Firearm-related injuries (FRI) are an increasing cause of morbidity and mortality among children and adolescents in the United States (U.S.). More than 3,900 children and adolescents die from FRI annually, and thousands more surviving children and adolescents are left with varying degrees of both physical and emotional injuries (1–3). Children and adolescents in the U.S. are estimated to be 36.5 times more likely to die from FRI compared to similar-aged children in other high-income countries (4).

In recent years, FRI surpassed motor vehicle collisions (MVCs) and became the leading cause of pediatric mortality in the U.S. (5, 6). Although pediatric trauma rates remained the same or even decreased, pediatric FRI continued to increase during the COVID-19 pandemic (7, 8). To further complicate this narrative, one study found that nonfatal per capita injuries in pediatrics have been decreasing while fatal injuries have been increasing in recent years (3). Taken together, these studies may indicate that while overall trauma rates have been decreasing over time, a greater proportion of injuries may be related to FRI. In 2021, 4,752 children and adolescents died from FRI, which translates to an average of 13 children every day (1). While it is likely that the COVID-19 pandemic contributed to this increase with economic instability, school closures, and social isolation (9, 10), additional factors such as state firearm regulation laws (11) and record setting firearm purchases (12, 13) also likely contributed. Recently in Georgia, a law passed, SB 319, that allowed for concealed carry of firearms without a permit (14). Both COVID-19 and this firearm law relate to and potentially impact pediatric FRI in our hospital system located in Atlanta, Georgia.

There is a paucity of literature that focus on populations most at risk. Regarding demographic groups, males, older adolescents, and children from minoritized groups (15) are known to have higher rates of FRI (1, 16). Black children are over 70% more likely to be hospitalized for FRI than White children; Hispanic children are 20% more likely to be hospitalized than White children (17). Regardless of neighborhood income level, Black children still have higher rates of FRI compared to White children (17). Within the U.S., Southern states have a disproportionately high volume of pediatric firearm incidents (18, 19).

Social determinants of health (SDH), the non-medical, environmental, and social conditions we live in, drive health inequalities in disease and injury (20) and FRI is no exception. Recent studies have shown that neighborhood poverty and deprivation associates with increased pediatric FRI risk and mortality (1, 19, 21, 22). Additionally, prior studies have shown that insurance associates with mortality following FRI (23) and in pediatric trauma (24, 25). Although these studies are few in number, they point to an urgent need to address the impact of SDH on pediatric FRI. As injuries are preventable, identifying trends in FRI in relation to SDH can inform preventative strategies (26).

The aims of this study are: (1) to characterize the trends in pediatric FRI with respect to patient demographics prior to and during the COVID-19 pandemic in our exclusive pediatric hospital system; (2) to examine the incidence of these injuries with respect to COVID-19 and a recent Georgia firearm law; (3) examine how SDH (race and insurance) relate to acute outcomes following FRI.

Our study highlights an alarming rise in pediatric FRI in pediatric level I and level II trauma centers in Atlanta, Georgia over the last 9 years. Results revealed distinctions in the rates of FRI during two notable dates, the start of the COVID-19 pandemic and the effective date of state firearm law SB 319. These findings are consistent with other studies documenting similar increases over time, some in relation to the start of COVID-19 (9, 10, 13, 40) and others not (1, 18). In the present study, and consistent with past literature, patients in our sample were majority male, Black, publicly insured, and injured by assault and unintentional shootings (19). Our sample was younger in age compared to national samples, where a majority of pediatric patients with FRI are in the older adolescent age group (19, 41). This is due, in-part, to our trauma center’s proximity to adult trauma centers; patients 15 years-old and older are often routed to adult centers.

Before the COVID-19 pandemic, a significant trend in pediatric firearm rate was not found. During COVID-19, there was a sustained increase of an additional 0.42 pediatric patients with FRI per 1,000 trauma visits each month. This increase, however, was not statistically different from pre-COVID-19. Moreover, when the COVID-19 period was separated into pre- and post-SB 319, the COVID-19/Pre-SB 319 slope was insignificant. We have two possible hypotheses for these findings. First, this may suggest that the increase in FRI rates during COVID-19 was driven by the introduction of SB 319 in our state. Alternatively, prior studies that observed increased FRI rates during COVID-19 analyzed a shorter period of time, typically 6-months to 1.5-years after the start of COVID-19 (9, 10, 13, 40). Increased rates of FRI were associated with acute changes during the start of the pandemic, such as school closures and record-setting firearm purchases (9, 10, 13). Today, there are arguably less societal and economic disruptions resulting from the pandemic.

