Toward reducing pediatric injuries from firearms: charting a legislative and regulatory course.

Each year in the United States, approximately 3000 children and adolescents younger than age 20 die as a result of homicides, suicides, and unintentional injuries from firearms. The young children, relatives, neighbors, and friends of the 30,000 adults killed by firearms each year in the United States are also affected by this uniquely American epidemic. It is estimated that half of all American homes contain 200 million firearms, including 60 million handguns. Increasingly, pediatricians are becoming involved in efforts to reduce the prevalence of injuries from firearms, as parent educators, experts on children and adolescents, and advocates in the political process. This commentary is intended to aid in the last of these roles. The advocacy goal is identified as reducing the accessibility of guns in the environments of children and adolescents. The pros and cons of 17 possible approaches--ranging from mandatory safety courses in schools to handgun bans--are presented. It is concluded that, while there is no perfect approach, many available approaches will help; there is every reason to be both bold and optimistic.

Reducing violent injuries: priorities for pediatrician advocacy.

A basic framework for developing an advocacy plan must systematically break down the large task of policy development implementation into manageable components. The basic framework described in detail in this paper includes three steps: Setting policy objectives by narrowing the scope of policy, by reviewing policy options, and by examining options against selected criteria. Developing strategies for educating the public and for approaching legislative/regulatory bodies. Evaluating the effectiveness of the advocacy action plan as a process and as an agent for change. To illustrate the variety of ways in which pediatricians can be involved in the policy process to reduce violent injuries among children and adolescents, we apply this systematic approach to three priority areas. Prohibiting the use of corporal punishment in schools is intended to curb the institutionalized legitimacy of violence that has been associated with future use of violence. Efforts to remove handguns from the environments of children and adolescents are aimed at reducing the numbers of firearm injuries inflicted upon and by minors. Comprehensive treatment of adolescent victims of assault is intended to decrease the reoccurrence of violent injuries.

Are toy guns too dangerous?

Toy guns with projectiles may injure young children. A study was undertaken to assess the danger posed by these toys and the regulations governing them. US Consumer Product Safety Commission (CPSC) data indicate that toy guns with projectiles cause relatively few injuries, mostly to young boys. The magnitude of the problem is smaller than that of nonpowder and powder firearms. Most often, toy gun injuries are to the face and eyes. Of the estimated 818 injuries in 1980 and 1981, 2.9% required hospitalization. More than 400 days were lost from school and work, and there were nearly 3,000 days of restricted activity due to these toy gun injuries. The hazard posed by toy guns with projectiles can be reduced through the legitimate regulatory authority of the Consumer Product Safety Commission with minor impact on retail cost, toy industry sales, and the play value of the toys. The yearly cost to consumers from increased regulation would probably be similar to the annual cost of the injuries. Regulation is warranted to protect young children who use these toys.

Pediatric emergencies in office practices: prevalence and office preparedness.

Because of a nationally apparent increased interest in emergency medical services for children and the need for a greater understanding of the relationship between office pediatric and emergency department care of children, a questionnaire was mailed to practitioners to (1) describe office physician involvement with emergent conditions, and (2) evaluate physician office preparedness for pediatric emergencies. Responses were received from 280 pediatricians and family practitioners, including information regarding the availability of equipment and medication, physician training, and practice characteristics. Of the responding physicians, 62% reported that they assessed in their offices more than one child each week who required hospitalization or urgent treatment. A preparedness score was developed and multiple regression analysis was used to investigate the relationship between this score and physician and practice characteristics. The mean overall preparedness score was 53.7 of a possible 156 (range 5 to 136, SD = 31.3). Characteristics related to this score were type of practice and advanced cardiac life support certification. Large multispecialty practices and practices with physicians trained in advanced cardiac life support tended to have better preparedness scores. Family practitioners tended to have more complete stock of medications than pediatricians. The data presented suggested that critically ill children who enter the medical system via the office setting may have a better than even chance of finding the office unprepared to treat the emergency: in fewer than one third of the offices in which it was reported that at least one patient was seen weekly with asthma, anaphylaxis, sickle cell vasoocclusive crisis, status epilepticus, and sepsis were they fully equipped to treat emergencies related to these conditions.(ABSTRACT TRUNCATED AT 250 WORDS)

Children's household exposure to guns: a pediatric practice-based survey.

