There are two well-established facts about firearm injury in the United States: It is a leading cause of death among children and adolescents, and racial and socioeconomic differences play a role.
Medical teams at Monroe Carell Jr. Children’s Hospital at Vanderbilt reviewed pediatric firearm deaths in Tennessee expecting to find the same data. But what they didn’t anticipate was the magnitude of hidden mortality cases, which are characterized as deaths that do not reach hospitals.
“The difference in these findings and previous reports is that most of the published data is single-institution or regional data, and often it misses the patients that never make it to the hospital,” said Anthony Strode, MHS, MS, an MD candidate at Meharry Medical College.
“That subset of victims who don’t make it to the hospital usually sustain the worst injuries and are referred directly to the medical examiner’s office. The magnitude of hidden mortality was shocking, with nearly half of all deaths occurring outside hospitals, meaning most clinicians rarely encounter these cases,” he said.
Strode, the first author of the report “Firearm-related deaths in Tennessee children”recently published in Trauma Surgery & Acute Care Open, said the findings further supported that firearm-related mortality is impacted by consistent, identifiable patterns that can be addressed directly. Strode developed the study in collaboration with Harold (Bo) Lovvorn, MD, professor of Pediatric Surgery at Monroe Carell and Strode’s mentor.
The pair partnered with the Tennessee Chief Medical Examiner’s (CME) Office under the leadership of Adele Lewis, MD, to design and execute the project.
“The work represents a sustained academic collaboration between Vanderbilt Health, Meharry and the Tennessee CME — an example of how mentorship and institutional partnership can advance rigorous research addressing urgent public health challenges,” said Lovvorn.
The report, a retrospective, cross-sectional analysis of the Tennessee CME database from 2012 to 2022, revealed 643 deaths of children ages 17 and younger who died from a firearm-related injury. The breakdown of cases was: 369 homicides, 202 suicides, 36 accidental, and 29 undetermined manner of death; seven were excluded for missing manner of death data.
The deeper dive also uncovered the need to drill down into specific neighborhoods that were the most impacted.
“The study revealed increasing homicide and suicide rates over time, demonstrating that pediatric firearm injury rates increase in a graded fashion with worsening neighborhood opportunity,” the authors wrote.
According to study investigators, several findings warrant explicit emphasis:
The hidden mortality captured through medical examiner data highlights a substantial burden that hospital-based studies often underrepresent or miss.
The stark racial divergence by manner of death, with homicide predominating among Black children and suicide among white children, underscores the need for relative prevention strategies rather than one-size-fits-all solutions.
The age concentration among older adolescents reinforces the urgency of intervention before and during mid-adolescence.
The graded relationship between worsening child opportunity and homicide risk is critical because it identifies modifiable environmental and structural factors rather than immutable individual traits.
Strode and colleagues hope the additional emphasis on firearm-related injuries will assist in efforts to recognize that these cases are worsening and should be labeled as a “true public health crisis.”
“The loss of a child to firearm violence has ripple effects that extend far beyond the individual family — affecting schools, neighborhoods, health care systems, and the social fabric of entire communities,” Strode said.
“The findings support the use of location-based prevention strategies and resource allocation to high-risk communities as a critical component of pediatric injury prevention and firearm policy efforts.”