A unique contribution of this manuscript was the inclusion of The Constitutional Carry Act, a Georgia law effective since April 2022 that allows for concealed carry of firearms in public without a permit. A recent study in West Virginia found that after a concealed firearm carry law was enacted, monthly firearm mortalities in the state increased, along with brief spikes in firearm sales and homicide (42). This suggests that concealed carry laws directly impact how people purchase and use guns and may lead to increases in firearm-related assaults. In our study, there was a sustained increase in pediatric FRI by 2.3 additional patients per 1,000 trauma visits each month after the law was in effect. Given the restricted timeline (12-months post-law) and nature of the study assessing one hospital system, outliers may be exaggerating this association. Over time, we will be able to assess the association of the law and pediatric FRI more accurately. However, in the year after the law was in effect, even the lowest predicted rates of pediatric FRI are remarkably high, unlike in previous periods. This concerning trend necessitates intervention and continued evaluation of incidence rates.

Studies have found that among the U.S., Southern states have the highest rates of pediatric FRI incidence (19), have worsening pediatric FRI mortality rates (1), and have one of the highest rates of pediatric firearm homicide (16). It has been estimated that 49% of Georgia households own a firearm (43). Southern states have high rates of firearm ownership and unsafe storage (44), as defined by storing firearms loaded and unlocked. Households where children and adolescents suffered unintentional injuries or intentionally self-inflicted injuries are more likely to have unlocked, loaded firearms in the home that were stored with ammunition (45). One study found that Black households are more likely than White households to store firearms loaded and unlocked (44). Almost half of the children and adolescents injured by firearms in our sample were injured unintentionally. This often looks like a child getting ahold of an unlocked, loaded firearm at home, playing with it, and accidentally injuring themselves or another child (16, 45, 46). Consistent with the literature, it is possible that many of the pediatric FRI in our sample occurred due to the availability of firearms, and non-powder guns, within the household.

Although we did not find statistical differences in mortality odds between racial groups, there were four times as many Black patients with FRI than there were White patients in our sample. The disproportionate increase in Black patients seen over time is corroborated in other studies as well (19), although our cohort appears to have more Black patients than national studies (74.9% vs. 50%) (1, 19). This may be due in-part to the racial profile of Atlanta. However, further review of the trauma registry data did not show similar racial distributions nor differences in rates of trauma over time, suggesting a discrepancy in rates of FRI in Black children and adolescents compared to White. Studies have found that deprived (21) or low-income areas correlate with higher pediatric FRI risk (19) and mortality rates (1). Studies have shown that Black and other minoritized race groups come from low socio-economic backgrounds that put them at increased risk for injuries (26). Future studies should investigate the correlation between neighborhood-level SDH, race, and FRI in Atlanta.

We did not find differences in acute outcomes based on race. A national analysis of pediatric FRI mortality data found that Black patients suffer 4 times the mortality rate of White patients (34), while another looking at national hospitalizations found that Black patients had lower odds of mortality than White patients (41). These mortality disparities often relate to mechanism of injury; a recent study found that White patients had higher odds of mortality due to higher rates of intentional self-inflicted injuries (32). Concurrent with national trends, Black patients in our sample suffered more assault injuries and less unintentional and intentional self-inflicted injuries than White patients did (32, 41, 47). The uneven distribution of race in our sample may have contributed to our lack of findings in mortality disparities. In addition, mortality was difficult to model as it was a rare outcome. The study sample’s unique characteristics may have contributed as well, such as the large proportion of younger children and adolescents.

