OBJECTIVES:

To investigate nonpowder firearm injuries treated in US emergency departments among children <18 years old.

METHODS:

National Electronic Injury Surveillance System data from 1990 through 2016 were analyzed.

RESULTS:

An estimated 364 133 (95% confidence interval 314 540–413 727) children <18 years old were treated in US emergency departments for injuries related to nonpowder firearms from 1990 to 2016, averaging 13 486 children annually. From 1990 to 2016, the number and rate of nonpowder firearm injuries decreased by 47.8% (P < .001) and 54.5% (P < .001), respectively. Most injuries occurred among 6- to 12-year-olds (47.4%) and 13- to 17-year-olds (47.0%). Boys accounted for 87.1% of injured children, the most common diagnosis was foreign body (46.3%), and 7.1% of children were admitted. BB guns accounted for 80.8% of injuries, followed by pellet guns (15.5%), paintball guns (3.0%), and airsoft guns (0.6%). The rate of eye injuries increased by 30.3% during the study period. Eye injuries accounted for 14.8% of all injuries and the most common diagnoses were corneal abrasion (35.1%), hyphema (12.5%), globe rupture (10.4%), and foreign body (8.6%).

CONCLUSIONS:

Although the number and rate of nonpowder firearm injuries declined during the study period, nonpowder firearms remain a frequent and important source of preventable and often serious injury to children. The severity and increasing rate of eye injuries related to nonpowder firearms is especially concerning. Increased prevention efforts are needed in the form of stricter and more consistent safety legislation at the state level, as well as child and parental education regarding proper supervision, firearm handling, and use of protective eyewear.

What’s Known on This Subject:

Although nonpowder firearms can cause serious pediatric injury, especially to the eyes, their regulation varies from state to state and no federal regulation exists. The American Academy of Pediatrics recommends use of protective eyewear when using nonpowder firearms.

What This Study Adds:

On average, 13 486 pediatric nonpowder firearm injuries were treated in US emergency departments annually. Although the overall rate of these injuries declined by 54.5% from 1990 to 2016, nonpowder firearm eye injuries increased by 30.3%. Increased prevention efforts are needed.

Nonpowder firearms have long been marketed to children and teenagers as toys or “starter” firearms and include paintball, airsoft, BB, and pellet guns. They use air pressure, carbon dioxide pressure, or spring-loaded action to propel metal or plastic projectiles of many shapes and sizes at varying velocities and are primarily used in target shooting, small animal hunting, and recreational combat simulation games (eg, paintball and airsoft). Although nonpowder firearms are recognized as an important source of pediatric injury, especially to the eyes,14  their regulation varies from state to state, and no federal regulation exists.5 

Previous studies of nonpowder firearm injuries have often focused on specific anatomic areas, such as the eyes, head, neck, or chest.611  Others have been limited to reports of fatalities.10,12,13  Most previous studies have had a small sample size or were conducted at a single center.4,1417  However, 3 previous studies analyzed a nationally representative sample from the National Electronic Injury Surveillance System (NEISS) database. One of those studies evaluated injuries from 1985 to 1999,18  the second concentrated on pediatric eye injuries from 2002 to 2012,6  and the third evaluated head and neck injuries from 2005 to 2014.19  To our knowledge, our study is the first to comprehensively investigate all types of nonpowder firearm injuries among children and adolescents using a nationally representative sample.

This study retrospectively analyzed data regarding nonpowder firearm injuries among children <18 years of age treated in US emergency departments (EDs) from 1990 through 2016. Data were obtained from the NEISS, which monitors injuries associated with consumer products and sports and recreational activities treated in US EDs. The NEISS is maintained by the US Consumer Product Safety Commission (CPSC) and includes ∼100 reporting hospitals that represent a stratified probability sample from the >5300 hospitals with at least 6 beds and a 24-hour ED in the United States and its territories.20  Trained NEISS coders at participating hospitals extracted data from ED medical records, including patient demographics (including age and sex), consumer products or activities involved, injury diagnosis, affected body region, location where the injury occurred, disposition from the ED, and a brief narrative describing the circumstances of the injury incident.20 

Nonpowder firearm injuries were identified by using NEISS product codes 1200 (for paintball [activity]: sports and recreational activity, not elsewhere classified), 1237 (gas, air, or spring-operated guns [including BB guns]), and 1936 (BBs or pellets [excluding shotgun pellets]). Each case narrative was reviewed and cases were excluded if they involved nonprojectile firearms, other projectile firearms, powder firearms, pellet or BB ingestions or foreign body insertions, injuries not directly related to use of the firearm, being hit or struck with the firearm, or if the mechanism of injury was unclear. The final data set consisted of 9739 actual cases included in analyses.

Children were categorized into 3 age groups: <6, 6 to 12, and 13 to 17 years old. Injury diagnosis was categorized as (1) contusion or abrasion, (2) foreign body, (3) fracture, (4) laceration, (5) puncture, and (6) other. Body region injured was grouped as (1) head and/or neck (including eyeball, face, head, neck, mouth, and ear), (2) trunk (including upper trunk, lower trunk, and pubic region), (3) upper extremity (including finger, hand, wrist, lower arm, elbow, upper arm, and shoulder), and (4) lower extremity (including toe, foot, ankle, lower leg, knee, and upper leg). Disposition from the ED was categorized as: (1) treated and released, (2) admitted (including hospitalized, transferred, held for observation for <24 hours, and treated and transferred for hospitalization), and (3) left against medical advice. Location of injury incident was grouped as (1) home (including home, mobile or manufactured home, apartment, and farm) and (2) other. Additional variables analyzed included sex and year.

