The effect of gun control laws on hospital admissions for children in the United States

A systematic review of the evidence for effectiveness of interventions to address transport and other unintentional injuries among adolescents

INTRODUCTION

Globally, injuries are a leading cause of mortality and morbidity for adolescents, which disproportionately affect the disadvantaged. To build an investment case for adolescent injury prevention, evidence is needed as to effective interventions.

METHODS

A systematic review of peer-reviewed original research published between 2010-2022 was conducted. CINAHL, Cochrane Central, Embase, Medline and PsycINFO databases were searched for studies reporting the effectiveness of unintentional injury prevention interventions for adolescents (10-24 years), with assessment of study quality and equity (e.g., age, gender, ethnicity, socio-economic status).

RESULTS

Sixty-two studies were included; 59 (95.2%) from high-income countries (HIC). Thirty-eight studies (61.3%) reported no aspect of equity. Thirty-six studies (58.1%) reported prevention of sports injuries (commonly neuromuscular training often focused on soccer-related injuries, rule changes and protective equipment). Twenty-one studies (33.9%) reported prevention of road traffic injury, with legislative approaches, commonly graduated driver licensing schemes, found to be effective in reducing fatal and nonfatal road traffic injury. Seven studies reported interventions for other unintentional injuries (e.g., falls).

DISCUSSION

Interventions were strongly biased towards HIC, which does not reflect the global distribution of adolescent injury burden. Low consideration of equity in included studies indicates current evidence largely excludes adolescent populations at increased risk of injury. A large proportion of studies evaluated interventions to prevent sports injury, a prevalent yet low severity injury mechanism. Findings highlight the importance of education and enforcement alongside legislative approaches for preventing adolescent transport injuries. Despite drowning being a leading cause of injury-related harm among adolescents, no interventions were identified.

CONCLUSION

This review provides evidence to support investment in effective adolescent injury prevention interventions. Further evidence of effectiveness is needed, especially for low- and middle-income countries, populations at increased risk of injury who would benefit from greater consideration of equity and for high lethality injury mechanisms like drowning.

EAST Evidence-Based Statement on "Stand Your Ground" Laws

ABSTRACT

Trauma surgeons have a mission to prevent injury as well as to treat it, and must address the underlying social and structural factors that expose individuals, communities, and populations to preventable injury. Laws regulating the sale, possession, carriage, and use of firearms have major health consequences deserving of our attention. This EAST evidence-based statement reviews and summarizes the literature on Stand Your Ground laws. Whereas previously civilians had a duty to retreat prior to the use of deadly force, Stand Your Ground laws remove this duty and allow civilians to use deadly force as a first response to a perceived threat. 42 states have a version of this policy in place. Strong, consistent evidence demonstrates that Stand Your Ground laws have no benefit in preventing violent crime and are instead associated with increases in homicide and inequity.

Comparing Firearm and Stabbing Injuries in the Pediatric Trauma Population Using Propensity Matching

OBJECTIVES

The objective of this study was to compare differences in mortality and nonhome discharge in pediatric patients with firearm and stab injuries, while minimizing bias. Our secondary objective was to assess the influence of insurance on these same outcomes.

METHODS

Patients aged 0 to 17 years included in the National Trauma Data Bank (2007-2015) with firearm and stabbing injury were matched by propensity score. Logistic regression was used to assess associations of injury type and insurance with long-term care discharge and death.

RESULTS

The average age was 14.8 years, 19.2% were female, 48% were African American, 58.4% had an injury severity score ≤8, and assaults accounted for 73.1% of cases. Firearm injuries were associated with a higher risk of discharge to long-term care (adjusted odds ratio [aOR], 2.07) compared with propensity-matched patients who were stabbed. Similarly, we found a higher risk of mortality in those with firearm injuries compared with stabbing injuries (aOR, 1.85). Regardless of mechanism, self-pay insurance status was associated with a higher risk of mortality (aOR, 2.41). When compared with stab wound patients with commercial insurance, self-pay firearm-injured patients were found to have an increased risk of mortality (aOR, 5.25).