Patients with private insurance had significantly higher odds of mortality than patients with public insurance. However, when controlled for confounding factors such as race, year of injury, and mechanism of injury, this difference was not found. As this analysis was more exploratory in nature, further investigation is needed to understand what is driving this change. Privately insured patients suffered more intentional self-inflicted injuries compared to publicly insured patients (10% vs. 2.6%); this mechanism is known to be more severe and lethal than other mechanisms and may help to explain differences in mortality between these groups (41). Other FRI studies that examined insurance have found disparities in mortality between uninsured and insured patients (19, 23). To our knowledge, we are among few studies that found disparities between private and public insurance, particularly in pediatric FRI. One pediatric trauma study found that insurance, rather than race, predicted mortality (25); another found that a combination of both is necessary to understand disparities (24). The disparities found in the present study are likely better explained by SDH; future investigations are needed to understand the intricacies between race, insurance, other SDH, and acute outcomes following FRI. Notably, insurance is an important SDH; it can serve as a proxy to socioeconomic status (SES), and it affects hospital-based care and care-seeking behaviors (39). However, it mainly reflects individual-level factors. Future studies will benefit from examining neighborhood-level SDH, such as neighborhood depravity. Additionally, mortality rates in our sample were found to have fluctuated across COVID-19 in privately insured patients but not publicly insured patients. This suggests a need for continued investigation into temporal differences.

There are several limitations within our study that are worth noting. Race and insurance analysis were balanced by mechanism of injury, among other factors, to avoid its potential confounding effects with the outcome. As such, the effects of mechanism of injury could not be included as a predictor in the regression analysis but should be addressed in future studies. As an outcome, mortality was a rare occurrence and presents challenges for constructing and interpreting models. Older adolescents are often sent to a neighboring adult Level I trauma center in Atlanta; thus, our older adolescent group is likely smaller and less representative of the adolescent population with FRI in our area. This study is also limited to available trauma registry data, which only collects acute outcomes, rather than long-term outcomes. Patients who were not at our hospitals (i.e., patients that passed away at the scene) are not included in this study. Notably, we did not validate trauma registry data with review of electronic medical records. Mechanism of injury, which is taken from ICD E-code, could be inaccurate (48). There may also be an overrepresentation of Medicaid insurance in the Trauma registry, as our institutional trauma registry defaults insurance type to Medicaid if the field is not entered. Additionally, race and ethnicity are pulled from medical records, which are entered by hospital staff who register patients upon entry. There is a possibility that given the busy nature of the hospital and severity of these injuries that some of the race and ethnicity fields could have been assumed based on phenotype rather than inquired of the patient or their family. Finally, our study was limited to single center design and may not be representative of the rest of our state or national pediatric rates of FRI. There may be a chance our hospital systems are receiving more of the state’s proportion of pediatric patients with FRI over time, this can be assessed in a future study examining state-wide pediatric FRI.

The observed increase of FRI in children and adolescents at our trauma centers is highly concerning. Both COVID-19 and the Constitutional Carry Act (SB 319) were followed by significant sustained increases in pediatric patients with FRI. The continual increase of children and adolescents injured by firearms requires both evidence-based interventions and continued research to evaluate trends and inform interventions. The high concentration of Georgian children and adolescents injured necessitates interventions in the Atlanta and surrounding area, such as violence prevention programs and safe firearm storage training (49). Further investigation into SDH and pediatric FRI are needed to understand the observed insurance-based differences in mortality odds and to identify factors driving the increased FRI incidence among Black children and adolescents. Although racial disparities were not found in acute outcomes, majority of pediatric patients survive FRI, thus necessitating research into long-term outcomes, including long-term physical, cognitive, and emotional functioning. With further research into FRI, acute and long-term outcomes, disparities, and the intersection of SDH, we can address the increase in pediatric FRI at its source and help children and adolescents live high-quality lives.

The datasets presented in this article are not readily available due to concerns regarding patient confidentiality. Requests to access the datasets should be directed to the corresponding author.

The studies involving humans were approved by Children's Healthcare of Atlanta Institutional Review Board. The studies were conducted in accordance with the local legislation and institutional requirements. The ethics committee/institutional review board waived the requirement of written informed consent for participation from the participants or the participants’ legal guardians because this study is a retrospective chart review and thus consent was not required.

MM: Conceptualization, Data curation, Investigation, Writing – original draft, Writing – review & editing. GB: Conceptualization, Writing – original draft. KP: Writing – original draft. SG: Formal analysis, Methodology, Visualization, Writing – review & editing, Software. LJ: Formal analysis, Methodology, Visualization, Writing – review & editing, Software. KD: Writing – review & editing. AR: Project administration, Resources, Writing – review & editing. LB: Conceptualization, Investigation, Project administration, Supervision, Writing – original draft, Writing – review & editing.