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Article

Nonpowder Firearm Injuries to Children Treated in Emergency Departments

Margaret Jones, Sandhya Kistamgari and Gary A. Smith
Pediatrics December 2019, 144 (6) e20192739; DOI: https://doi.org/10.1542/peds.2019-2739
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Abstract

OBJECTIVES: To investigate nonpowder firearm injuries treated in US emergency departments among children <18 years old.

METHODS: National Electronic Injury Surveillance System data from 1990 through 2016 were analyzed.

RESULTS: An estimated 364 133 (95% confidence interval 314 540–413 727) children <18 years old were treated in US emergency departments for injuries related to nonpowder firearms from 1990 to 2016, averaging 13 486 children annually. From 1990 to 2016, the number and rate of nonpowder firearm injuries decreased by 47.8% (P < .001) and 54.5% (P < .001), respectively. Most injuries occurred among 6- to 12-year-olds (47.4%) and 13- to 17-year-olds (47.0%). Boys accounted for 87.1% of injured children, the most common diagnosis was foreign body (46.3%), and 7.1% of children were admitted. BB guns accounted for 80.8% of injuries, followed by pellet guns (15.5%), paintball guns (3.0%), and airsoft guns (0.6%). The rate of eye injuries increased by 30.3% during the study period. Eye injuries accounted for 14.8% of all injuries and the most common diagnoses were corneal abrasion (35.1%), hyphema (12.5%), globe rupture (10.4%), and foreign body (8.6%).

CONCLUSIONS: Although the number and rate of nonpowder firearm injuries declined during the study period, nonpowder firearms remain a frequent and important source of preventable and often serious injury to children. The severity and increasing rate of eye injuries related to nonpowder firearms is especially concerning. Increased prevention efforts are needed in the form of stricter and more consistent safety legislation at the state level, as well as child and parental education regarding proper supervision, firearm handling, and use of protective eyewear.

  • Abbreviations:
    ASTM —
    American Society for Testing and Materials
    CI —
    confidence interval
    CPSC —
    US Consumer Product Safety Commission
    ED —
    emergency department
    NEISS —
    National Electronic Injury Surveillance System
    OR —
    odds ratio

    • What’s Known on This Subject:

    Although nonpowder firearms can cause serious pediatric injury, especially to the eyes, their regulation varies from state to state and no federal regulation exists. The American Academy of Pediatrics recommends use of protective eyewear when using nonpowder firearms.

    What This Study Adds:

    On average, 13 486 pediatric nonpowder firearm injuries were treated in US emergency departments annually. Although the overall rate of these injuries declined by 54.5% from 1990 to 2016, nonpowder firearm eye injuries increased by 30.3%. Increased prevention efforts are needed.

    Nonpowder firearms have long been marketed to children and teenagers as toys or “starter” firearms and include paintball, airsoft, BB, and pellet guns. They use air pressure, carbon dioxide pressure, or spring-loaded action to propel metal or plastic projectiles of many shapes and sizes at varying velocities and are primarily used in target shooting, small animal hunting, and recreational combat simulation games (eg, paintball and airsoft). Although nonpowder firearms are recognized as an important source of pediatric injury, especially to the eyes,1–4 their regulation varies from state to state, and no federal regulation exists.5

    Previous studies of nonpowder firearm injuries have often focused on specific anatomic areas, such as the eyes, head, neck, or chest.6–11 Others have been limited to reports of fatalities.10,12,13 Most previous studies have had a small sample size or were conducted at a single center.4,14–17 However, 3 previous studies analyzed a nationally representative sample from the National Electronic Injury Surveillance System (NEISS) database. One of those studies evaluated injuries from 1985 to 1999,18 the second concentrated on pediatric eye injuries from 2002 to 2012,6 and the third evaluated head and neck injuries from 2005 to 2014.19 To our knowledge, our study is the first to comprehensively investigate all types of nonpowder firearm injuries among children and adolescents using a nationally representative sample.

