation of comprehensive intervention programs,¹⁴ although D'Argenio et al²⁴ described a successful multifaceted intervention campaign during the New Year holiday season in Naples, Italy. However, its appropriateness for application within the United States is uncertain.

Some authors have suggested banning firecrackers and bottle rockets,^5,10,12 often considered the most dangerous types of fireworks, as a means of injury prevention. Although this could eliminate many fireworks-related injuries, it clearly does not address the injuries caused by other currently legal fireworks such as Roman candles/fountains and sparklers/novelty devices. Despite claims by the American Pyrotechnics Association that fireworks-related injury rates are decreasing,²⁵ the inconsistent declines in injuries over time demonstrated in this study and others^1,5,7 show that more comprehensive prevention efforts are required across all subgroups of age and type of fireworks.

A more universal approach to injury prevention, especially for reducing bystander injuries, would be national restriction on all consumer fireworks sales and use. At the state level, Berger et al²³ examined the effect of firework sales restrictions and found a significantly decreased rate of fireworks-related injury in states that restrict fireworks sales. A national ban on the sale and use of all consumer fireworks, in accordance with recommendations by the American Academy of Pediatrics⁴ and other national organizations,^3,14 would allow for more consistent and effective regulation of fireworks. The National Fire Protection Association's model fireworks law, which bans all fireworks sales except toy paper caps for consumers other than professionals,²⁶ has been implemented in several states as a means to regulate the sale of fireworks.²⁶ The model law parallels the policy recommendations regarding fireworks use by the American Academy of Pediatrics⁴ and can serve as a guideline for a national fireworks-restriction plan (Table 5).

The fact that the limitations of this study mean our findings represent a conservative estimate of fireworks-related injuries should underscore the urgent need for prevention efforts. Few publications have described or evaluated interventions.²⁴ Therefore, additional research is needed in this area. Examination of parental and societal attitudes toward fireworks use stands out as one direction for this type of research, because these attitudes are likely to affect the outcomes of implementing preventive interventions.

	CONCLUSIONS

TOP ABSTRACT METHODS RESULTS DISCUSSION CONCLUSIONS REFERENCES

 
An unacceptably large number of children in the United States sustain preventable fireworks-related injuries serious enough to require ED care each year. In addition, the use of fireworks puts bystanders at risk for injuries that can be just as serious as those sustained by fireworks users. Consumer fireworks should not be used by or near children. Parents should be warned of the dangers of fireworks and advised to celebrate the Fourth of July holiday by taking their children to safer public fireworks displays conducted by professionals. Consistent with the policy position of the American Academy of Pediatrics, a complete restriction on the sale and use of consumer fireworks should be promulgated by the CPSC to prevent fireworks-related injuries in the United States.

	FOOTNOTES

 
Accepted Mar 4, 2006.

Address correspondence to Rachel J. Witsaman, BA, Center for Injury Research and Policy, Columbus Children's Research Institute, Children's Hospital, 700 Children's Dr, Columbus, OH 43205. E-mail: witsaman{at}pediatrics.ohio-state.edu

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

	REFERENCES

TOP ABSTRACT METHODS RESULTS DISCUSSION CONCLUSIONS REFERENCES

 

