A study recently published in the Journal of Pediatric Surgery, titled “Beyond the Index: Family Fragility as a Geographic Risk Factor for Pediatric Firearm Injuries,” begins with a stunning statement. 

“In the United States, firearm injuries are the leading cause of death among children and adolescents.” 

According to the study’s lead author, Christopher W. Snyder, M.D., M.S.P.H., a pediatric general surgeon at Johns Hopkins All Children’s Hospital in St. Petersburg, Florida, and medical director of the hospital’s pediatric trauma program, the high rates of pediatric injury and death from firearms makes primary prevention essential. 

“A study we published last year found that pediatric firearm injuries have been increasing in Florida,” explains Snyder, who is also the assistant director of the pediatric surgery research program. “We wanted to dig deeper, so we carried out this study to gain a better understanding of the factors that can lead to pediatric firearm injury, and which of those factors might be modifiable so that we could potentially better protect kids through primary prevention.”

Snyder noted that previous research has shown that firearm injuries are generally more prevalent in large cities, but emerging evidence suggests that, in per capita terms, firearm injuries may disproportionately impact rural communities. 

‘Crunching the Numbers’ 

To carry out their new study, the researchers used a number of databases, including a comprehensive statewide Florida hospital discharge database and analyzed it for all patients ages 0 to19 years, who were hospitalized in Florida from 2012 to 2021 with primary or secondary diagnosis of having a firearm injury.

Study co-author Etienne Pracht, Ph.D., an associate professor in the Department of Health Policy and Systems Management at the University of South Florida College of Public Health, provided extensive “data crunching” services using myriad additional databases, including those for Social Determinants of Health (SDOH; the Social Vulnerability Index (SVI); the Federal Emergency Management Agency (FEMA), and the Metropolitan Statistical Area (MSA), among others. 

According to Pracht, SVI categorical “themes” include socio-economic status; household composition; minority status/language; housing type/transportation; rural county; family fragility; non-marital births; and divorces involving minor children. 

Family Fragility as a Major Risk Factor 

The researchers focused on SVI data relating to “family frailty” for a number of reasons. 

“We had hypothesized that markers of “family fragility” would be independently associated with firearm injury in the context of other social determinants of health,” Snyder says. 

According to the researchers, family fragility is a term used to denote the degree of disruption of intact family structures.

“While family disruption has been associated with community violence and negative pediatric outcomes, it has not been studied as a driver of pediatric firearm injury disparities,” says study team member Caitlin Rempson, M.S.P.H., a researcher at the Johns Hopkins Bloomberg School of Public Health in Baltimore, Maryland, and whose research interests include child and adolescent health. 

“A positive relationship between pediatric firearm injuries and family fragility may exist for many reasons,” the researchers say. “For example, single parents face increased responsibilities, burdens, and risk of poverty, coinciding with the common association of lower socioeconomic status and with higher rates of pediatric firearm injuries.” 

Additionally, patient social demographics; injury characteristics; resource utilization; (such as operating room or anesthesia services, intensive care unit level of care, hospital length of stay, and hospital charges), discharge outcomes; and geographic details of the county in which the patient lived, were analyzed to determine not only risk factors, but treatment data as well. 

Study Results 

The average age of that cohort was 16.4 years old, and a majority were male (87%). Slightly over half of those patients resided in moderate to high Social Vulnerability Index communities. 

Study team member Alyssa Green, M.D., a surgical research fellow at Johns Hopkins All Children’s Hospital, pointed out that most of these patients needed surgical interventions and many of them spent a long time in the hospital. Seventy percent of the patients required operative/anesthesia service and 52% required intensive care unit (ICU) care. The average hospital length of stay was seven days and incurred average hospital charges were $138,336. While the overall fatality rate was 7%, 17% of these patients were discharged to a facility other than home.

County-by-county Analysis 

The researchers found a strikingly high degree of variability in pediatric firearm injury hospitalization incidence rates by individual Florida county. 

Rates of hospitalization for firearm injury, per capita in the pediatric age group, ranged from 1 to 16 events per 100,000 person-years among urban counties Among Florida’s 23 rural counties, the variation was even more stark – ranging from 0 to 24 events per 100,000 person-years.

The county with the highest incidence of pediatric firearm injury hospitalization was Hendry County, a rural south Florida county where the Big Cypress Reservation serves as home to Florida’s Native American Seminole tribe.

“Further studies should be done to determine if specific vulnerabilities, as well as firearm injury risk mitigation opportunities, exist in this unique Native American population,” suggest the study’s authors. 

Following up Nationally 

“Should future studies validate our findings at the national level, applying existing social science best practices for strengthening fragile families can be valuable and can also inform both county-level primary prevention efforts as well as aid in resource allocation decisions,” says study co-author Nicole M. Chandler M.D., associate professor of pediatric surgery and chief of the Division of Pediatric Surgery and the Pediatric Surgery Fellowship Program Director at the Johns Hopkins All Children’s.

Future Research 

Snyder said that the researchers are currently in the design phase for developing a larger follow-up study and will eventually investigate at a national level to see if the same patterns they found in this study will be validated nationally.

Although it was not an issue covered in this study, Snyder is concerned that small hospitals in rural areas may not be well-prepared to treat pediatric firearm injury, and greater awareness needs to be raised regarding pediatric firearm injury risk generally, but especially in rural areas.

“All hospitals — especially small, rural hospitals — need to have some level of readiness because these injuries happen quickly, and they can be life-threatening, requiring urgent treatment,” he emphasizes.