CONCLUSIONS

Pediatric victims of firearm violence were more likely to die or need additional care outside the home than victims of other types of penetrating injury when accounting for confounding characteristics to minimize bias.

Unintentional firearm mortality in African-American youths, 2010-2019

BACKGROUND/ PURPOSE

There is a dearth of studies that have examined unintentional firearm-related mortality in African-American (AA) youths. The purpose of this article is to assess the epidemiology of unintentional firearm mortality in AA youth, examine the risk factors associated with unintentional AA youth firearm mortality, and explore the evidence for preventing unintentional firearm-mortality in AA youths.

METHODS

In this cross-sectional study, the Web-Based Injury Statistics Query and Reporting System (WISQARS) data from the Centers for Disease Control and Prevention (CDC) was used. Data were analyzed from the years 2010-2019 using descriptive statistics.

RESULTS

Between the years 2010 and 2019, the AA youth unintentional firearm mortality rate increased by 48% while the rate for White youths declined by 29%. The decade from 2010 to 2019 saw almost 400 AA youths lose their lives to unintentional firearm trauma. AA male children averaged 87% of all AA unintentional firearm deaths during this time. The years of potential life lost due to unintentional firearm mortality ranged between 21,200 and 24,300 years. The risk factors for unintentional firearm mortality in AA youths include living in states with high rates of firearm ownership, living in a home with firearms, being an older adolescent, and being of lower socioeconomic status. Of all the strategies to prevent unintentional firearm mortality in youths, the most effective include strong (felony penalty) Child Access Prevention laws, the absence of Stand-Your-Ground laws, and physicians engaging in anticipatory guidance with patients regarding safe storage of firearms.

CONCLUSIONS

Despite the limited scale of unintentional firearm mortality in AA youths, primary prevention dictates that public health professionals intervene to keep this public health problem from becoming an epidemic and a larger contributor to health disparities.

Comparison of cost and resource utilization between firearm injuries and motor vehicle collisions at pediatric hospitals

BACKGROUND/OBJECTIVES

Firearm injuries are converging with motor vehicle collisions (MVC) as the number one cause of death for children in the United States. Thus we examine differences in hospital cost and hospital resource utilization between motor vehicle and firearm injury.

METHODS

This retrospective, cross-sectional study compares hospital costs and resource utilization of motor vehicle and firearm-injured children aged 0 to 19 years of age over a 5-year time frame (January 1, 2013-December 31, 2017) in 35 freestanding children's hospitals that submitted data to the Pediatric Health Information System. The primary outcome was hospital-adjusted comparative cost per patient presentation. Generalized linear mixed models were used to quantify the relationship between the type of injury and each outcome, adjusting for patient characteristics and hospital.

RESULTS

There were 89,133 emergency department (ED) visits attributed to MVCs and 3,235 for firearm injury. Of the youths who presented for firearm injury, 49% were hospitalized versus 14% of youths presenting with MVC (adjusted odds ratio [aOR] = 6.6, 95% confidence interval [CI] = 6.1 to 7.2). Youths with firearm injury were more likely to be admitted to an intensive care unit (aOR = 6.7, 95% CI = 5.9 to 7.7) and had longer lengths of stays (aOR = 2.2, 95% CI = 1.9 to 2.6) compared to their MVC counterparts. Children admitted for firearm injury had more imaging and ED return visits, along with subsequent inpatient admission within 3 days (aOR = 3.4, 95% CI = 2.1 to 5.5) and 1 year (aOR = 2.5, 95% CI = 2.1 to 2.9). The mean relative per-patient costs were nearly fivefold higher for the firearm-injured group.

CONCLUSIONS

Hospital costs and markers of resource utilization were higher for youths with firearm injury compared to MVC. High medical resource utilization is one of several important reasons to advocate for a comparable national focus and funding on firearm-related injury prevention.