Guns in the home are a factor in pediatric unintentional and intentional firearm injuries, yet the patterns of ownership and use are unclear. OBJECTIVES. To describe the prevalence of firearms in households containing children who go to pediatricians, the types of firearms owned, the purposes of such ownership, the conditions of firearm storage, and the social correlates of ownership. METHODS. Survey of parents attending 29 (urban, suburban, and rural) pediatric practices in Chicago, New Jersey, Houston, Utah, Georgia, Iowa, and South Carolina for well or sick child care during a 1-week study period. The main outcome measure was ownership of rifle/shotgun and/or handgun. RESULTS. Gun ownership was reported by 37% of 5233 respondent families: rifles (26%), handguns (17%), and powder firearm (32%). Ownership varied significantly across practices and geographical locations. Thirteen percent of 823 handguns and 1% of 1327 rifles were reported both unlocked and loaded. Recreation was the most common reason for both rifle (75%) and handgun (59%) ownership; 48% of handguns were kept for self-protection versus 21% of rifles. In logistic regression models, predictor variables for firearm ownership included rural area, single family dwelling, at least one adult male, and fewer preschool children (for handgun and rifle); mother with at least 12 years education (for handgun), and white mother (for rifle). CONCLUSIONS. The data presented suggest that US pediatricians routinely see children in families that own firearms, including a worrisome number that keep loaded and unlocked handguns. Until more detailed information becomes available, it is reasonable for pediatricians to be guided by these data, and so to counsel routinely about gun exposure.

Adapting the gang model: peer mentoring for violence prevention.

OBJECTIVES: This study assessed the effectiveness of an inner-city peer-mentoring program in modifying the attitudes and behaviors involving violence of preadolescent mentees. METHODS: In a case-matched cohort study involving 7- to 13-year-old children, 50 children enrolled in peer mentoring (case subjects) were compared with 75 control subjects. Case subjects were involved before enrollment in the community program in which the intervention occurred; control subjects lived in the same housing project and were matched with case subjects on age, sex, and census tract. A total of 19 community adolescents mentored the case subjects by designing and presenting violence prevention lessons. Two reliable self-report scales, Determining our Viewpoints of Violent Events and Normative Beliefs About Aggression Scale, were used to measure attitudinal change. Teachers completed the Revised Behavior Problem Checklist to assess changes in behavior. RESULTS: At baseline, the survey scores of the case and control subjects were not different. After the intervention period, the case scores indicated less support for violence than the control scores. Case behavior scores did not change, but control behavior scores worsened. CONCLUSIONS: The data suggest that peer mentoring for younger children may be an important component of efforts to reduce youth violence. A larger multisite trial is warranted.

Cervical spine fractures sustained by young children in forward-facing car seats.

Child passenger safety restraint laws have reduced the number of children killed or injured in motor vehicle accidents in the past few years. However, the increased used of child safety seats has brought with it an increase in the misuse of these devices. High cervical spine injuries sustained by five children less than 2 years of age while in forward-facing car seats are described. In the cases of three children, the care safety seat use was correct. Misuse of car seats and anatomic and biomechanical factors in the cervical spines of infants and young children appear to have contributed to the occurrence of these previously rare injuries. Like seat belts, car safety seats are now a factor in child passenger injury characteristics, and therefore, car safety seat design merits reevaluation. In light of this development, public and parent education by health care professionals concerning the correct use of car safety seats is necessary.

Family history evaluation as a predictive screen for childhood hypercholesterolemia. Pediatric Practice Research Group.

