When pediatricians and other pediatric providers are given training and resource materials, levels of firearm screenings and anticipatory guidance about firearm safety increase significantly, according to two new studies presented October 9 at the American Academy of Pediatrics (AAP) 2021 National Conference.
“With the rise in firearm sales and injuries during the COVID-19 pandemic, it is more important than ever that pediatricians address the firearm epidemic,” said Alexandra Byrne, MD, a pediatric resident at the University of Florida in Gainesville, who presented one of the studies.
There were 4.3 million more firearms purchased from March through July 2020 than expected, a recent study estimates, and 4075 more firearm injuries than expected from April through July 2020.
In states with more excess purchases, firearm injuries related to domestic violence increased in April (rate ratio [RR], 2.60; 95% CI, 1.32 – 5.93) and May (RR, 1.79; 95% CI, 1.19 – 2.91) 2020. However, excess gun purchases had no effect on rates of firearm violence outside the home.
In addition to the link between firearms in the home and domestic violence, they are also linked to a three- to fourfold greater risk for teen suicide, and both depression and suicidal thoughts have risen in teens during the pandemic.
“The data are pretty clear that if you have an unlocked, loaded weapon in your home, and you have a kid who’s depressed or anxious or dysregulated or doing maladaptive things for the pandemic, they’re much more likely to inadvertently take their own or someone else’s life by grabbing [a gun],” said Cora Breuner, MD, MPH, professor of pediatrics at Seattle Children’s Hospital.
However, there is no difference in gun ownership or gun-safety measures between homes with and without at-risk children, previous research shows.
Training, Guidance, and Locks
Previous research has also shown that there has been a reluctance by pediatricians to conduct firearm screenings and counsel parents about gun safety in the home.
For their two-step program, Byrne’s team used a plan-do-study-act approach. They started by providing training on firearm safety, evidence-based recommendations for firearm screening, and anticipatory guidance regarding safe firearm storage to members of the general pediatrics division at the University of Florida. And they supplied clinics with free firearm locks.
Next they supplied clinics with posters and educational cards from the Be SMART campaign, an initiative of the Everytown for Gun Safety Support Fund, which provides materials for anyone, including physicians, to use.
During their study, the researchers sent three anonymous six-question online surveys — at baseline and 3 to 4 months after each of the two steps — to pediatric residents, physician assistants, advanced practice registered nurses, and attendings to assess the project. There were 52 responses to the first survey, for a response rate of 58.4%, 42 responses to the second survey, for a response rate of 47.2%, and 23 responses to the third survey, for a rate of response 25.8%.
The program nearly doubled screenings during well-child visits and dramatically increased the proportion of families who received a firearm lock when they told providers they had a firearm at home.
| Survey Responses Before and After Completion of the Program | ||
| Safety Measure | Baseline, % | After Completion, % |
|---|---|---|
| Firearm screenings during well-child visits | 37.8 | 72.4 |
| Free firearm locks distributed | 9.6 | 79.3 |
| Advice that the safest home is one without firearms | 53.1 | 66.2 |
| Advice on safe firearm storage | 88.0 | 93.1 |
Previous research has shown “a significant increase in safe firearm storage when firearm locks were provided to families in clinic compared to verbal counseling alone,” Byrne said. “We know that safe firearm storage reduces injuries. Roughly one in three children in the United States lives in a home with a firearm. Individuals with a firearm are at two times the risk of homicide and three to four times the risk of suicide, so it is essential we further study how pediatricians can be most effective when it comes to firearm counseling.”
The difference in lock distribution as a result of the program is a “tremendous increase,” said Christopher S. Greeley, MD, MS, chief of the division of public health pediatrics at Texas Children’s Hospital and professor of pediatrics at Baylor College of Medicine in Houston, who was not involved in the research.
“Locks could go a long way to minimizing the risk,” he told Medscape Medical News, adding that nearly half of all teen suicide deaths that occurred over a decade in Houston involved a firearm.
Adding a Social-History Component
A program to increase firearm screening was also presented at the AAP conference.
After random review of medical records from 30 patients admitted to the hospital documented zero firearm screenings, Marjorie Farrington, MD, and Samantha Gunkelman, MD, from Akron Children’s Hospital in Ohio, implemented a program that they hope will increase firearm screenings during inpatient admissions to at least 50%.
They started their ongoing program in April 2020 by adding a social-history component to the history and physical (H&P) exam template and educating residents on how to screen and included guidance on safe firearm storage.
They also had physicians with firearm expertise give gun-safety lectures, and they plan to involve the Family Resource Center at their hospital in the creation of resources that can be incorporated into discharge instructions.
From April 2020 to June 2021, after the addition to the H&P template, 63% of the 5196 patients admitted to the hospital underwent a firearm screening. Of the 25% of patients who reported guns at home, 3% were not storing their firearms safely.
The pair used the “Store It Safe” Physician Handout provided by the Ohio chapter of the AAP.
Many pediatricians and pediatric trainees are not comfortable counseling on firearm safety, often a result of inadequate training on the topic.
The BulletPoints Project — developed by the Violence Prevention Research Program at the University of California, Davis — can also help physicians talk to patients about guns.
“Many pediatricians and pediatric trainees are not comfortable counseling on firearm safety, often a result of inadequate training on the topic,” Byrne told Medscape Medical News. “Additionally, it is a challenging topic that can often be met with resistance from patients and families. Lack of time during visits is also a huge barrier.”
Lack of training is an obstacle to greater firearm screenings, Greeley agreed, as are the feeling that guidance simply won’t make a difference and concerns about political pressure and divineness. The lack of research on firearm injuries and the impact of firearm screenings and anticipatory guidance is a challenge, he added, although that is starting to change.
Pediatricians need education on how to make a difference when it comes to firearm safety, and should follow AAP guidelines, Greeley said.
Counseling on firearm safety is in the same category as immunizations, seatbelts, substance use, helmets, and other public-health issues that are important to address at visits, regardless of how difficult it might be, Breuner told Medscape Medical News.
“It is our mission, as pediatricians, to provide every ounce of prevention in our well-child and anticipatory guidance visits,” she said. “It’s our job, so we shouldn’t shy away from it even though it’s hard.”
Doctors are more comfortable discussing firearm safety if they are firearm owners, previous research has shown, so she advises pediatricians who feel unqualified to discuss firearms to seek guidance from their peers on how to approach screenings and anticipatory guidance, she noted.
The firearm study being done in an academic center gives me great pause. The populations are often very different than private practice.E
Both of these studies were conducted at single institutions and might not reflect what would work in private clinics.
“The firearm study being done in an academic center gives me great pause,” Greeley said. “The populations are often very different than private practice. I think that there is still a lot that remains unknown about decreasing household firearm injury and death.”
And the degree to which findings from these two gun-safety programs can be generalized to other academic centers or children’s hospitals is unclear.
“There are states where, I suspect, firearm screening is much more common. Some states have very pro-firearm cultures and others are anti-firearm,” Greeley said. “There are also likely differences within states,” particularly between urban and rural regions.
“Firearms are often a very personal issue for families, and pediatricians in ‘pro-firearm’ communities may have greater resistance to working on this,” he pointed out.
Nevertheless, Greeley said, “this is a promising strategy that could be part of a broad injury prevention initiative.”
Neither study noted any external funding. Byrne is a member of the Moms Demand Action Gainesville Chapter, which donated the firearm locks for the project. Breuner, Greeley, and Farrington have disclosed no relevant financial relationships.
American Academy of Pediatrics (AAP) 2021 National Conference. Presented October 10, 2021.
Tara Haelle is a Dallas-based science and medical journalist.
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