Guns, scalpels, and sutures: The cost of gunshot wounds in children and adolescents

BACKGROUND

Firearm injuries are the second leading cause of death among US children. While injury prevention has been shown to be effective for blunt mechanisms of injury, the rising incidence of accidental gunshot wounds, school shootings, and interpersonal gun violence suggests otherwise for firearm-related injuries. The purpose of the study is to describe the incidence, injury severity, and institutional costs of pediatric gun-related injuries in Colorado.

METHODS

Pediatric patients (≤18 years), who sustained firearm injuries between 2008 and 2018, were identified from the trauma registries of three pediatric trauma centers in Colorado. Patients were stratified based on age: those younger than 14 years were defined as children and those 15 years to 18 years as adolescents.

RESULTS

Our cohort (n = 308) was predominantly male (87%), with a median age of 14 years. The overall mortality rate was 11% (34/308), with significantly fewer children (5%) dying from their injuries when compared with adolescents (14%; p = 0.04). Sixty-five (21%) patients required blood product transfusions, with 23 (7.4%) patients receiving a massive transfusion. Overall, 52% (161/308) required a major operation, with 15% undergoing an exploratory laparotomy. One third (4/13) of the patients who had a thoracotomy in the emergency department survived to hospital discharge. Overall, 14.0% of patients had psychiatric follow-up at both 30 days and 1 year. The readmission rate for complications was 11.6% at 30 days and 14% at 1 year. The total cost of care for all pediatric firearm-related injuries was approximately US $26 million.

CONCLUSION

The survivors of pediatric firearm injuries experience high operative and readmission rates, sustain long-term morbidities, and suffer from mental health sequelae. Combining these factors with the economic impact of these injuries highlights the immense burden of disease. This burden may be palliated by a multipronged approach, which includes the development and dissemination of injury prevention strategies and better follow-up care for these patients.

LEVEL OF EVIDENCE

Epidemiological, Level III.

Geodemographic analysis of pediatric firearm injuries in Miami, FL

PURPOSE

Firearm injuries (GSW) are a growing public health concern and leading cause of morbidity and mortality among children, yet predictors of injury remain understudied. This study examines the correlates of pediatric GSW within our county.

METHODS

We retrospectively queried an urban Level 1 trauma center registry for pediatric (0-18 years) GSW from September 2013 to January 2019, examining demographic, clinical, and injury information. We used a geographic information system to map GSW rates and perform spatial and spatiotemporal cluster analysis to identify zip code "hot spots."

RESULTS

393 cases were identified. The cohort was 877% male, 87% African American, 10% Hispanic, and 22% Caucasian/Other. Injuries were 92% violence-related and 4% accidental, with 63% occurring outside school hours. Mortality was 12%, with 53% of deaths occurring in the resuscitation unit. Zip-level GSW rates ranged from 0 to 9 (per 1000 < 18 years) by incident address and 0-6 by home address. Statistically significant hot spots were in predominantly underserved African American and Hispanic neighborhoods.

CONCLUSIONS

Geodemographic analysis of pediatric GSW injuries can be utilized to identify at-risk neighborhoods. This methodology is applicable to other metropolitan areas where targeted interventions can reduce the burden of gun violence among children.

TYPE OF STUDY

Retrospective study.

LEVEL OF EVIDENCE

Level III.

Human and economic costs of pediatric firearm injury

PURPOSE

Pediatric firearm injury is a national crisis that inflicts significant trauma. No studies have captured risk factors for readmissions after firearm injury, including cost analysis.

METHODS

Nationwide Readmissions Database (2010-2014) was queried for patients <18 years admitted after acute firearm injury. Outcomes included mortality, length of stay, hospital costs, and readmission rates (30-day and 1-year). Multivariable logistic regression identified risk factors, significance set at p < 0.05.