The narrative from each case was reviewed and a variable describing the user of the nonpowder firearm was created, which included the categories of (1) self and (2) other person (including peer, adult, and other person of unspecified age). Using each case narrative, a variable describing the type of nonpowder firearm was created, which included the categories of (1) BB gun, (2) pellet gun, (3) airsoft gun, and (4) paintball gun.

Data were analyzed by using SPSS version 20.0 (IBM SPSS Statistics, IBM Corporation) and SAS 9.4 (SAS Institute, Inc, Cary, NC). Complex survey procedures were used to calculate the national estimates using sample weights provided by the CPSC. All the estimates in the study are stable estimates unless stated otherwise. The CPSC considers an estimate to be unstable if the estimate is <1200, the sample size is <20 actual cases, or the coefficient of variation is >33%. Injury rates were calculated by using intercensal and postcensal population estimates obtained from the US Census Bureau.2123  Secular trends in the estimated annual number and rate of injuries were assessed using simple or piecewise linear regression as appropriate. The estimated slope from regression models was reported along with the associated P value. Other statistical analyses included calculation of odds ratios (ORs) with 95% confidence intervals (CIs) using complex survey procedures. Statistical significance was set at 0.05. This study was determined to be exempt by the institutional review board of the authors’ institution.

An estimated 364 133 (95% CI: 314 540–413 727) children <18 years of age with nonpowder firearm injuries were treated in US EDs from 1990 through 2016, averaging 13 486 children annually or 18.8 injuries per 100 000 US children <18 years old. Most injuries occurred among children 6 to 12 years old (47.4%) and 13 to 17 years old (47.0%), with only 5.6% of injuries being observed among children <6 years of age. The average age was 11.8 years (SD: 3.5; interquartile range: 10–14 years). Boys accounted for 87.1% of injuries, and among cases with a documented location of injury, most (89.4%) occurred at home (Table 1).

TABLE 1

Characteristics of Nonpowder Firearm Injuries Treated in US EDs by Age Group (NEISS 1990–2016)