A study was conducted to evaluate the efficacy of family history factors as screening criteria for childhood hypercholesterolemia. When they were seen for routine care at one of eight office practices, 1005 prepubertal children underwent random serum cholesterol determinations. Parental and grandparental histories of cardiovascular risk factors and atherosclerotic complications prior to 55 years of age were also obtained. Of the initial group, 274 children had total cholesterol levels greater than or equal to 175 mg/dL, and 175 of these children returned for retesting after an overnight fast. A total of 88 children were found to have low-density lipoprotein-cholesterol (LDL-C) values greater than or equal to 90th percentile for age and sex. Maternal and paternal histories of hypercholesterolemia were significantly associated with elevated LDL-C (odds ratio = 7.3 and 2.9, respectively), but had extremely low sensitivities (0.09, 0.15) despite modest positive predictive values (0.42, 0.22). Grandparental histories of sudden death, peripheral vascular disease, and gout were associated with elevated LDL-C, but sensitivities and positive predictive values for all of these factors were less than 0.22. Family history factors most commonly recommended as criteria for cholesterol screening in children did not identify half of all the children with elevated LDL-C and did not selectively identify the most severely affected children. Adding information concerning the presence of childhood obesity did not result in appreciable improvement in LDL-C detection beyond that achieved by family history factors alone. It was concluded that if thorough identification of young children with elevated LDL-C is desired, inclusive population screening rather than a family history-based strategy would be the most effective approach.

Childhood injury prevention counseling in primary care settings: a critical review of the literature.

OBJECTIVES: The American Academy of Pediatrics (AAP) believes that health education, through office-based counseling, can contribute to childhood injury prevention. This report presents the results of a critical review of the scientific literature on the effectiveness of primary care-based counseling to prevent childhood unintentional injury. METHODS: A panel selected from the AAP Committee and the AAP Section on Injury and Poison Prevention searched the English-language scientific literature for all articles about childhood unintentional injury prevention counseling. A standardized format was developed to record data on each study. Two members of the panel independently reviewed each article. Articles that were original reports and in which unintentional injury prevention counseling took place in a primary care setting were included. Articles were encoded and analyzed by computer and then grouped by quality of evidence using the US Preventive Services Task Force (USPSTF) method of categorizing results of medical care evaluation. Articles were rated by strength of study design in order to compare studies within each USPSTF group. RESULTS: Twenty articles met the criteria for inclusion. Of these, 18 showed positive effects of injury prevention counseling including five randomized/controlled, 10 non-randomized/controlled, two multiple time series, and one descriptive study. In 15 of the positive studies, physicians performed the counseling. Positive outcomes as measured by increased knowledge, improved behavior, or decreased injury occurrence were reported for both motor vehicle and non-motor vehicle injuries. CONCLUSIONS: The literature review supports the recommendation of the AAP to include injury prevention counseling as part of routine health supervision. This recommendation has implications for health care reimbursement and care content.

Foreign body ingestions in children: risk of complication varies with site of initial health care contact. Pediatric Practice Research Group.

Current recommendations for the management of pediatric foreign body ingestions are based on studies of patients cared for at tertiary care hospitals; they call for aggressive evaluation because of a high incidence of complications. Two hundred forty-four children with suspected foreign body ingestions were prospectively followed to analyze adverse outcomes, ie, procedures, complications, and hospitalizations. Patient enrollment into the study was from three sources: (1) patients who referred themselves to a tertiary pediatric emergency department, (2) patients referred to the same tertiary pediatric emergency department after an initial evaluation by another hospital or physician, and (3) patients who reported their foreign body ingestions to a private pediatric practitioner participating in the study. Most children were well toddlers in normal circumstances, under parent supervision at the time of ingestion. Coins were the most common item ingested (46%). Procedures were done in 53 (24%) of 221 patients and complications occurred in 48 (22%) of 221. Complications were higher in patients referred to the emergency department (63%) than in emergency department self-referred patients (13%) or private practice patients (7%) (chi 2, P < .01). These findings demonstrate the risk of drawing conclusions regarding a universal standard of care from studies involving only hospital-based patients.

Psychosocial factors in childhood pedestrian injury: a matched case-control study. Kid's'n'Cars Team.

