August 2019, VOLUME144 /ISSUE 2

No Silver Bullet: Firearm Laws and Pediatric Death Prevention

  1. Lois K. Lee, MD, MPHa and
  2. Judy Schaechter, MD, MBAb
  1. aDivision of Emergency Medicine, Boston Children’s Hospital, Boston, Massachusetts; and
  2. bDepartment of Pediatrics, University of Miami and Holtz Children’s Hospital, Miami, Florida

Firearm fatality rates in the United States among children and youth 1 to 24 years old have been increasing since 2013, after an overall decline from 1999 to 2012.1,2 The upward trend in pediatric firearm fatalities includes a 32% rise in firearm homicide and a 28% rise in firearm suicide rates.2 A better understanding of effective prevention, such as the role of legislation, is essential in addressing this growing public health crisis. In this issue of Pediatrics, Goyal et al3 analyze the association of pediatric firearm fatality rates with stricter state gun laws in aggregate and with a focus on 3 specific laws. These laws were selected on the basis of work by Kalesan et al,4 in which a multivariate Poisson regression model that included 25 different firearm laws was used to examine the association of these laws with reductions in firearm homicides and suicides. This regression model identified 3 laws associated with decreased firearm deaths: (1) universal background checks for firearm purchase, (2) background checks for ammunition purchase, and (3) firearm identification requirements with microstamping or ballistic fingerprinting.4 Building on this work, in the current study, Goyal et al3 conclude that stricter state firearm laws in aggregate, and universal background check laws for the purchase of firearms in particular, are associated with decreased firearm deaths in children and youth 0 to 24 years. There were insufficient numbers of states with the other 2 laws for meaningful analysis.

Gun death is the outcome of a disease with guns as the consistent mechanism, yet it is a disease with differing intents of injury (ie, unintentional, homicide, suicide, and legal intervention). Like other diseases, firearm injury presents at different rates and with different intents and circumstances across the pediatric age range.1,57 Thus, each age group may have different responses to the same legislation. An analysis of which specific laws may be most effective in curbing gun deaths for 0- to 24-year-old youth seeks to segregate children and youth from the general population. The age range in the Goyal et al3 study, inclusive of young adults, does reflect pediatric clinical practice; however, a more defined analysis by age group would be beneficial.

Rates of gun death are highest for youth 18 to 24 years old, followed by youth 13 to 17 years old. Because the intent and circumstances of firearm injuries vary with age, the specifics of preventability likewise vary. Young children at risk for unintentional gun death, women at risk for intimate-partner violence, youth in urban areas at risk for homicide, persons at risk for suicide, and anyone caught at the site of a mass shooting are distinct groups. The effect of legislation on firearm fatalities from different intents and age groups within the pediatric age range was not explored by Goyal et al.3 Further research establishing the relative role of policies targeting gun injury by more narrowly defined age groups and intent is necessary to target specific interventions.

As meaningful as universal background checks appear, there is no single silver-bullet policy that will lead to significant reductions in pediatric gun deaths throughout the pediatric age range. Rather than the effect of 1 law, it is more likely that the synergistic effects of multiple laws targeting different aspects of firearm regulations will be required to substantially decrease firearm fatalities in the United States.8 Increasingly, there is evidence that stricter gun laws are associated with reductions in gun death.810 In contrast, some permissive laws, such as Stand Your Ground (removing the duty to retreat and allowing for the use of lethal force when a threat is perceived), may promote gun violence.3,4,810

Consensus agendas on firearm research have stated the need for improved data sources, enhanced access to existing data, and increased research on the circumstances of firearm injury.11,12 More comprehensive, detailed, and accurate data sources for household firearm ownership, firearm storage, licensing, and nonfatal firearm injuries are required. Future research must be focused on the effects of policies on specific populations and circumstances (eg, unintentional pediatric firearm injuries), the interactions of different laws, enforcement of these laws, and the combination of legislation with other injury-prevention strategies, including provider anticipatory guidance.8,10 To do this, we must have robust funding that supports high-quality research to examine the effectiveness of legislation and other preventive measures to advance knowledge and implementation of effective policies.

Gun violence is a disease that disproportionately affects children and youth with differing presentations on the basis of developmental stage, intent, environment, and circumstance. To change this, we must move beyond “thoughts and prayers” as well as our current research limitations. We need policy informed by research on gun laws detailing the subtypes of this fatal yet preventable disease. Only then can we move forward in promoting stronger policies to stay, or ideally, reverse the current course of increasing gun deaths to protect people of all ages, most especially our children and youth.


    • Accepted May 7, 2019.
  • Address correspondence to Judy Schaechter, MD, MBA, Department of Pediatrics, University of Miami and Holtz Children’s Hospital, 1601 NW 12th Ave, 9th Floor, Miami, FL 33136. E-mail: jschaechter{at}
  • Opinions expressed in these commentaries are those of the authors and not necessarily those of the American Academy of Pediatrics or its Committees.

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

  • FUNDING: No external funding.

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

  • COMPANION PAPER: A companion to this article can be found online at