CharacteristicsAge Group
<18 y Old<6 y Old6–12 y Old13–17 y Old
n (%)a95% CIn (%)a95% CIn (%)a95% CIn (%)a95% CI
Sex         
 Male 317 220 (87.1) 273 565–360 875 14 019 (68.4) 11 216–16 823 151 650 (87.9) 128 191–175 109 151 550 (88.5) 130 181–172 920 
 Female 46 831 (12.9) 39 892–53 770 6473 (31.6) 4869–8077 20 762 (12.0) 17 218–24 305 19 597 (11.4) 16 385–22 809 
 Unknown 83b 0–173 61b 0–147 21b 0–54 
Body region injured         
 Head and/or neck 143 046 (39.3) 122 224–163 869 10 435 (50.9) 8335–12 534 67 094 (39.0) 55 978–78 210 65 518 (38.3) 55 612–75 424 
 Upper extremity 111 784 (30.7) 96 207–127 361 5350 (26.1) 4002–6698 49 311 (28.6) 41 433–57 190 57 123 (33.4) 48 656–65 590 
 Trunk 33 990 (9.3) 28 423–39 557 2734 (13.3) 1867–3600 18 183 (10.6) 14 721–21 646 13 073 (7.6) 10 518–15 628 
 Lower extremity 74 770 (20.6) 63 503–86 037 1968 (9.6) 1156–2780 37 588 (21.8) 30 862–44 313 35 214 (20.6) 29 843–40 586 
 Other 229 (<0.1)b 13–444 6 (<0.1)b 0–17 12 (<0.1)b 0–28 211 (0.1)b 0–425 
 Not specified 315b 68–562 286b 41–530 29b 0–66 
Diagnosis         
 Contusion or abrasion 49 006 (13.5) 39 529–58 482 3660 (17.9) 2432–4888 23 691 (13.8) 18 903–28 479 21 655 (12.7) 16 913–26 397 
 Foreign body 168 276 (46.3) 142 874–193 679 7231 (35.3) 5502–8960 77 673 (45.1) 64 552–90 795 83 372 (48.8) 70 112–96 632 
 Fracture 6755 (1.9) 5023–8488 265 (1.3)b 40–489 3202 (1.9) 2118–4286 3288 (1.9) 2232–4345 
 Laceration 15 464 (4.3) 12 721–18 207 1338 (6.5) 663–2013 7044 (4.1) 5464–8623 7082 (4.1) 5481–8683 
 Puncture 81 182 (22.3) 67 376–94 987 5733 (28.0) 4323–7143 40 081 (23.3) 31 746–48 415 35 368 (20.7) 29 280–41 456 
 Other 42 882 (11.8) 35 187–50 578 2266 (11.1) 1409–3122 20 571 (11.9) 16 390–24 751 20 046 (11.7) 16 254–23 838 
 Not specified 568b 105–1031 212b 0–471 356b 0–746 
Disposition from ED         
 Treated and released 336 280 (92.4) 290 269–382 290 17 924 (87.5) 14 409–21 439 158 362 (91.9) 134 408–182 317 159 993 (93.5) 137 352–182 634 
 Admitted 26 002 (7.1) 21 182–30 821 2307 (11.3) 1508–3106 13 397 (7.8) 10 280–16 513 10 298 (6.0) 8161–12 434 
 Left against medical advice 1638 (0.5) 780–2496 261 (1.3)b 0–638 588 (0.3)b 197–979 789 (0.5)b 259–1319 
 Not specified 214b 20–408 126b 0–253 88b 0–240 
Location of incident         
 Home 195 584 (89.4) 161 180–229 988 13 955 (96.9) 11 008–16 902 97 262 (91.5) 79 141–115 383 84 367 (86.0) 68 307–100 428 
 Other 23 256 (10.6) 18 003–28 510 444 (3.1)b 82–805 9077 (8.5) 6833–11 321 13 736 (14.0) 10 194–17 279 
 Not specified 145 293 120 867–169 720 6094 4432–7755 66 135 53 314–78 956 73 065 61 129–85 000 
Intent         
 Unintentional 188 129 (99.0) 159 860–216 397 10 332 (99.8) 8125–12 539 85 988 (98.6) 72 132–99 843 91 809 (99.2) 77 063–106 555 
 Intentional 1960 (1.0) 1130–2791 21 (0.2)b 0–52 1221 (1.4) 651–1790 719 (0.8)b 292–1146 
 Not specified 174 045 148 276–199 813 10 139 7387–12 892 85 265 70 618–99 912 78 640 67 353–89 926 
Type of firearm         
 BB gun 240 522 (80.8) 207 158–273 885 14 566 (86.5) 11 635–17 497 118 084 (83.6) 100 011–136 156 107 872 (77.3) 92 222–123 522 
 Pellet gun 46 208 (15.5) 38 952–53 463 1867 (11.1) 1162–2571 19 391 (13.7) 15 444–23 338 24 950 (17.9) 20 724–29 176 
 Airsoft gun 1915 (0.6) 654–3176 115 (0.7)b 0–267 752 (0.5)b 228–1275 1048 (0.8)b 220–1876 
 Paintball gun 8958 (3.0) 6244–11 672 297 (1.8)b 0–608 3034 (2.1) 1916–4153 5627 (4.0) 3748–7505 
 Not specified 66 531 55 597–77 466 3647 2570–4724 31 213 25 254–37 172 31 671 26 319–37 023 
User of firearm         
 Self 103 416 (52.8) 86 564–120 267 3819 (33.2) 2414–5224 43 934 (47.5) 36 210–51 658 55 663 (60.6) 45 956–65 370 
 Other 92 466 (47.2) 78 793–106 138 7688 (66.8) 5902–9473 48 515 (52.5) 40 150–56 880 36 263 (39.4) 30 424–42 102 
 Not specified 168 253 144 151–192 355 8986 6688–11 283 80 024 66 848–93 201 79 242 68 025–90 460 
Total 364 133 (100.0) 314 540–413 727 20 492 (5.6) 16 711–24 273 172 473 (47.4) 146 332–198 615 171 168 (47.0) 147 393–194 943 