RESULTS

There were 13,596 children admitted for firearm injury. Mortality rate was 6% (n = 797). Self-inflicted injury was the most lethal (37%, n = 218) followed by unintentional (5%, n = 186), and assault (4%, n = 340), all p < 0.01. Readmission rates at 30 days and 1-year were 6% (12% to different hospital) and 12% (19% to different hospital), respectively. Medicaid patients were more frequently readmitted to the index hospital, whereas self-pay and/or high income were readmitted to a different hospital. The total hospitalizations cost was over $382 million, with $5.4 million due to readmission to a different hospital.

CONCLUSION

While guns cause significant morbidity, disability, and premature mortality in children, they also have a substantial economic impact. This study quantifies the previously unreported national burden of readmission costs and discontinuity of care for this preventable public health crisis.

TYPE OF STUDY

Retrospective Comparative Study.

LEVEL OF EVIDENCE

Level III.

Toy Guns, Real Danger: An Update on Pediatric Injury Patterns Related to Nonpowder Weapons

BACKGROUND

Design changes of nonpowder guns, including BB and air guns, have significantly increased their potential to injure. We sought to characterize the demographics of children injured with nonpowder weapons and the specific injuries suffered.

METHODS

A cross-sectional analysis of the study years 2006, 2009, and 2012 was performed by combining the Kids' Inpatient Database into a single dataset. We identified cases (age < 21 years) of air gun injuries using external cause of injury codes. Patient characteristics and injuries were analyzed using ICD-9 codes, and national estimates were obtained using case weighting.

RESULTS

There were 1028 pediatric admissions for nonpowder weapon related injuries. The victims were predominately male (87.0%), non-Hispanic white (52.3%), resided in the South (47.3%), and in the lowest income quartile (39.2%). Half required a major surgical procedure. The predominant injuries were open wounds to the head, neck, or trunk (40.3%), and contusion (22.5%). Notable other injuries were intracranial injury (9.1%) and blindness or vision defects (3.3%).

CONCLUSIONS

The nonpowder weapons available to this generation can paralyze, blind, and cause lasting injury to children. Injuries frequently require surgical intervention, and these weapons should no longer be considered toys. Further research and legislation should be aimed at limiting children's access to these weapons.

LEVEL OF EVIDENCE

III.

National Instant Criminal Background Check and Youth Gun Carrying

BACKGROUND

Despite being unable to purchase firearms directly, many adolescents have access to guns, leading to increased risk of injury and death. We sought to determine if the National Instant Criminal Background Check System (NICS) changed adolescents' gun-carrying behavior.

METHODS

We performed a repeated cross-sectional study using National Youth Risk Behavior Survey data from years 1993 to 2017. We used a survey-weighted multivariable logistic regression model to determine if the NICS had an effect on adolescent gun carrying, controlling for state respondent characteristics, state laws, state characteristics, the interaction between the NICS and state gun laws, and time.

RESULTS

On average, 5.8% of the cohort reported carrying a gun. Approximately 17% of respondents who carried guns were from states with a universal background check (U/BC) provision at the point of sale, whereas 83% were from states that did not have such laws (P < .001). The model indicated that the NICS together with U/BCs significantly reduced gun carrying by 25% (adjusted relative risk = 0.75 [95% confidence interval: 0.566-0.995]; P = .046), whereas the NICS independently did not (P = .516).

CONCLUSIONS

Adolescents in states that require U/BCs on all prospective gun buyers are less likely to carry guns compared with those in states that only require background checks on sales through federally licensed firearms dealers. The NICS was only effective in reducing adolescent gun carrying in the presence of state laws requiring U/BCs on all prospective gun buyers. However, state U/BC laws had no effect on adolescent gun carrying until after the NICS was implemented.

The persistent southern disadvantage in US early life mortality, 1965-2014

BACKGROUND

Recent studies of US adult mortality demonstrate a growing disadvantage among southern states. Few studies have examined long-term trends and geographic patterns in US early life (ages 1 to 24) mortality, ages at which key risk factors and causes of death are quite different than among adults.