HYPOTHESIS: Psychosocial factors--such as hyperactivity and low family cohesion--contribute to the risk for child pedestrian injury (PI), even after controlling for known demographic risk factors. PARTICIPANTS: Urban PI victims aged 5 to 12 years were recruited from one large, urban pediatric trauma center in a large city. One hundred twenty-eight cases were matched to uninjured children on age, sex, race, location of residence, and parental education. Among matched cases: 70% were male, 41% were black, 33% were Hispanic, and 66% of the mothers had a high school education or less. RESEARCH DESIGN AND MEASUREMENTS: Case-control comparisons on 19 psychosocial variables drawn from interviews and standardized tests, using one-tailed matched-pairs t tests and conditional logistic regression analyses. RESULTS: Cases had higher reported physical quotient [PQ] (P = .01), self-help quotient (P = .04), and family stress (P = .02), and lower family supportiveness (P = .03). Multivariate analyses confirmed that PQ was higher in cases (10-point increase: odds ratio (OR) = 1.32 [90% confidence interval (CI) 1.01-1.76], that stress was higher in cases (1 log increase: OR 2.13, [1.26-3.61]), and that cases had lower family supportiveness (25-point decrease: OR 1.43 [1.25-1.63]). It also identified household crowding as a factor for non-black cases (OR for increase of 0.25 people per room: 2.18, [1.31-3.62]). CONCLUSION: Even when controlling for demographic risk, several family factors and one child factor place children at risk for PI. Clinicians may choose to use these as indicators for injury prevention counseling. Research on family effects may help clarify means to protect children who are demographically at risk for PI.

Practice-based research: opportunities and obstacles.

Renewed interest in practice-based research reflects growing realization of the limitations of research from a hospital perspective. Practice-based pediatric research promises to broaden the range and severity of conditions commonly studied, to enhance the study of the natural history of disease and of normal development, to provide normal controls and standards, and to facilitate recruitment of adequate sample sizes. Cohort, incidence, and health services research will be promoted by the development of patients registries. The Chicago area Pediatric Practice Research Group is a research consortium of 81 practitioners in 27 office practices. Formed in 1984, it receives logistic and financial support from Children's Memorial Hospital, with which it is affiliated. The Pediatric Practice Research Group has undertaken six studies, most with outside funding. During these studies, some unifying characteristics of practice-based research have emerged. These include the need to tailor study protocols to individual practice characteristics and routines and the critical role of office staff in the conduct of research. Features can be identified that make specific studies more or less intrusive into office functioning. It has proved feasible to obtain data of high quality and reproducibility despite geographically scattered data collection sites. This review of Pediatric Practice Research Group activities and experience is intended to open an exchange of ideas with others interested in practice-based research.

Standard definitions for childhood injury research: excerpts of a conference report.

As awareness of the huge human and other costs of injury has grown, research has expanded. There has not been any standard set of terminology for use in this research. As a result, research and surveillance data are too often difficult to interpret and compare. To overcome this impediment to gains in needed knowledge about childhood injuries, a conference was held in 1989 by the National Institute of Child Health and Human Development to develop a set of standard definitions. The full conference report is available from the US Government Printing Office. This report presents excerpts, emphasizing those--core--variables likely to be of use to the largest number of investigators. The conference recommendations presented address cross-cutting factors (age, race/ethnicity, location, socioeconomic status, and biopsychosocial development), effect modifiers (exposure, medical risk factors, substance abuse, time, injury severity, and social risk factors), and specific injuries (motor vehicle injuries, central nervous system injuries, falls, fire/burns, drowning, and violence). It is expected that childhood injury investigators will strive to meet the recommendations of this conference and that use of these definitions will lead to improvements in research and, ultimately, to revision of the definitions.

Behavioral and emotional problems among preschool children in pediatric primary care: prevalence and pediatricians' recognition. Pediatric Practice Research Group.