CharacteristicsAge Group
<18 y Old<6 y Old6–12 y Old13–17 y Old
n (%)a95% CIn (%)a95% CIn (%)a95% CIn (%)a95% CI
Sex         
 Male 317 220 (87.1) 273 565–360 875 14 019 (68.4) 11 216–16 823 151 650 (87.9) 128 191–175 109 151 550 (88.5) 130 181–172 920 
 Female 46 831 (12.9) 39 892–53 770 6473 (31.6) 4869–8077 20 762 (12.0) 17 218–24 305 19 597 (11.4) 16 385–22 809 
 Unknown 83b 0–173 61b 0–147 21b 0–54 
Body region injured         
 Head and/or neck 143 046 (39.3) 122 224–163 869 10 435 (50.9) 8335–12 534 67 094 (39.0) 55 978–78 210 65 518 (38.3) 55 612–75 424 
 Upper extremity 111 784 (30.7) 96 207–127 361 5350 (26.1) 4002–6698 49 311 (28.6) 41 433–57 190 57 123 (33.4) 48 656–65 590 
 Trunk 33 990 (9.3) 28 423–39 557 2734 (13.3) 1867–3600 18 183 (10.6) 14 721–21 646 13 073 (7.6) 10 518–15 628 
 Lower extremity 74 770 (20.6) 63 503–86 037 1968 (9.6) 1156–2780 37 588 (21.8) 30 862–44 313 35 214 (20.6) 29 843–40 586 
 Other 229 (<0.1)b 13–444 6 (<0.1)b 0–17 12 (<0.1)b 0–28 211 (0.1)b 0–425 
 Not specified 315b 68–562 286b 41–530 29b 0–66 
Diagnosis         
 Contusion or abrasion 49 006 (13.5) 39 529–58 482 3660 (17.9) 2432–4888 23 691 (13.8) 18 903–28 479 21 655 (12.7) 16 913–26 397 
 Foreign body 168 276 (46.3) 142 874–193 679 7231 (35.3) 5502–8960 77 673 (45.1) 64 552–90 795 83 372 (48.8) 70 112–96 632 
 Fracture 6755 (1.9) 5023–8488 265 (1.3)b 40–489 3202 (1.9) 2118–4286 3288 (1.9) 2232–4345 
 Laceration 15 464 (4.3) 12 721–18 207 1338 (6.5) 663–2013 7044 (4.1) 5464–8623 7082 (4.1) 5481–8683 
 Puncture 81 182 (22.3) 67 376–94 987 5733 (28.0) 4323–7143 40 081 (23.3) 31 746–48 415 35 368 (20.7) 29 280–41 456 
 Other 42 882 (11.8) 35 187–50 578 2266 (11.1) 1409–3122 20 571 (11.9) 16 390–24 751 20 046 (11.7) 16 254–23 838 
 Not specified 568b 105–1031 212b 0–471 356b 0–746 
Disposition from ED         
 Treated and released 336 280 (92.4) 290 269–382 290 17 924 (87.5) 14 409–21 439 158 362 (91.9) 134 408–182 317 159 993 (93.5) 137 352–182 634 
 Admitted 26 002 (7.1) 21 182–30 821 2307 (11.3) 1508–3106 13 397 (7.8) 10 280–16 513 10 298 (6.0) 8161–12 434 
 Left against medical advice 1638 (0.5) 780–2496 261 (1.3)b 0–638 588 (0.3)b 197–979 789 (0.5)b 259–1319 
 Not specified 214b 20–408 126b 0–253 88b 0–240 
Location of incident         
 Home 195 584 (89.4) 161 180–229 988 13 955 (96.9) 11 008–16 902 97 262 (91.5) 79 141–115 383 84 367 (86.0) 68 307–100 428 
 Other 23 256 (10.6) 18 003–28 510 444 (3.1)b 82–805 9077 (8.5) 6833–11 321 13 736 (14.0) 10 194–17 279 
 Not specified 145 293 120 867–169 720 6094 4432–7755 66 135 53 314–78 956 73 065 61 129–85 000 
Intent         
 Unintentional 188 129 (99.0) 159 860–216 397 10 332 (99.8) 8125–12 539 85 988 (98.6) 72 132–99 843 91 809 (99.2) 77 063–106 555 
 Intentional 1960 (1.0) 1130–2791 21 (0.2)b 0–52 1221 (1.4) 651–1790 719 (0.8)b 292–1146 
 Not specified 174 045 148 276–199 813 10 139 7387–12 892 85 265 70 618–99 912 78 640 67 353–89 926 
Type of firearm         
 BB gun 240 522 (80.8) 207 158–273 885 14 566 (86.5) 11 635–17 497 118 084 (83.6) 100 011–136 156 107 872 (77.3) 92 222–123 522 
 Pellet gun 46 208 (15.5) 38 952–53 463 1867 (11.1) 1162–2571 19 391 (13.7) 15 444–23 338 24 950 (17.9) 20 724–29 176 
 Airsoft gun 1915 (0.6) 654–3176 115 (0.7)b 0–267 752 (0.5)b 228–1275 1048 (0.8)b 220–1876 
 Paintball gun 8958 (3.0) 6244–11 672 297 (1.8)b 0–608 3034 (2.1) 1916–4153 5627 (4.0) 3748–7505 
 Not specified 66 531 55 597–77 466 3647 2570–4724 31 213 25 254–37 172 31 671 26 319–37 023 
User of firearm         
 Self 103 416 (52.8) 86 564–120 267 3819 (33.2) 2414–5224 43 934 (47.5) 36 210–51 658 55 663 (60.6) 45 956–65 370 
 Other 92 466 (47.2) 78 793–106 138 7688 (66.8) 5902–9473 48 515 (52.5) 40 150–56 880 36 263 (39.4) 30 424–42 102 
 Not specified 168 253 144 151–192 355 8986 6688–11 283 80 024 66 848–93 201 79 242 68 025–90 460 
Total 364 133 (100.0) 314 540–413 727 20 492 (5.6) 16 711–24 273 172 473 (47.4) 146 332–198 615 171 168 (47.0) 147 393–194 943 
a