OBJECTIVE

This article examines trends and variations in early life mortality rates across US states and census divisions. We assess whether those variations have changed over a 50-year time period and which causes of death contribute to contemporary geographic disparities.

METHODS

We calculate all-cause and cause-specific death rates using death certificate data from the Multiple Cause of Death files, combining public-use files from 1965-2004 and restricted data with state geographic identifiers from 2005-2014. State population (denominator) data come from US decennial censuses or intercensal estimates.

RESULTS

Results demonstrate a persistent mortality disadvantage for young people (ages 1 to 24) living in southern states over the last 50 years, particularly those located in the East South Central and West South Central divisions. Motor vehicle accidents and homicide by firearm account for most of the contemporary southern disadvantage in US early life mortality.

CONTRIBUTION

Our results illustrate that US children and youth living in the southern United States have long suffered from higher levels of mortality than children and youth living in other parts of the country. Our findings also suggest the contemporary southern disadvantage in US early life mortality could potentially be reduced with state-level policies designed to prevent deaths involving motor vehicles and firearms.

The association of firearm laws with firearm outcomes among children and adolescents: a scoping review

We conducted a scoping review to determine the current state of knowledge and areas for advancements in research on the association of firearm laws with child and adolescent firearm-related outcomes. We queried Scopus, EMBASE, Pubmed, and CJ Abstracts for English language original empirical research articles on policies affecting child and adolescent firearm-related outcomes published between January 1, 1985 and July 1, 2018. Data were abstracted, and methodologic quality assessed. Twenty articles met inclusion criteria. Among the policies studied were child access prevention laws (12 studies) and minimum age restrictions for firearm purchase and possession (4 studies). Outside of child access prevention laws, which are associated with reductions in child and adolescent unintentional and firearm suicide deaths, there is, at best, equivocal evidence of policy effects. This area is understudied, particularly in regard to nonfatal firearm injuries, for which the lack of a national surveillance system hampers research efforts. Further rigorous firearm policy evaluations are needed.

In harm's way: Unintentional firearm injuries in young children

PURPOSE

Firearm-related trauma represents a major source of preventable injury and death. Many firearm injuries in young children are unintentional, and the true incidence may be underestimated. We sought to characterize the morbidity of unintentional firearm injuries.

METHODS

National Trauma Data Bank data from 2007 to 2014 was obtained for patients aged 0-14 sustaining gunshot wounds (GSW). We analyzed demographics, injury severity score, hospital and ICU length of stay (LOS), ventilator days, discharge to rehab, and mortality. We categorized intention as assault, unintentional, self-inflicted or other, and compared unintentional firearm injuries against all others using Student's t test or chi-square analysis.

RESULTS

We identified 7487 GSW patients aged 0-14, of whom 2514 (33.6%) sustained unintentional injuries. The mortality rate for unintentionally injured patients was 9.2%, compared with 14.2% for all other intentions (p<0.0001). Unintentionally injured children were more likely to be male (p=0.01) and Caucasian (p<0.0001) and had lower rates of ICU admission (p=0.02), ventilator use (p=0.0004), and discharge to rehab (p<0.0001).

CONCLUSIONS

Unintentional injuries comprise one-third of firearm injuries and approximately 10% of GSW-related mortality in young children. Since these injuries are entirely preventable, our findings suggest a major opportunity to reduce disease burden.

LEVEL OF EVIDENCE

IV.

Firearm-related injuries among Canadian children and youth from 2006 to 2013: A CHIRPP study

OBJECTIVE

The purpose of this study was to describe Canadian contextual trends in pediatric firearm injuries and death from powder and non-powder firearms.