This study examined how well private-practice pediatricians can identify emotional/behavioral problems among preschool children. Children aged 2 through 5 (N = 3876) were screened during a visit to 1 of 68 pediatricians who rendered an opinion about the presence of emotional/behavioral problems. Subsequently, children who scored above the 90th percentile for behavioral problems on the Child Behavior Checklist, along with children matched on age, sex, and race who had screened low, were invited for an intensive second-stage evaluation. There were 495 mothers and children who participated in that evaluation, which included a behavioral questionnaire, maternal interview, play observation, and developmental testing. Two PhD-level clinical child psychologists rendered independent opinions about the presence of an emotional/behavioral disorder. The psychologists identified significantly higher rates of problems overall--13.0% when the criterion was independent agreement that the child had an emotional/behavioral problem and a regular psychiatric diagnosis was assigned, vs 8.7% based on pediatricians' ratings. Prevalence rates based on psychologists' independent ratings were significantly higher than pediatricians' for both sexes, 4- through 5-year-olds, and whites, but not for 2- through 3-year-olds, African-Americans, and all minorities. Prevalence rates based on psychologists' ratings were significantly higher than the pediatricians' for all subgroups when V-code diagnoses were included in the psychologists' ratings. Overall, pediatricians' sensitivity was 20.5%, and specificity was 92.7%. At least 51.7% of the children who had an emotional/behavioral problem based on the psychologist's independent agreement had not received counseling, medication, or a mental health referral from the pediatrician.(ABSTRACT TRUNCATED AT 250 WORDS)

Restructuring asthma care in a hospital setting to improve outcomes.

STUDY OBJECTIVES: To restructure asthma care as the pilot program in hospital-wide redesign aimed at providing better and more standardized care. We chose asthma care to begin our reorganization because it is the highest-volume diagnosis at our hospital and it involves a broad spectrum of services. DESIGN: Key elements of our restructuring included the following: (1) establishing a pulmonary unit with expanded bed capacity from 8 to 22 beds for asthma patients; (2) standardized treatment protocols; (3) availability of direct admission by primary care physicians who maintained management of their patients with the option of consultation with a specialist; and (4) use of case managers who helped patients and their families overcome obstacles to optimum care. SETTING: A hospital serving a high proportion of Medicaid patients. PATIENTS/PARTICIPANTS: Children with asthma and their families. INTERVENTIONS: Standardized care for asthma; use of case managers to facilitate adherence to treatment. RESULTS: With the restructured asthma care program, parent satisfaction with treatment was sustained; the average length of stay and use of the emergency department (ED) were reduced; observation unit use increased; and there were fewer readmissions to both the inpatient unit and the ED. CONCLUSIONS: We conclude that an inner-city hospital can provide optimum care for asthma patients by standardizing treatment, aggregating asthma patients in one location, and providing education and follow-up through the use of case managers. The protocol shifts some costs from expensive services such as the pediatric ICU and the ED to less costly case management and outreach personnel. In the long run, this allocation of resources should help to lower costs as well as improve quality of care.

Obesity in preschool and school-age children. Treatment early and often may be best.

OBJECTIVE: To determine if timing and frequency of interventions affect the outcome of treatment of obesity in pediatric patients. DESIGN: Retrospective chart review; comparison of subgroups defined by age and frequency of visits. SETTING: A nutrition evaluation clinic, an outpatient referred care clinic at a metropolitan hospital. PARTICIPANTS: All 93 obese children, aged 1 to 10 years, seen within 1 year and with one or more subsequent visits in the next year. Obesity was defined as greater than 120% ideal body weight for height age (IBWH). Mean percent IBWH was 171% (median, 199%; range, 127% to 251%). INTERVENTIONS: (1) Initial visit. Comprehensive history and physical examination, by physician, registered dietician, and licensed clinical social worker; design of individualized care plan, including prescribed frequency and size of meals and snacks; and type, frequency, and duration of exercise. (2) Subsequent visits (after 1 month, then with frequency tailored to need). Review of progress, adjustment of energy intake and expenditure; management of biopsychosocial obstacles to needed changes. MEASUREMENTS/MAIN RESULTS: Four patient groups were defined by two variables: age (preschool vs school-age children) and frequency of visits in 1 year (two to three vs four or more). Groups were compared on change in mean percent IBWH and on mean change in percent IBWH. All groups showed significant change in percent IBWH (P < or = .040 for school-age children, P < or = .012 for preschool children). For all visits, the mean change was more than twice as great for preschool as for school-age children (4.7 +/- 5.4 vs 1.9 +/- 4.8, P = .027). CONCLUSIONS: (1) The most successful treatment of pre-adolescent obesity may be in preschool children with frequent visits. (2) A randomized trial is warranted to test this possibility. (3) Many of the techniques used to treat early obesity can be adapted for prevention and intervention in early obesity during the preschool years, and this is the preferred approach.