Column percentages may not sum to 100.0% because of rounding error.

b

Potentially unstable estimate because the sample is <20, estimate is <1200, or coefficient of variation is >33%.

The head and neck were the most commonly injured body region (39.3%), followed by upper extremity (30.7%) and lower extremity (20.6%). BB guns (35.4%), paintball guns (80.6%), and airsoft guns (100.0%) commonly were associated with injuries to the head and neck, whereas injuries from pellet guns (33.7%) were often to the upper extremity (Table 2). Patients <6 years old more commonly sustained an injury to the head and neck (OR: 1.65; 95% CI: 1.31–2.07) than older patients, and patients 13 to 17 years old were treated more often (OR: 1.26; 95% CI: 1.12–1.43) for an upper extremity injury than younger patients. Among injuries to the head and neck, 36.1% were diagnosed as foreign body, 23.6% were diagnosed as a contusion or abrasion, and 11.9% resulted in hospital admission. Among the head and neck injuries, 37.7% (n = 53 994; 95% CI: 43 602–64 386) were related to the eye. Eye injuries accounted for 14.8% of all nonpowder firearm injuries.

TABLE 2

Characteristics of Nonpowder Firearm Injuries Treated in US EDs by Type of Firearm (NEISS 1990–2016)

CharacteristicsType of Firearm
BB GunPellet GunAirsoft GunPaintball Gun
n (%)a95% CIn (%)a95% CIn (%)a95% CIn (%)a95% CI
Sex         
 Male 208 482 (86.7) 179 468–237 497 40 304 (87.2) 33 735–46 873 1766 (92.2) 629–2904 8122 (90.7) 5627–10 617 
 Female 32 018 (13.3) 26 806–37 231 5904 (12.8) 4386–7421 149 (7.8)b 0–341 836 (9.3)b 410–1261 
 Unknown 21b 0–54 — — —  — — 
Age group, y         
 <6 14 566 (6.1) 11 635–17 497 1867 (4.0) 1162–2571 115 (6.0)b 0–267 297 (3.3)b 0–608 
 6–12 118 084 (49.1) 100 011–136 156 19 391 (42.0) 15 444–23 338 752 (39.3)b 228–1275 3034 (33.9) 1916–4153 
 13–17 107 872 (44.8) 92 222–123 522 24 950 (54.0) 20 724–29 176 1048 (54.7)b 220–1876 5627 (62.8) 3748–7505 
Body region injured         
 Head and/or neck 85 178 (35.4) 72 841–97 515 13 775 (29.9) 11 012–16 538 1915 (100.0) 654–3176 7224 (80.6) 4998–9451 
 Upper extremity 78 551 (32.7) 67 028–90 075 15 531 (33.7) 12 833–18 229 — — 859 (9.6)b 351–1368 
 Trunk 23 201 (9.7) 18 984–27 418 5742 (12.5) 4254–7229 — — 430 (4.8)b 127–732 
 Lower extremity 53 226 (22.1) 45 319–61 133 11 052 (24.0) 8577–13 527 — — 445 (5.0)b 84–805 
 Other 194 (0.1)b 0–405 6 (0.1)b 0–17 — — — — 
 Not specified 171b 0–352 103b 0–264 — — — — 
Diagnosis         
 Contusion or abrasion 25 030 (10.4) 19 802–30 258 5203 (11.3) 3805–6601 941 (49.1)b 343–1539 4500 (50.2) 2923–6078 
 Foreign body 121 500 (50.6) 102 753–140 247 19 272 (41.7) 15 200–23 344 122 (6.4)b 0–286 197 (2.2)b 0–428 
 Fracture 4514 (1.9) 3238–5791 1292 (2.8) 711–1873 — — 122 (1.4)b 0–276 
 Laceration 9441 (3.9) 7373–11 509 3079 (6.7) 2230–3927 11 (0.6)b 0–34 653 (7.3)b 259–1046 
 Puncture 57 848 (24.1) 47 882–67 814 11 784 (25.5) 9197–14 370 70 (3.7)b 0–199 92 (1.0)b 0–233 
 Other 21 713 (9.0) 17 345–26 081 5573 (12.1) 4211–6934 770 (40.2)b 183–1358 3394 (37.9) 2162–4627 
 Not specified 475b 75–876 6b 0–18 — — — — 
Disposition from ED         
 Treated and released 223 915 (93.2) 192 712–255 118 42 131 (91.2) 35 408–48 855 1766 (92.2) 583–2948 7835 (87.5) 5280–10 390 
 Admitted 15 518 (6.5) 12 438–18 599 3854 (8.3) 2779–4928 134 (7.0)b 0–292 1091 (12.2)b 542–1641 
 Left against medical advice 880 (0.4)b 351–1409 223 (0.5)b 0–464 15 (0.8)b 0–46 32 (0.4)b 0–75 
 Not specified 208b 16–400 — — — — — — 
Location of incident         
 Home 135 851 (91.3) 111 343–160 359 27 058 (93.3) 21 606–32 510 1087 (91.2)b 225–1949 2717 (54.3) 1662–3772 
 Other 12 992 (8.7) 9992–15 991 1933 (6.7) 1306–2559 105 (8.8)b 0–253 2291 (45.7) 1253–3330 
 Not specified 91 679 75 812–107 546 17 217 13 652–20 783 723b 253–1193 3950 2252–5648 
Totalc 240 522 (100.0) 207 158–273 885 46 208 (100.0) 38 952–53 463 1915 (100.0) 654–3176 8958 (100.0) 6244–11 672 
CharacteristicsType of Firearm
BB GunPellet GunAirsoft GunPaintball Gun
n (%)a95% CIn (%)a95% CIn (%)a95% CIn (%)a95% CI
Sex         
 Male 208 482 (86.7) 179 468–237 497 40 304 (87.2) 33 735–46 873 1766 (92.2) 629–2904 8122 (90.7) 5627–10 617 
 Female 32 018 (13.3) 26 806–37 231 5904 (12.8) 4386–7421 149 (7.8)b 0–341 836 (9.3)b 410–1261 
 Unknown 21b 0–54 — — —  — — 
Age group, y         
 <6 14 566 (6.1) 11 635–17 497 1867 (4.0) 1162–2571 115 (6.0)b 0–267 297 (3.3)b 0–608 
 6–12 118 084 (49.1) 100 011–136 156 19 391 (42.0) 15 444–23 338 752 (39.3)b 228–1275 3034 (33.9) 1916–4153 
 13–17 107 872 (44.8) 92 222–123 522 24 950 (54.0) 20 724–29 176 1048 (54.7)b 220–1876 5627 (62.8) 3748–7505 
Body region injured         
 Head and/or neck 85 178 (35.4) 72 841–97 515 13 775 (29.9) 11 012–16 538 1915 (100.0) 654–3176 7224 (80.6) 4998–9451 
 Upper extremity 78 551 (32.7) 67 028–90 075 15 531 (33.7) 12 833–18 229 — — 859 (9.6)b 351–1368 
 Trunk 23 201 (9.7) 18 984–27 418 5742 (12.5) 4254–7229 — — 430 (4.8)b 127–732 
 Lower extremity 53 226 (22.1) 45 319–61 133 11 052 (24.0) 8577–13 527 — — 445 (5.0)b 84–805 
 Other 194 (0.1)b 0–405 6 (0.1)b 0–17 — — — — 
 Not specified 171b 0–352 103b 0–264 — — — — 
Diagnosis         
 Contusion or abrasion 25 030 (10.4) 19 802–30 258 5203 (11.3) 3805–6601 941 (49.1)b 343–1539 4500 (50.2) 2923–6078 
 Foreign body 121 500 (50.6) 102 753–140 247 19 272 (41.7) 15 200–23 344 122 (6.4)b 0–286 197 (2.2)b 0–428 
 Fracture 4514 (1.9) 3238–5791 1292 (2.8) 711–1873 — — 122 (1.4)b 0–276 
 Laceration 9441 (3.9) 7373–11 509 3079 (6.7) 2230–3927 11 (0.6)b 0–34 653 (7.3)b 259–1046 
 Puncture 57 848 (24.1) 47 882–67 814 11 784 (25.5) 9197–14 370 70 (3.7)b 0–199 92 (1.0)b 0–233 
 Other 21 713 (9.0) 17 345–26 081 5573 (12.1) 4211–6934 770 (40.2)b 183–1358 3394 (37.9) 2162–4627 
 Not specified 475b 75–876 6b 0–18 — — — — 
Disposition from ED         
 Treated and released 223 915 (93.2) 192 712–255 118 42 131 (91.2) 35 408–48 855 1766 (92.2) 583–2948 7835 (87.5) 5280–10 390 
 Admitted 15 518 (6.5) 12 438–18 599 3854 (8.3) 2779–4928 134 (7.0)b 0–292 1091 (12.2)b 542–1641 
 Left against medical advice 880 (0.4)b 351–1409 223 (0.5)b 0–464 15 (0.8)b 0–46 32 (0.4)b 0–75 
 Not specified 208b 16–400 — — — — — — 
Location of incident         
 Home 135 851 (91.3) 111 343–160 359 27 058 (93.3) 21 606–32 510 1087 (91.2)b 225–1949 2717 (54.3) 1662–3772 
 Other 12 992 (8.7) 9992–15 991 1933 (6.7) 1306–2559 105 (8.8)b 0–253 2291 (45.7) 1253–3330 
 Not specified 91 679 75 812–107 546 17 217 13 652–20 783 723b 253–1193 3950 2252–5648 
Totalc 240 522 (100.0) 207 158–273 885 46 208 (100.0) 38 952–53 463 1915 (100.0) 654–3176 8958 (100.0) 6244–11 672 

