Pediatric hospitalists have a critical role to play in the prevention of firearm death and injury in children. Gun violence is the second leading cause of death for children and adolescents.1  Just over half of these deaths are homicide, with the remaining attributed to suicide and unintentional shootings. There are more child deaths from gun violence than child deaths from cancer, heart disease, and lung disease combined.1  These startling statistics should urge all pediatricians to act, including those invested in the care of hospitalized children.

This uniquely American problem is driven, in part, by access to unsecured firearms. In America, 4.6 million children live in a household with at least 1 loaded, unlocked gun.2  Access to unsecured firearms puts children at risk for unintentional shootings and adolescents at risk for suicide.3  Responsible storage (keeping guns locked, unloaded, and separate from ammunition) can decrease these risks.3  The majority of children in gun-owning households are aware of where their parents store the gun, with more than one-third reporting previously handling the gun.4  We cannot rely on curious children to not find a gun that is “hidden” or to know what to do if they encounter a gun. Educational programs that are focused on teaching children about gun safety do not work. In fact, after completing gun safety training programs, preschool- and school-aged children are just as likely to approach and play with a handgun as those not given the training.5  Access to a firearm is key modifiable risk factor for adolescent suicide in the United States.6  Of the adolescents screened in 1 study, >50% reported they had a friend or relative who owned a gun, and 28% stated they could access a loaded gun within 3 hours.7  Households with locked firearms and separate locked ammunition have an 85% lower risk of unintentional injury and a 78% lower risk of self-inflicted firearm injury.3 

In this month’s issue of Hospital Pediatrics, Monroe et al8  evaluated the frequency of screening for firearms in the home by inpatient pediatric providers in the academic tertiary care hospital setting. Via retrospective chart review, they found a low rate of documented screening, with an overall rate of 2.94%. The most frequently screened diagnosis was mood disorders, and the most frequent screening provider type was child psychiatrist. Although it is encouraging that children and adolescents with mood disorders are being screened at higher rates, this number is still drastically low at 37.3%. As the authors point out, what is most concerning is that even when screening took place, the conversation often stops there, with no anticipatory guidance or safe storage counseling provided. The authors describe this as a missed opportunity, and we could not agree more. It is past time for pediatricians, including hospitalists, to adopt strategies to incorporate firearm access screening and safe storage counseling into their practice. Every health care encounter is an opportunity to prevent a child’s death or injury from a firearm whether that be in the outpatient, emergency department, or inpatient setting. Considering the number of childhood firearm deaths in 2016 (3143) in the context of the number of childhood asthma deaths in 2016 (169), it is hard to argue that hospitalists should not be focused on finding solutions to this public health epidemic.1,9 

As this study by Monroe et al8  reveals, hospitalists have significant room for improvement in firearm screening and safe storage counseling. Even modest improvements in screening and counseling rates could have a significant impact on child health, particularly in states with high rates of gun ownership. Fortunately, there are evidence-based strategies that can provide a blueprint for change. In studies, researchers have shown that physician counseling, when used in combination with a tangible tool (provision of a gun lock), can improve firearm storage practices. A randomized control trial by Barkin et al10  revealed that brief physician counseling combined with the distribution of a cable gun lock was effective in increasing safe storage of home firearms, with the intervention group having twice the odds of storing all firearms with a gun lock compared to the control group. Carbone et al11  and Grossman et al12  also demonstrated improved gun safety behaviors after family education and provision of gun safety devices.

The authors discuss potential barriers to physician firearm screening and safe storage counseling including misconceptions about legal restrictions and worry about engaging in a politically charged conversation. There are currently no legal restrictions on a physician’s ability to screen and counsel patients and families regarding firearm access and safe storage.13  Although Florida did pass the Firearm Owners’ Privacy Act in 2011, shortly after it was passed, a federal judge blocked the law from taking effect. After years of court battles, in a 10-to-1 decision in 2017, the US Court of Appeals for the 11th Judicial Circuit found that the law violates physicians’ First Amendment rights. The ruling noted that there was no evidence that asking about guns was infringing on the Second Amendment rights of patients.13  Although we recognize that discussions about firearms can be politically charged, screening for firearm access and promoting safe storage is in line with the American Academy of Pediatrics (AAP) recommendations and does not conflict with the Second Amendment or the legal rights of firearm owners. In fact, studies have revealed that gun owners and nonowners agree on taking an evidenced-based approach to firearm safety.14 

The AAP provides tool kits and other resources for providers to guide screening and safe storage counseling.15  One specific tool we have used with success is the Be SMART program.16  The Be SMART message provides an apolitical, easy-to-follow, AAP-aligned framework for physicians to screen and counsel patients regarding firearm safety. Be SMART stands for Secure all guns in your homes and vehicles, Model responsible behavior around guns, Ask about unsecured guns in other homes, Recognize the role of guns in suicide, and Tell your peers to Be SMART. Studies are in progress to evaluate the use of the Be SMART program in both the inpatient and outpatient setting. The Be SMART program has volunteers all over the country and can provide a clinical setting with posters for examination rooms and handouts for families; the program also offers a brief educational video (available on their Web site). Additionally, we suggest partnering with a local law enforcement agency because they can often provide gun locks for patients and families.

As Monroe et al8  point out, hospitalists have a unique and powerful opportunity to prevent firearm death and injury in children. The difficulties encountered with other pediatric health care visits such as time constraints, limited messaging opportunities, and maternal-only presence are often alleviated by hospitalizations. In the hospital, we are gifted a captive audience, not constrained to a 15-minute time slot, and are able to reach a wide range of family members often including extended family members who could benefit from safe storage messaging. Hospitalists are well versed in the discussion surrounding safe sleep, car seats, and tobacco cessation, and firearm safety can and should be an equal part of this conversation. Furthermore, academic hospital pediatricians have the opportunity to educate trainees about the importance of firearm screening and can model effective counseling.

Children are being injured and killed by firearms at an alarming rate in America, and pediatric hospitalists are poised to address this public health emergency. Although the AAP states that the safest home for a child is a home without a gun, it is important to have open and unbiased conversations with families about safe storage practices. By adopting the mind-set of screening each child for unsecured guns in the home during every encounter and providing safe storage counseling, pediatric hospitalists can contribute to the medical community’s response to the epidemic of gun violence in our communities.

FUNDING: No external funding.

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Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.