METHODS

This is a registry study of firearm-related injuries captured by the Canadian Hospitals Injury and Reporting Prevention Program (CHIRPP) for children ages 0 to 18 years presenting to participating CHIRPP emergency departments (EDs) from 2006 to 2013. Data included age, sex, year, setting, circumstance, and disposition for each case.

RESULTS

The CHIRPP dataset included 325 non-powder firearm injuries and 80 powder gun injuries. The rate of firearm injuries remained stable from 2006 to 2013 (44 per 100,000 ED visits). Forty-five patients required hospital admission and 2 died in the ED; 8 of 9 intentional self-harm injuries were inflicted with a powder gun. Most injuries occurred unintentionally from non-powder firearms (n=298, 71%) in the context of recreation (n=179) and sport (n=48). Eyes were the most commonly injured body part (n=150), 98% of which resulted from a non-powder firearm. Forty-three percent (n=141) of non-powder firearm injuries required treatment or admission.

CONCLUSIONS

Eye injuries inflicted by non-powder firearms are a prevalent category of firearm-related injury. Most occurred through recreation and sport, highlighting a potential focus for primary prevention.

The Epidemiology of Emergency Department Trauma Discharges in the United States

OBJECTIVE

Injury-related morbidity and mortality is an important emergency medicine and public health challenge in the United States. Here we describe the epidemiology of traumatic injury presenting to U.S. emergency departments (EDs), define changes in types and causes of injury among the elderly and the young, characterize the role of trauma centers and teaching hospitals in providing emergency trauma care, and estimate the overall economic burden of treating such injuries.

METHODS

We conducted a secondary retrospective, repeated cross-sectional study of the Nationwide Emergency Department Data Sample (NEDS), the largest all-payer ED survey database in the United States. Main outcomes and measures were survey-adjusted counts, proportions, means, and rates with associated standard errors (SEs) and 95% confidence intervals. We plotted annual age-stratified ED discharge rates for traumatic injury and present tables of proportions of common injuries and external causes. We modeled the association of Level I or II trauma center care with injury fatality using a multivariable survey-adjusted logistic regression analysis that controlled for age, sex, injury severity, comorbid diagnoses, and teaching hospital status.

RESULTS

There were 181,194,431 (SE = 4,234) traumatic injury discharges from U.S. EDs between 2006 and 2012. There was a mean year-to-year decrease of 143 (95% CI = -184.3 to -68.5) visits per 100,000 U.S. population during the study period. The all-age, all-cause case-fatality rate for traumatic injuries across U.S. EDs during the study period was 0.17% (SE = 0.001%). The case-fatality rate for the most severely injured averaged 4.8% (SE = 0.001%), and severely injured patients were nearly four times as likely to be seen in Level I or II trauma centers (relative risk = 3.9 [95% CI = 3.7 to 4.1]). The unadjusted risk ratio, based on group counts, for the association of Level I or II trauma centers with mortality was risk ratio = 4.9 (95% CI = 4.5 to 5.3); however, after sex, age, injury severity, and comorbidities were accounted for, Level I or II trauma centers were not associated with an increased risk of fatality (odds ratio = 0.96 [95% CI = 0.79 to 1.18]). There were notable changes at the extremes of age in types and causes of ED discharges for traumatic injury between 2009 and 2012. Age-stratified rates of diagnoses of traumatic brain injury increased 29.5% (SE = 2.6%) for adults older than 85 and increased 44.9% (SE = 1.3%) for children younger than 18. Firearm-related injuries increased 31.7% (SE = 0.2%) in children 5 years and younger. The total inflation-adjusted cost of ED injury care in the United States between 2006 and 2012 was $99.75 billion (SE = $0.03 billion).

CONCLUSIONS

Emergency departments are a sensitive barometer of the continuing impact of traumatic injury as an important cause of morbidity and mortality in the United States. Level I or II trauma centers remain a bulwark against the tide of severe trauma in the United States, but the types and causes of traumatic injury in the United States are changing in consequential ways, particularly at the extremes of age, with traumatic brain injuries and firearm-related trauma presenting increased challenges.