—, not applicable.

a

Column percentages may not sum to 100.0% because of rounding error.

b

Potentially unstable estimate because the sample is <20, estimate is <1200, or coefficient of variation is >33%.

c

Total may not add to all estimated cases in the study because of missing values.

The most common diagnosis was foreign body (46.3%), followed by puncture (22.3%) and contusion or abrasion (13.5%); this pattern was consistent across all age groups. More than two-thirds (68.9%) of contusions and abrasions were to the head and neck, whereas foreign body injuries were commonly to an upper extremity (37.2%), followed by head and neck (30.7%). Corneal abrasion (35.1%) was the most common diagnosis among eye injuries. Patients 13 to 17 years of age had higher odds (OR: 1.74; 95% CI: 1.36–2.22) of being diagnosed with a foreign body than patients <13 years old. BB guns (50.6%) and pellet guns (41.7%) commonly resulted in foreign body-related injuries, whereas paintball guns were frequently associated a contusion or abrasion (50.2%; Table 2). Fractures were most commonly associated with hospital admission (9.7%), followed by punctures (6.7%) and lacerations (5.9%).

Corneal abrasion (35.1%), hyphema (12.5%), foreign body (10.9%), and globe rupture (10.4%) were the most common diagnoses among the eye injuries (Table 3). The proportion of injured children who required hospital admission varied by type of eye injury and was highest for globe rupture (62.0%), followed by foreign body (41.5%) and hyphema (27.5%). Globe rupture had higher odds of hospital admission than other types of eye injury (OR: 7.68; 95% CI: 5.02–11.74), and foreign body also had greater odds of admission than other eye injury diagnoses (OR: 2.88; 95% CI: 1.82–4.56).

