Blog Gun Violence Initiative Violence & Abuse

Firearm injuries: A pediatric public health crisis

Written by Robert M. Kennedy, MD, pediatric emergency medicine physician; Martin S. Keller, MD, director of trauma services; Angela Lumba-Brown, MD, pediatric emergency medicine physician; and Fahd A. Ahmad, MD, MSCI, pediatric emergency medicine physician at St. Louis Children’s Hospital

As pediatric emergency and trauma physicians at St. Louis Children’s Hospital we are alarmed by the growing epidemic of firearm-related injuries that threaten the safety, health, and well-being of our children in St. Louis and in the United States.

Sobering statistics and stories about children and guns

Since 2002 St. Louis Children’s Hospital has cared for 916 children injured or killed by firearms; 35% were younger than 15 years. These include:

  • the recent 9-year-old girl who was killed by a stray bullet while she sat in her room doing her homework;
  • the 12-year-old boy accidentally killed by his friend when playing with his grandfather’s pistol kept under his pillow;
  • the 2-year-old boy paralyzed when his father accidentally discharged his gun during loading;
  • the 5-year-old girl caught in a cross-fire as she sat on her front porch;
  • the 10-year-old boy killed by his mother overwhelmed with mental illness;
  • the 5-month-old girl shot by her father’s pistol when it fell from his coat;
  • the 4-year-old boy who found a handgun at home and placed the barrel into his mouth and pulled the trigger as he had often done to get a drink from his water-pistol.

Many of these children died despite the heroic efforts of the highly trained pre-hospital, emergency, surgical and critical care staff at St. Louis Children’s Hospital.

In 2013, 1,670 American children 19 years and younger died by gunshot, 5 each day, and an additional 9,718 were injured.(10) This is twice the number of children who die from cancer, 5 times the number from heart disease, and 15 times the number from infections. This is the equivalent of more than 80 Newtown shootings every year.

Guns in the home

At least 38% of American households own a gun. In homes with children younger than 18 years of age, 22% store the firearm loaded, 32% store the firearm unlocked, and 8% store the firearm unlocked and loaded.(2) The children in these homes know the gun is present, and many handle the gun in the absence of their parents.(3) A study of 64 different handguns found 25% of 3-4 year old and 70% of 5-6 year old children had the physical strength and dexterity to pull the triggers.(4)

On average, a gun in the home is much more likely to harm the inhabitants than to protect them.

A firearm in the home is associated with a nearly three-fold increase in the risk of homicide of the home’s inhabitants, and a five-fold increase in the risk of suicide as compared to homes without firearms.(6,7) In 2009, suicide was the third leading cause of death for American youth 15 to 19 years of age; firearms were the most common method used.(8) On average, a gun in the home is much more likely to harm the inhabitants than to protect them.

Firearm safety training

Firearm safety training is not enough to prevent these accidental shootings, as children who receive firearm safety training are as likely to fire a gun during play as children who do not receive training. In one study, 8–12 year old boys were observed via one-way mirror as they played for 15 minutes in a waiting room with a disabled .38 caliber handgun concealed in a desk drawer. Seventy two percent of these children discovered the gun, and 48% pulled the trigger. Among those who handled the gun and/or pulled the trigger, 90% had prior gun safety instruction.(5)

Recommendations and next steps

The American Academy of Pediatrics has concluded, “The most effective measure to prevent suicide, homicide, and unintentional firearm-related injuries to children and adolescents is the absence of guns from homes and communities.”(9) The American Academy of Pediatrics, the Academic Pediatric Association, and the American College of Surgeons have called for action in three areas: reinstating and revising the ban on assault weapons and on large ammunition magazines; improving quality and availability of mental health services; and reducing the amount of exposure our children have to media violence.

St. Louis Children’s Hospital and Washington University support these action items and, in addition, have taken steps to increase research on the relationship of all of these factors on the epidemic of death and injury to St. Louis children caused by firearm violence. Missouri is one of 17 states and the District of Columbia where more people die from shootings than motor vehicle crashes.(11) The 2007 repeal of the Missouri Permit-to-Purchase handgun law has been associated with a 23% increase in the annual firearm related homicide rates in our state.(12)

Acting to ensure a safer future

As physicians who care for children and families devastated by firearm related injuries, we know first-hand the importance of taking action that will begin to make the environment in St. Louis safer for children. We need additional research to help us better understand what interventions are effective, but we also need to act on what interventions we already know make a difference.

As Gabrielle Giffords, the former Congresswoman who survived after being critically wounded by a firearm assault, challenged Congress: “Too many children are dying. Too many children. We must do something. It will be hard, but the time is now. You must act. Be bold, be courageous. Americans are counting on you.” Our children of Missouri and of the larger United States are counting on us all to act, to make their world safer, to determine how to protect them from this epidemic.

In much the same way as we have approached injuries to children from automobile crashes, infectious diseases, and tobacco, viewing firearm related injuries as a public health problem can help determine underlying causes, effects, and outcomes and guide development of programs to reduce the tragic impact gun violence is having on our children.


1. Palfrey JS, Palfrey S. Preventing Gun Deaths in Children. New England Journal of Medicine 2013;368(5):401-403.

2. Johnson RM, Miller M, Vriniotis M, Azrael D, Hemenway D. Are Household Firearms Stored Less Safely in Homes With Adolescents? Analysis of a National Random Sample of Parents. Arch Pediatr Adolesc Med. 2006;160:788-792.

3. Baxley F, Miller M. Parental Misperceptions About Children and Firearms. Arch Pediatr Adolesc Med. 2006;160:542-547.

4. Naureckas SM, Galanter C, Naureckas ET, Donovan M, Christoffel K. Children’s and Women’s Ability to Fire Handguns. Arch Pediatr Adolesc Med 1995;149:1318-1322.

5. Jackman GA, Farah MM, Kellermann AL, Simon HK. Seeing Is Believing: What Do Boys Do When They Find a Real Gun? Pediatrics 2001;107;1247-1250.

6. Kellermann A, Rivara F, et al. Gun Ownership as a Risk Factor for Homicide in the Home. New England Journal of Medicine, 1993:329:1084-91.

7. Kellermann A, Rivara F, et al. Suicide in the Home in Relation to Gun Ownership. New England Journal of Medicine 1992;327:467-72.

8. National Center for Injury Prevention and Control, US Centers for Disease Control and Prevention:

9. Firearm-Related Injuries Affecting the Pediatric Population.



12. Webster D, Crifasi CK, Vernick JS. Effects of the Repeal of Missouri’s Handgun Purchaser Licensing Law on Homicides. J Urban Health: Bulletin of the New York Academy of Medicine 2014; 91( 2):293-302.