    Methods

    Data Source and Case Selection Criteria

    This study retrospectively analyzed data regarding nonpowder firearm injuries among children <18 years of age treated in US emergency departments (EDs) from 1990 through 2016. Data were obtained from the NEISS, which monitors injuries associated with consumer products and sports and recreational activities treated in US EDs. The NEISS is maintained by the US Consumer Product Safety Commission (CPSC) and includes ∼100 reporting hospitals that represent a stratified probability sample from the >5300 hospitals with at least 6 beds and a 24-hour ED in the United States and its territories.20 Trained NEISS coders at participating hospitals extracted data from ED medical records, including patient demographics (including age and sex), consumer products or activities involved, injury diagnosis, affected body region, location where the injury occurred, disposition from the ED, and a brief narrative describing the circumstances of the injury incident.20

    Nonpowder firearm injuries were identified by using NEISS product codes 1200 (for paintball [activity]: sports and recreational activity, not elsewhere classified), 1237 (gas, air, or spring-operated guns [including BB guns]), and 1936 (BBs or pellets [excluding shotgun pellets]). Each case narrative was reviewed and cases were excluded if they involved nonprojectile firearms, other projectile firearms, powder firearms, pellet or BB ingestions or foreign body insertions, injuries not directly related to use of the firearm, being hit or struck with the firearm, or if the mechanism of injury was unclear. The final data set consisted of 9739 actual cases included in analyses.

    Study Variables

    Children were categorized into 3 age groups: <6, 6 to 12, and 13 to 17 years old. Injury diagnosis was categorized as (1) contusion or abrasion, (2) foreign body, (3) fracture, (4) laceration, (5) puncture, and (6) other. Body region injured was grouped as (1) head and/or neck (including eyeball, face, head, neck, mouth, and ear), (2) trunk (including upper trunk, lower trunk, and pubic region), (3) upper extremity (including finger, hand, wrist, lower arm, elbow, upper arm, and shoulder), and (4) lower extremity (including toe, foot, ankle, lower leg, knee, and upper leg). Disposition from the ED was categorized as: (1) treated and released, (2) admitted (including hospitalized, transferred, held for observation for <24 hours, and treated and transferred for hospitalization), and (3) left against medical advice. Location of injury incident was grouped as (1) home (including home, mobile or manufactured home, apartment, and farm) and (2) other. Additional variables analyzed included sex and year.

    The narrative from each case was reviewed and a variable describing the user of the nonpowder firearm was created, which included the categories of (1) self and (2) other person (including peer, adult, and other person of unspecified age). Using each case narrative, a variable describing the type of nonpowder firearm was created, which included the categories of (1) BB gun, (2) pellet gun, (3) airsoft gun, and (4) paintball gun.

    Statistical Analysis

    Data were analyzed by using SPSS version 20.0 (IBM SPSS Statistics, IBM Corporation) and SAS 9.4 (SAS Institute, Inc, Cary, NC). Complex survey procedures were used to calculate the national estimates using sample weights provided by the CPSC. All the estimates in the study are stable estimates unless stated otherwise. The CPSC considers an estimate to be unstable if the estimate is <1200, the sample size is <20 actual cases, or the coefficient of variation is >33%. Injury rates were calculated by using intercensal and postcensal population estimates obtained from the US Census Bureau.21–23 Secular trends in the estimated annual number and rate of injuries were assessed using simple or piecewise linear regression as appropriate. The estimated slope from regression models was reported along with the associated P value. Other statistical analyses included calculation of odds ratios (ORs) with 95% confidence intervals (CIs) using complex survey procedures. Statistical significance was set at 0.05. This study was determined to be exempt by the institutional review board of the authors’ institution.

    Results

    General Characteristics

    An estimated 364 133 (95% CI: 314 540–413 727) children <18 years of age with nonpowder firearm injuries were treated in US EDs from 1990 through 2016, averaging 13 486 children annually or 18.8 injuries per 100 000 US children <18 years old. Most injuries occurred among children 6 to 12 years old (47.4%) and 13 to 17 years old (47.0%), with only 5.6% of injuries being observed among children <6 years of age. The average age was 11.8 years (SD: 3.5; interquartile range: 10–14 years). Boys accounted for 87.1% of injuries, and among cases with a documented location of injury, most (89.4%) occurred at home (Table 1).