TABLE 3

Frequency and Percentage of Specific Diagnoses Among Nonpowder Firearm Eye Injuries Treated in US EDs (NEISS 1990–2016)

Eye Injury DiagnosisEstimated Frequency (95% CI)%a
Corneal abrasion 18 960 (14 309–23 610) 35.1 
Hyphema 6763 (5007–8519) 12.5 
Foreign body 5922 (4192–7652) 10.9 
Globe rupture 5640 (4320–6959) 10.4 
Contusion 3675 (2386–4964) 6.8 
Traumatic iritis or uveitis 1804 (954–2655) 3.3 
Subconjunctival hemorrhage 1667 (940–2393) 3.1 
Retinal injuryb 380 (99–661) 0.7 
Iridodialysisb 359 (39–679) 0.7 
Vitreous hemorrhageb 269 (23–514) 0.5 
Other or unspecified 8555 (5078–12 066) 18.2 
Total 53 994 (43 602–64 386) 100.0 
Eye Injury DiagnosisEstimated Frequency (95% CI)%a
Corneal abrasion 18 960 (14 309–23 610) 35.1 
Hyphema 6763 (5007–8519) 12.5 
Foreign body 5922 (4192–7652) 10.9 
Globe rupture 5640 (4320–6959) 10.4 
Contusion 3675 (2386–4964) 6.8 
Traumatic iritis or uveitis 1804 (954–2655) 3.3 
Subconjunctival hemorrhage 1667 (940–2393) 3.1 
Retinal injuryb 380 (99–661) 0.7 
Iridodialysisb 359 (39–679) 0.7 
Vitreous hemorrhageb 269 (23–514) 0.5 
Other or unspecified 8555 (5078–12 066) 18.2 
Total 53 994 (43 602–64 386) 100.0 
a

Percentages may not sum to 100.0% because of rounding error.

b

Potentially unstable estimate because the sample is <20, estimate is <1200, or coefficient of variation is >33%.

Hospital admission occurred for 7.1% of patients with a nonpowder firearm injury. There were no fatalities. Among admitted patients, 47.5% were 6 to 12 years old, 65.9% had an injury to the head and neck, and 36.9% were diagnosed with a foreign body. Paintball gun–related injuries had the highest proportion of hospital admission (12.2%), followed by pellet guns (8.3%) and airsoft guns (7.0%). Compared with 13- to 17-year-old patients, patients <6 years old (OR: 1.98; 95% CI: 1.31–2.98) and patients 6 to 12 years old (OR: 1.31; 95% CI: 1.03–1.67) had higher odds of admission. Injuries to the head and neck (OR: 8.24; 95% CI: 5.32–12.75) and upper extremity (OR: 9.01; 95% CI: 5.67–14.32) had greater odds of admission compared with injuries to the lower extremity.

Injury intent was documented in 52.2% of cases, of which 1.0% (assaults and self-injury) were intentional. Among cases for which the user of the firearm could be determined (53.8%), the majority (52.8%) of injuries were self-inflicted. Self-inflicted injuries were more common among 13- to 17-year-olds (60.6%), while injuries involving others predominated among patients <6 years old (66.8%). Among cases in which the type of firearm could be determined, BB guns accounted for 80.8% of injuries, followed by pellet guns (15.5%), paintball guns (3.0%), and airsoft guns (0.6%).

From 1990 to 2016, the annual number and rate (per 100 000 children <18 years old) of nonpowder firearm injuries decreased significantly by 47.8% (slope = −415.32; P < .001) and 54.5% (slope = −0.67; P < .001), respectively (Fig 1). The decreasing trend was consistent across all age groups and both sexes, with the greatest decrease in injury rate observed among 13- to 17-year-olds (−59.7%; slope = −1.09; P < .001) and boys (−56.7%; slope = −1.14; P < .001). BB guns showed the greatest decrease in injury rate (−60.9%; slope = −0.5; P < .001), followed by pellet guns (−14.3%; slope = −0.05; P < .001; Fig 2). Contrary to this overall trend, the annual number and rate (per 100 000 children <18 years old) of eye injuries associated with nonpowder firearms increased significantly from 1990 to 2016 by 49.5% (slope = 54.19; P = .003) and 30.3% (slope = 0.46; P = .006), respectively, with a peak in 2006 (Fig 3).

FIGURE 1

Estimated annual number and rate of nonpowder firearm injuries by sex (NEISS 1990–2016).

FIGURE 1

Estimated annual number and rate of nonpowder firearm injuries by sex (NEISS 1990–2016).

Close modal
FIGURE 2

Estimated annual number of children treated in US EDs with a nonpowder firearm injury by type of firearm (NEISS 1990–2016). a Potentially unstable estimates because the sample is <20, estimate is <1200, or coefficient of variation is >33%.

FIGURE 2

Estimated annual number of children treated in US EDs with a nonpowder firearm injury by type of firearm (NEISS 1990–2016). a Potentially unstable estimates because the sample is <20, estimate is <1200, or coefficient of variation is >33%.

Close modal
FIGURE 3

Estimated annual number and rate of nonpowder firearm eye injuries (NEISS 1990–2016). a Potentially unstable estimates because the sample is <20, estimate is <1200, or coefficient of variation is >33%.

FIGURE 3

Estimated annual number and rate of nonpowder firearm eye injuries (NEISS 1990–2016). a Potentially unstable estimates because the sample is <20, estimate is <1200, or coefficient of variation is >33%.

Close modal

There were an estimated 364 133 children with nonpowder firearm injuries treated in US EDs from 1990 through 2016, averaging 13 486 annually. Consistent with previous studies, the head and neck were the most commonly injured body region, with frequent involvement of the eyes.4,6,19,24  The overall number and rate of nonpowder firearm injuries decreased significantly during the study period by 47.8% and 54.5%, respectively. However, eye injuries associated with nonpowder firearms demonstrated the opposite trend, with the number and rate increasing significantly by 49.5% and 30.3%, respectively. This is in agreement with previous reports.6,24 

Nonpowder firearms should be regarded as potentially lethal weapons. Most fire projectiles in excess of the minimum velocity to penetrate human skin, which is ∼70 m per second (230 ft per second) with an energy/area of presentation of ∼2.1 m-kg per cm,3,25  and many achieve a muzzle velocity similar to a handgun.26,27  Fatal injuries from nonpowder firearms have been reported and most often are associated with penetrating wounds to the head, neck, or chest.10,12,13  Although there were no deaths reported in our study, the NEISS does not adequately capture fatalities because deaths are not consistently transported to the ED and those that occur after admission to the hospital are missed when only the ED medical record is reviewed.