Gun storage patterns in US homes with children. A pediatric practice-based survey. Pediatric Practice Research Group.

OBJECTIVE: To describe gun storage patterns in gun-owning families with children. DESIGN: Survey of parents attending participating offices. SETTING: Twenty-nine urban, suburban, and rural pediatric practices in Chicago, Ill; New Jersey; Houston, Tex; Utah; Georgia; Iowa; and South Carolina. SUBJECTS: Parents of children attending offices for well- or sick-child care. SELECTION PROCEDURE: Consecutive sample of families seen during the 1-week study period. MEASUREMENTS AND ANALYSES: Logistic regression models were constructed to identify sociodemographic factors associated with keeping guns loaded. RESULTS: Of 5233 surveys, 1682 (32%) indicated ownership of at least one powder firearm. Of the gun-owning families, 61% reported at least one gun unlocked, and 15% reported at least one gun loaded. Rifles were more often stored unlocked (62% rifles vs 52% handguns, P<.001, z=4.60; two-proportion z-test), but handguns were more likely to be kept loaded (3% rifles vs 27% handguns, P<.001). Seven percent of gun-owning families reported at least one gun unlocked and loaded (handguns 12 times more likely than rifles). Only 30% of households reported all guns stored unloaded and locked up. The best-fit logistic regression model for keeping a gun loaded identified four predictor variables: owning a gun for self-protection, work-related gun ownership, owning a handgun, and no men in the home. CONCLUSIONS: Because most gun-owning families store guns loaded, unlocked, or both, anticipatory guidance should address gun storage in all such families. Interventions designed to alter the way work guns are dealt with after work, and to provide safe and effective means of self-protection might affect these storage patterns.

Children's exposure to violence in an urban setting.

OBJECTIVE: To assess the exposure to violence of a representative sample of children living in an inner-city public housing development. DESIGN: Self-report survey. SETTING: Chicago public housing development that covers 4 census tracts; population, 95% African American, 75% below the poverty level. PARTICIPANTS: One hundred forty-six African American youth, aged 7 through 13 years, completed the survey; 53% were male, mean and median ages, 11 years. Seventy-two children (case subjects) are involved in a community-based health and recreation program. They completed the survey prior to participating in a peer-mentoring violence prevention curriculum. The other 74 children (control subjects) were recruited by a community member going door to door. Control subjects were matched to case subjects for age, sex, and census tract. RESULTS: The case and control subjects were similar in their exposure to violence and so were grouped for analysis. Of the 146 children, 42% had seen someone shot and 37% had seen someone stabbed; 21% lived with someone who had been shot and 16% lived with someone who had been stabbed. Forty-seven percent of the girls and 55% of the boys had witnessed violence (P > .25). Almost all subjects (90%) felt safe at home. Two thirds (65%) of the children were not afraid to play outside, but almost half (43%) worried about getting hurt at school. CONCLUSIONS: These data, which describe a representative sample of children from an inner-city housing project, confirm the results from older clinic- and school-based convenience samples. In this low-income community, children are frequently exposed to deadly violence. In contrast with other reports, girls here are not spared.

Pediatricians' experience with and attitudes toward firearms. Results of a national survey.