    View this table:
    TABLE 1

    Characteristics of Nonpowder Firearm Injuries Treated in US EDs by Age Group (NEISS 1990–2016)

    Body Region Injured

    The head and neck were the most commonly injured body region (39.3%), followed by upper extremity (30.7%) and lower extremity (20.6%). BB guns (35.4%), paintball guns (80.6%), and airsoft guns (100.0%) commonly were associated with injuries to the head and neck, whereas injuries from pellet guns (33.7%) were often to the upper extremity (Table 2). Patients <6 years old more commonly sustained an injury to the head and neck (OR: 1.65; 95% CI: 1.31–2.07) than older patients, and patients 13 to 17 years old were treated more often (OR: 1.26; 95% CI: 1.12–1.43) for an upper extremity injury than younger patients. Among injuries to the head and neck, 36.1% were diagnosed as foreign body, 23.6% were diagnosed as a contusion or abrasion, and 11.9% resulted in hospital admission. Among the head and neck injuries, 37.7% (n = 53 994; 95% CI: 43 602–64 386) were related to the eye. Eye injuries accounted for 14.8% of all nonpowder firearm injuries.

    View this table:
    TABLE 2

    Characteristics of Nonpowder Firearm Injuries Treated in US EDs by Type of Firearm (NEISS 1990–2016)

    Diagnosis

    The most common diagnosis was foreign body (46.3%), followed by puncture (22.3%) and contusion or abrasion (13.5%); this pattern was consistent across all age groups. More than two-thirds (68.9%) of contusions and abrasions were to the head and neck, whereas foreign body injuries were commonly to an upper extremity (37.2%), followed by head and neck (30.7%). Corneal abrasion (35.1%) was the most common diagnosis among eye injuries. Patients 13 to 17 years of age had higher odds (OR: 1.74; 95% CI: 1.36–2.22) of being diagnosed with a foreign body than patients <13 years old. BB guns (50.6%) and pellet guns (41.7%) commonly resulted in foreign body-related injuries, whereas paintball guns were frequently associated a contusion or abrasion (50.2%; Table 2). Fractures were most commonly associated with hospital admission (9.7%), followed by punctures (6.7%) and lacerations (5.9%).

    Corneal abrasion (35.1%), hyphema (12.5%), foreign body (10.9%), and globe rupture (10.4%) were the most common diagnoses among the eye injuries (Table 3). The proportion of injured children who required hospital admission varied by type of eye injury and was highest for globe rupture (62.0%), followed by foreign body (41.5%) and hyphema (27.5%). Globe rupture had higher odds of hospital admission than other types of eye injury (OR: 7.68; 95% CI: 5.02–11.74), and foreign body also had greater odds of admission than other eye injury diagnoses (OR: 2.88; 95% CI: 1.82–4.56).

    View this table:
    TABLE 3

    Frequency and Percentage of Specific Diagnoses Among Nonpowder Firearm Eye Injuries Treated in US EDs (NEISS 1990–2016)

    Disposition From the ED

    Hospital admission occurred for 7.1% of patients with a nonpowder firearm injury. There were no fatalities. Among admitted patients, 47.5% were 6 to 12 years old, 65.9% had an injury to the head and neck, and 36.9% were diagnosed with a foreign body. Paintball gun–related injuries had the highest proportion of hospital admission (12.2%), followed by pellet guns (8.3%) and airsoft guns (7.0%). Compared with 13- to 17-year-old patients, patients <6 years old (OR: 1.98; 95% CI: 1.31–2.98) and patients 6 to 12 years old (OR: 1.31; 95% CI: 1.03–1.67) had higher odds of admission. Injuries to the head and neck (OR: 8.24; 95% CI: 5.32–12.75) and upper extremity (OR: 9.01; 95% CI: 5.67–14.32) had greater odds of admission compared with injuries to the lower extremity.