There were an estimated 53 994 eye injuries in our study, accounting for 14.8% of all nonpowder firearm injuries. These injuries were often serious with 22.2% requiring admission to the hospital. The rate of eye injuries increased by 30.3% during the study period. These findings agree with previous studies, which emphasize that eye injuries are commonly reported in association with nonpowder firearms and can result in serious adverse outcomes, including partial or complete vision loss.4,6,7,11  Indeed, nonpowder firearms account for most pediatric eye injuries that are admitted to the hospital.6  Educational efforts to prevent nonpowder firearm eye injuries often focus on the use of appropriate eye protective equipment, with 1 study estimating that eye protection was absent in >98% of eye injuries.6  Voluntary safety standards exist for eye protective equipment for paintball and airsoft guns.28,29  A policy statement by the American Academy of Pediatrics provides specific recommendations for protective eyewear for children participating in various sports and recreational activities, including use of nonpowder firearms.30 

Unlike powder firearms, which fall under the oversight of the Bureau of Alcohol, Tobacco, Firearms, and Explosives within the US Department of Justice, the CPSC has federal jurisdiction over nonpowder firearms. Although the CPSC has no mandatory safety regulations for nonpowder firearms, 2 voluntary safety standards have been adopted, American Society for Testing and Materials (ASTM) F589 Standard Consumer Safety Specification for Non-Powder Guns and ASTM F590 Standard Consumer Safety Specification for Non-Powder Gun Projectiles and Propellants.8,13  Manufacturers are extensively involved in the development of ASTM voluntary standards and generally comply with the safety specifications included in the standards.

Despite the lack of federal mandatory safety standards for nonpowder firearms, 23 states and the District of Columbia have adopted laws to address the safety concerns of these products. In addition, local jurisdictions such as New York City, have passed their own ordinances.5  The 4 major categories of state regulations include (1) defining nonpowder firearms as firearms (New Jersey and Rhode Island), (2) defining certain high-power or large caliber nonpowder firearms as firearms (Illinois and Michigan), or (3) defining nonpowder firearms as dangerous weapons (Connecticut, Delaware, and North Dakota). Each of these definitions carry restrictions on the purchase, transfer, possession, or use of the nonpowder firearm, which vary by state. The fourth category of state regulation restricts access by children. Most state regulations fall into this last category, vary greatly by state, and frequently can easily be circumvented with parental consent or adult supervision. Variability includes the age cutoff for these regulations, some applying to children <18 years of age and others applying to those as young as <12 years of age.5 

This study has several limitations. The number of nonpowder firearm injuries is underestimated by the NEISS because it only includes individuals treated in EDs and not in other health care settings, such as urgent care facilities and private physician offices. Individuals treated in EDs also may not be representative of the entire spectrum of individuals with these injuries. NEISS case narratives may not consistently provide information about the user of the firearm, whether the injury was intentional or unintentional, and other details of the injury incident; however, all narratives were individually reviewed to ensure, to the best of our ability, that each case was categorized appropriately. There were no fatalities in this study; however, the NEISS does not capture fatal injuries well, so we are unable to comment on fatal injuries associated with nonpowder firearms on the basis of this database. We did not have access to pediatric nonpowder firearm exposure data; therefore, US population data were used to calculate injury rates. Despite these limitations, this study provides a comprehensive epidemiological investigation of pediatric nonpowder firearm injuries over a 26-year study period by using a nationally representative sample.

Although the number and rate of nonpowder firearm injuries declined during the study period, nonpowder firearms remain a frequent and important source of preventable and often serious injury to children. The severity and increasing rate of eye injury related to nonpowder firearms is especially concerning. Increased prevention efforts are needed in the form of stricter and more consistent safety legislation at the state level, as well as in child and parental education regarding proper supervision, firearm handling, and use of protective eyewear.

Ms Jones conducted data analysis and drafted and revised the manuscript; Ms Kistamgari assisted in data analysis and revised the manuscript; Dr Smith conceptualized the study, obtained the data, assisted in data analysis, and critically reviewed and revised the manuscript; and all authors approved the final manuscript as submitted.

FUNDING: Ms Jones received a research stipend from the National Student Injury Research Training Program at the Center for Injury Research and Policy at Nationwide Children’s Hospital, funded by the National Center for Injury Prevention and Control, Centers for Disease Control and Prevention (grant 1R49CE002106), and Child Injury Prevention Alliance, while she worked on this study. The interpretations and conclusions in this article do not necessarily represent those of the funding organizations.

     
  • ASTM

    American Society for Testing and Materials

  •  
  • CI

    confidence interval

  •  
  • CPSC

    US Consumer Product Safety Commission

  •  
  • ED

    emergency department

  •  
  • NEISS

    National Electronic Injury Surveillance System

  •  
  • OR

    odds ratio

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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.