BACKGROUND: In 1992, the American Academy of Pediatrics issued statements calling for aggressive actions to reduce the dangers of firearms to children and adolescents, including removing handguns from homes with children and working toward a ban on the manufacture, sale, and private possession of handguns. OBJECTIVES: To determine the extent to which pediatricians support these positions against firearms and to describe the demographic and practice determinants of their views. INTERVENTIONS: In 1994, data were obtained from 982 pediatricians involved in direct patient care in a national, random-sample survey of American Academy of Pediatrics members (response rate, 68.9%). This article focuses on 4 areas: (1) recent experience treating gun injuries, (2) attitudes toward legislation to reduce the availability of guns, (3) attitudes toward gun safety counseling by pediatricians, and (4) current gun safety counseling practices. Wherever possible, chi 2 and t tests were used to compare responses to a similar 1988 survey of American Academy of Pediatrics members. Logistic regression was used to examine the multivariate relationships between the outcome variables and demographic and practice characteristics of the responding pediatricians. RESULTS: Almost 1 in 5 pediatricians treated a gun injury in the past 12 months. In 1988, 86.5% of pediatricians supported restricting the sale and possession of handguns; in 1994, support for such legislation increased to 92.5% (P < .01). Also in 1994, 76% supported banning the sale or possession of handguns. Most respondents (82%) believe anticipatory guidance on firearm safety can reduce injury and death; 95% support asking parents to unload and lock firearms, and 66% support encouraging parents to remove handguns from the home. Current counseling practices lag behind attitudinal support of anticipatory guidance on firearm safety (eg, half of respondents report never identifying families with firearms in the home). Demographic factors as well as professional experience were found to affect attitudes (eg, women, older pediatricians, and those who did not own guns were more likely to support gun-control legislation; and pediatricians who have recently treated gun injuries and those practicing in the inner city are more likely to counsel families about gun safety). CONCLUSIONS: The data indicate that practicing pediatrician overwhelmingly agree that handguns in the home are hazardous and that steps should be taken to reduce this hazard through legislation and patient counseling. They support the policies on firearms and handguns of the American Academy of Pediatrics; most support even the strongest recommendation, which is a ban on handguns. A substantial lag between attitudes that favor counseling about firearms and reported practices indicates the need for further training in and evaluation of firearm counseling in office settings.

Children's bicycle helmet attitudes and use. Association with parental rules. The Pediatric Practice Research Group.

BACKGROUND: Previous studies have assessed the attitudes of parents and children toward bicycle helmet ownership and use in various settings, but they have not addressed the role of parental rules in promoting bicycle helmet use by children. OBJECTIVES: To further explore the attitudes of parents and children at pediatric practices toward bicycle helmet ownership and use by children and to assess the role of parental rules in promoting bicycle helmet use by children. DESIGN: One hundred sixty-nine 5- to 14-year-old children who owned bicycles and their parents were surveyed during well-child visits at 5 general pediatric practices in the Chicago, Ill, area. One hundred twenty-nine families were represented. Of the children, 60% were aged 5 to 9 years, and 50% were girls. RESULTS: Forty-eight children (28%) reported helmet ownership. Of the helmet owners, 21 (45%) reported helmet use; thus, the overall percentage of helmet use was 12%. Helmet ownership by children was significantly (P < .05) related to parental characteristics: educational level, race, perceived effectiveness of bicycle helmets, seat belt use, and parental helmet ownership. The most common reasons parents gave for lack of helmet ownership by children were "never thought about purchasing" a helmet (35%), "never got around to purchasing" a helmet (29%), "child wouldn't wear it anyway" (26%), and the bicycle helmet was "too expensive" (16%). Only 33% of the parents reported hearing about helmets from their children's pediatrician, but 40% of these parents regarded pediatricians as their most important information source. Of the children who did not own helmets, 64% said they would wear a bicycle helmet if they had one, a more frequent comment for 5- to 9-year-old children than 10- to 14-year-old children (76% vs 49%, P < .01). The most common reasons for not wearing a helmet among owners were as follows: forgot or lost it and not needed. The most common reasons for not wearing a helmet among nonowners were as follows: uncomfortable and appearance or perception of others. Children who owned helmets and whose parents had a strict rule about wearing helmets were more likely to always wear their helmets than helmet owners whose parents had a partial rule or no rule (88% vs 19%, P < .001). CONCLUSIONS: Parental rules are associated with bicycle helmet use by children. Pediatricians may increase helmet use rates by promoting strict parental helmet rules as part of their anticipatory guidance regarding bicycle safety. More research about the effectiveness of this strategy is needed.