Firearm Deaths in America: Can We Learn From 462,000 Lives Lost?

OBJECTIVE

We sought to determine whether state firearm legislation correlated with firearm-related fatality rates (FFR) during a 15-year period.

BACKGROUND

The politicized and controversial topic of firearm legislation has been grossly understudied when the relative impact of American firearm violence is considered. Scientific evidence regarding gun legislation effectiveness remains scant.

METHODS

Demographic and intent data (1999-2013) were collected from the Centers for Disease Control and Prevention's Web-Based Injury Statistics Query and Reporting System database and compared by state firearm legislation rankings with respect to FFR. State scorecards were obtained from firearm-restrictive (Brady Campaign/Law Center against Gun Violence [BC/LC]) and less-restrictive (National Rifle Association) groups. FFR were compared between restrictive and least-restrictive states during 3 periods (1999-2003, 2004-2008, 2009-2013).

RESULTS

During 1999 to 2013, 462,043 Americans were killed by firearms. Overall FFR did not change during the 3 periods (10.89 ± 3.99/100,000; 10.71 ± 3.93/100,000; 11.14 ± 3.91/100,000; P = 0.87). Within each period, least-restrictive states had greater unintentional, pediatric, and adult suicide, White and overall FFR than restrictive states (all P < 0.05). Conversely, no correlation was seen, during any of the 3 time periods, with either homicide or Black FFR-population subsets accounting for 41.7% of firearm deaths.

CONCLUSIONS

Restrictive firearm legislation is associated with decreased pediatric, unintentional, suicide, and overall FFR, but homicide and Black FFR appear unaffected. Future funding and research should be directed at both identifying the most effective aspects of firearm legislation and creating legislation that equally protects every segment of the American population.

Assault in children admitted to trauma centers: Injury patterns and outcomes from a 5-year review of the national trauma data bank

IMPORTANCE

While assault is commonly reported or suspected in children with traumatic wounds, a recent overview of these injuries, especially those requiring trauma surgery consultation is lacking in the literature.

OBJECTIVES

Explore the incidence, demographics and injury patterns of children presenting to trauma centers following an assault.

DESIGN

Retrospective review of the National Trauma Data Bank 2007 to 2011.

SETTING AND PARTICIPANTS

Subjects up to 18 years old with "assault" reported as the intent of injury. Patients were divided into infants (<2 years), young children (2-5 years), children (6-11 years), and adolescents (12-18 years).

MAIN OUTCOMES AND MEASURES

Mechanism of injury, injury severity and mortality based on age groups and race.

RESULTS

Of 609,207 children, 58,299 (9.6%) were victims of an assault. The median age was 16 years and 81% were male, with a median injury severity score (ISS) of 8. The majority of patients were adolescents (76%), followed by infants (17%) and young children (4%). There was a stepwise increase in the proportion of assaulted Black children with increasing age (23.2% for infants and up to 46.7% for adolescents, trend p < 0.01, effect size: 0.175) while the opposite applied for White children (46.0% for infants and down to 19.5% for adolescents, trend p < 0.01, effect size: -0.230). With increasing age, White subjects had the highest trend of being assaulted during an unarmed fight or brawl (p < 0.01, effect size: 0.393), while for Black victims the highest trend was noted for assault with a firearm (p < 0.01, effect size: 0.323). Almost 2 out of 3 infants sustained severe head trauma (59%). The overall mortality was 8%, highest among young children, where it reached 16% (p < 0.01).

CONCLUSIONS

Up to 10% of children admitted following trauma are victims of assault with traumatic brain injuries predominant in infants and firearm injuries predominant in adolescents. Injury patterns largely correlate to age and race. Assault in children is associated with a high mortality risk. These data highlight the magnitude of the problem and calls for further involvement of trauma surgeons to improve outcomes, bring awareness and promote preventative strategies to eliminate assault in children.