1. Greene MA, Joholske J. 2004 fireworks annual report: fireworks-related deaths, emergency department-treated injuries, and enforcement activities during 2004. Available at: www.cpsc.gov/LIBRARY/2004fwreport.pdf. Accessed October 31, 2005
2. US Consumer Product Safety Commission. Fireworks Publication #12 Washington DC: US Consumer Product Safety Commission; 2005
3. Smith GA, Knapp JF, Barnett TM, Shields BJ. The rockets' red glare, the bombs bursting in air: fireworks-related injuries to children. Pediatrics. 1996;98 :1 –9[Abstract/Free Full Text]
4. American Academy of Pediatrics, Committee on Injury and Poison Prevention. Fireworks-related injuries to children. Pediatrics. 2001;108 :190 –191[Abstract/Free Full Text]
5. See LC, Lo SK. Epidemiology of fireworks injuries: the National Electronic Injury Surveillance System, 1980–1989. Ann Emerg Med. 1994;24 :46 –50[ISI][Medline]
6. Fogarty BJ, Gordon DJ. Firework related injury and legislation: the epidemiology of firework injuries and the effect of legislation in Northern Ireland. Burns. 1999;25 :53 –56[CrossRef][ISI][Medline]
7. Greene MA, Joholske J. 2003 fireworks annual report: fireworks-related deaths, emergency department-treated injuries, and enforcement activities during 2003. Available at: www.cpsc.gov/LIBRARY/2003fwreport.pdf. Accessed October 31, 2005
8. US Fire Administration and National Fire Data Center. The dangers of fireworks. Available at: www.usfa.fema.gov/downloads/pdf/tfrs/v5i4.pdf. Accessed October 31, 2005
9. Hall JR Jr. Fireworks. Available at: www.nfpa.org/assets/files/pdf/os.fireworks.pdf. Accessed October 31, 2005
10. McFarland LV, Harris JR, Kobayashi JM, Dicker RC. Risk factors for fireworks-related injury in Washington State. JAMA. 1984;251 :3251 –3254[Abstract]
11. Moore RS Jr, Tan V, Dormans JP, Bozentka DJ. Major pediatric hand trauma associated with fireworks. J Orthop Trauma. 2000;14 :426 –428[CrossRef][ISI][Medline]
12. Singh DV, Sharma YR, Azad RV. Visual outcome after fireworks injuries. J Trauma. 2005;59 :109 –111[ISI][Medline]
13. Centers for Disease Control and Prevention. Serious eye injuries associated with fireworks: United States, 1990–1994. JAMA. 1995;274 :110 –111[CrossRef][ISI][Medline]
14. Sundelin K, Norrsell K. Eye injuries from fireworks in Western Sweden. Acta Ophthalmol Scand. 2000;78 :61 –64[CrossRef][ISI][Medline]
15. Abdulwadud O, Ozanne-Smith J. Injuries associated with fireworks in Victoria: an epidemiological overview. Inj Prev. 1998;4 :272 –275[Abstract/Free Full Text]
16. Vassilia K, Eleni P, Dimitrios T. Firework-related childhood injuries in Greece: a national problem. Burns. 2004;30 :151 –153[CrossRef][ISI][Medline]
17. US Consumer Product Safety Commission. NEISS: the National Electronic Injury Surveillance System—a tool for researchers. Available at: www.cpsc.gov/Neiss/2000d015.pdf. Accessed October 31, 2005
18. US Consumer Product Safety Commission. NEISS coding manual. Available at: www.cpsc.gov/Neiss/completemanual.pdf. Accessed October 31, 2005
19. US Consumer Product Safety Commission. 2005 Fireworks Survey. Washington, DC: Consumer Product Safety Commission; 2005:1 –2
20. US Consumer Product Safety Commission. Instructions for ER Admitting Staff Washington, DC: Consumer Product Safety Commission; 2005
21. US Bureau of the Census. Annual estimates of the population by sex and five-year age groups for the United States: April 1, 2000, to July 1, 2004. Available at: www.census.gov/popest/national/asrh/NC-EST2004-sa.html. Accessed October 31, 2005
22. US Bureau of the Census. 1990 to 1999 annual time series of state population estimates by single year of age and sex: April 1, 1990, to July 1, 1999, with short-term projection to November 1, 2000. 2001. Available at: www.census.gov/popest/archives/1990s/st_age_sex.html. Accessed October 31, 2005
23. Berger LR, Kalishman S, Rivara FP. Injuries from fireworks. Pediatrics. 1985;75 :877 –882[Abstract/Free Full Text]
24. D'Argenio P, Cafaro L, Santonastasi F, Taggi F, Binkin N. Capodanno Senza Danno: the effects of an intervention program on fireworks injuries in Naples. Am J Public Health. 1996;86 :84 –86[Abstract/Free Full Text]
25. Heckman JL. APA Credits Fireworks Industry for Record Low Injury Rate Bethesda, MD: American Pyrotechnics Association; 2003
26. International Fire Marshals Association and the National Fire Protection Association. Model fireworks law: 2006 edition. Available at: www.nfpa.org/assets/files/PDF/ModelFireworks.pdf. Accessed October 31, 2005
27. Powell EC, Tanz RR. Incidence and description of scooter-related injuries among children. Ambul Pediatr. 2004:4 :495 –499[CrossRef][ISI][Medline]
28. Smith GA. Injuries to children in the United States related to trampolines, 1990–1995: a national epidemic. Pediatrics. 1998;101 :406 –412[Abstract/Free Full Text]

This Article Abstract Full Text (PDF) P3Rs: Submit a response Alert me when this article is cited Alert me when P3Rs are posted Alert me if a correction is posted Citation Map Services E-mail this article to a friend Similar articles in this journal Similar articles in ISI Web of Science Similar articles in PubMed Alert me to new issues of the journal Add to My File Cabinet Download to citation manager Citing Articles Citing Articles via CrossRef Citing Articles via ISI Web of Science (3) Citing Articles via Google Scholar Google Scholar Articles by Witsaman, R. J. Articles by Smith, G. A. Search for Related Content PubMed PubMed Citation Articles by Witsaman, R. J. Articles by Smith, G. A. Related Collections Office Practice

	Home | My Pediatrics | Journal Information | Current Issue | Past Issues | Subscriptions & Services | Contact Us Click here for faster international access © 2006 American Academy of Pediatrics. All rights reserved.