    Injury Intent, Firearm User, and Type of Firearm

    Injury intent was documented in 52.2% of cases, of which 1.0% (assaults and self-injury) were intentional. Among cases for which the user of the firearm could be determined (53.8%), the majority (52.8%) of injuries were self-inflicted. Self-inflicted injuries were more common among 13- to 17-year-olds (60.6%), while injuries involving others predominated among patients <6 years old (66.8%). Among cases in which the type of firearm could be determined, BB guns accounted for 80.8% of injuries, followed by pellet guns (15.5%), paintball guns (3.0%), and airsoft guns (0.6%).

    Trends

    From 1990 to 2016, the annual number and rate (per 100 000 children <18 years old) of nonpowder firearm injuries decreased significantly by 47.8% (slope = −415.32; P < .001) and 54.5% (slope = −0.67; P < .001), respectively (Fig 1). The decreasing trend was consistent across all age groups and both sexes, with the greatest decrease in injury rate observed among 13- to 17-year-olds (−59.7%; slope = −1.09; P < .001) and boys (−56.7%; slope = −1.14; P < .001). BB guns showed the greatest decrease in injury rate (−60.9%; slope = −0.5; P < .001), followed by pellet guns (−14.3%; slope = −0.05; P < .001; Fig 2). Contrary to this overall trend, the annual number and rate (per 100 000 children <18 years old) of eye injuries associated with nonpowder firearms increased significantly from 1990 to 2016 by 49.5% (slope = 54.19; P = .003) and 30.3% (slope = 0.46; P = .006), respectively, with a peak in 2006 (Fig 3).

    FIGURE 1
    FIGURE 1

    Estimated annual number and rate of nonpowder firearm injuries by sex (NEISS 1990–2016).

    FIGURE 2
    FIGURE 2

    Estimated annual number of children treated in US EDs with a nonpowder firearm injury by type of firearm (NEISS 1990–2016). a Potentially unstable estimates because the sample is <20, estimate is <1200, or coefficient of variation is >33%.

    FIGURE 3
    FIGURE 3

    Estimated annual number and rate of nonpowder firearm eye injuries (NEISS 1990–2016). a Potentially unstable estimates because the sample is <20, estimate is <1200, or coefficient of variation is >33%.

    Discussion

    There were an estimated 364 133 children with nonpowder firearm injuries treated in US EDs from 1990 through 2016, averaging 13 486 annually. Consistent with previous studies, the head and neck were the most commonly injured body region, with frequent involvement of the eyes.4,6,19,24 The overall number and rate of nonpowder firearm injuries decreased significantly during the study period by 47.8% and 54.5%, respectively. However, eye injuries associated with nonpowder firearms demonstrated the opposite trend, with the number and rate increasing significantly by 49.5% and 30.3%, respectively. This is in agreement with previous reports.6,24

    Nonpowder firearms should be regarded as potentially lethal weapons. Most fire projectiles in excess of the minimum velocity to penetrate human skin, which is ∼70 m per second (230 ft per second) with an energy/area of presentation of ∼2.1 m-kg per cm,3,25 and many achieve a muzzle velocity similar to a handgun.26,27 Fatal injuries from nonpowder firearms have been reported and most often are associated with penetrating wounds to the head, neck, or chest.10,12,13 Although there were no deaths reported in our study, the NEISS does not adequately capture fatalities because deaths are not consistently transported to the ED and those that occur after admission to the hospital are missed when only the ED medical record is reviewed.

    There were an estimated 53 994 eye injuries in our study, accounting for 14.8% of all nonpowder firearm injuries. These injuries were often serious with 22.2% requiring admission to the hospital. The rate of eye injuries increased by 30.3% during the study period. These findings agree with previous studies, which emphasize that eye injuries are commonly reported in association with nonpowder firearms and can result in serious adverse outcomes, including partial or complete vision loss.4,6,7,11 Indeed, nonpowder firearms account for most pediatric eye injuries that are admitted to the hospital.6 Educational efforts to prevent nonpowder firearm eye injuries often focus on the use of appropriate eye protective equipment, with 1 study estimating that eye protection was absent in >98% of eye injuries.6 Voluntary safety standards exist for eye protective equipment for paintball and airsoft guns.28,29 A policy statement by the American Academy of Pediatrics provides specific recommendations for protective eyewear for children participating in various sports and recreational activities, including use of nonpowder firearms.30

    Unlike powder firearms, which fall under the oversight of the Bureau of Alcohol, Tobacco, Firearms, and Explosives within the US Department of Justice, the CPSC has federal jurisdiction over nonpowder firearms. Although the CPSC has no mandatory safety regulations for nonpowder firearms, 2 voluntary safety standards have been adopted, American Society for Testing and Materials (ASTM) F589 Standard Consumer Safety Specification for Non-Powder Guns and ASTM F590 Standard Consumer Safety Specification for Non-Powder Gun Projectiles and Propellants.8,13 Manufacturers are extensively involved in the development of ASTM voluntary standards and generally comply with the safety specifications included in the standards.

    Despite the lack of federal mandatory safety standards for nonpowder firearms, 23 states and the District of Columbia have adopted laws to address the safety concerns of these products. In addition, local jurisdictions such as New York City, have passed their own ordinances.5 The 4 major categories of state regulations include (1) defining nonpowder firearms as firearms (New Jersey and Rhode Island), (2) defining certain high-power or large caliber nonpowder firearms as firearms (Illinois and Michigan), or (3) defining nonpowder firearms as dangerous weapons (Connecticut, Delaware, and North Dakota). Each of these definitions carry restrictions on the purchase, transfer, possession, or use of the nonpowder firearm, which vary by state. The fourth category of state regulation restricts access by children. Most state regulations fall into this last category, vary greatly by state, and frequently can easily be circumvented with parental consent or adult supervision. Variability includes the age cutoff for these regulations, some applying to children <18 years of age and others applying to those as young as <12 years of age.5

    This study has several limitations. The number of nonpowder firearm injuries is underestimated by the NEISS because it only includes individuals treated in EDs and not in other health care settings, such as urgent care facilities and private physician offices. Individuals treated in EDs also may not be representative of the entire spectrum of individuals with these injuries. NEISS case narratives may not consistently provide information about the user of the firearm, whether the injury was intentional or unintentional, and other details of the injury incident; however, all narratives were individually reviewed to ensure, to the best of our ability, that each case was categorized appropriately. There were no fatalities in this study; however, the NEISS does not capture fatal injuries well, so we are unable to comment on fatal injuries associated with nonpowder firearms on the basis of this database. We did not have access to pediatric nonpowder firearm exposure data; therefore, US population data were used to calculate injury rates. Despite these limitations, this study provides a comprehensive epidemiological investigation of pediatric nonpowder firearm injuries over a 26-year study period by using a nationally representative sample.

    Conclusions

    Although the number and rate of nonpowder firearm injuries declined during the study period, nonpowder firearms remain a frequent and important source of preventable and often serious injury to children. The severity and increasing rate of eye injury related to nonpowder firearms is especially concerning. Increased prevention efforts are needed in the form of stricter and more consistent safety legislation at the state level, as well as in child and parental education regarding proper supervision, firearm handling, and use of protective eyewear.

    Footnotes

      • Accepted September 26, 2019.
    • Address correspondence to Gary A. Smith, MD, DrPH, Center for Injury Research and Policy, The Research Institute at Nationwide Children’s Hospital, 700 Children’s Dr, Columbus, OH 43205. E-mail: gary.smith{at}nationwidechildrens.org

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

    • FUNDING: Ms Jones received a research stipend from the National Student Injury Research Training Program at the Center for Injury Research and Policy at Nationwide Children’s Hospital, funded by the National Center for Injury Prevention and Control, Centers for Disease Control and Prevention (grant 1R49CE002106), and Child Injury Prevention Alliance, while she worked on this study. The interpretations and conclusions in this article do not necessarily represent those of the funding organizations.

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

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    Pediatrics
    Vol. 144, Issue 6
    1 Dec 2019
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    Nonpowder Firearm Injuries to Children Treated in Emergency Departments
    Margaret Jones, Sandhya Kistamgari, Gary A. Smith
    Pediatrics Dec 2019, 144 (6) e20192739; DOI: 10.1542/peds.2019-2739
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