Pediatric Annals

Healthy Baby/Healthy Child 

Fireworks-Related Injury in Children

M. Denise Dowd, MD, MPH

Abstract

Many children are attracted to the color, noise, light, and excitement generated by fireworks. Both home and public displays of fireworks are a festive part of American culture, enjoyed on holidays, during sporting events, and on a variety of other occasions. However, fireworks pose a risk of serious injury to children and youth. Each year, thousands of children sustain major and minor injuries due to fireworks, with many resulting in permanent disability. Regulations concerning private sales and use of fireworks vary greatly from state to state, so children's exposure varies geographically. Fortunately, by leaving fireworks to professionals, injuries to both adults and children can be prevented. [Pediatr Ann. 2018;47(6):e227–e229.]

Abstract

Many children are attracted to the color, noise, light, and excitement generated by fireworks. Both home and public displays of fireworks are a festive part of American culture, enjoyed on holidays, during sporting events, and on a variety of other occasions. However, fireworks pose a risk of serious injury to children and youth. Each year, thousands of children sustain major and minor injuries due to fireworks, with many resulting in permanent disability. Regulations concerning private sales and use of fireworks vary greatly from state to state, so children's exposure varies geographically. Fortunately, by leaving fireworks to professionals, injuries to both adults and children can be prevented. [Pediatr Ann. 2018;47(6):e227–e229.]

Each year in the United States, an average of seven people die of injuries related to fireworks.1 In 2016, the Consumer Product Safety Commission (CPSC) reported four deaths and an estimated 11,000 nonfatal injuries related to fireworks.1 Approximately one-third of those injuries occurred in children younger than age 15 years, and three-quarters of the injured were boys.1 Reflecting developmental vulnerabilities, the highest rates of injuries were documented in young adults age 20 to 24 years (4.9 injuries/100,000 people), followed by children younger than age 5 years (4.4 injuries/100,000 people).1 The annual rate of injuries decreased 30% in a 25-year period between 1990 and 2014.2 In a study examining pediatric fireworks injuries, Witsaman et al.3 found that users made up approximately one-half of all those injured, bystanders made up 22%, and the remainder were undetermined.

Almost all people (92%) requiring emergency department (ED) care for fireworks-related injury are treated and released, whereas the remainder are admitted to the hospital;1 however, many injuries are unreported and are treated at home. Fireworks injuries are costly given the frequent need for burn and other specialized care (eg, plastic surgery and ophthalmology). In one study, the average charge for a firework injury treated in the ED was $1,256.4 In addition to heath care costs, millions of dollars in property damage are caused each year by fireworks. A 2016 report by the National Fire Prevention Association estimated that US fire departments responded to 15,600 fires caused by fireworks in 2013, resulting in $21 million in direct property damage.5

Clinical Aspects

According to data from the National Electronic Injury Surveillance System of the CPSC, most injuries (69%) treated in EDs related to fireworks are burns, and the most common body parts injured are hands and fingers, accounting for one-third of all injuries.1 Injuries to the head, face, and ears comprise approximately 20% of all injuries.1 Injuries to eyes, primarily from projectiles, make up approximately 9%.1 Kuhn et al.6 reported that 80% of eye injuries are due to bottle rockets. Injuries to the eyes are particularly concerning as there are a significant number that result in permanent visual loss, with one study reporting that one-third of all such eye injuries result in permanent blindness.7

Firework Type and Use

Fireworks sold to the public for recreational use are currently termed “consumer fireworks” or 1.4G fireworks, and those sold to and used by professionals are termed “display fireworks” or 1.3G fireworks. The CPSC defines what fireworks can be considered consumer fireworks. Currently, consumer fireworks are limited to those containing up to 500 g of material, and firecrackers may have up to 50 mg of flash powder.8 All fireworks are classified as hazardous by the Federal Hazardous Substances Act (FHSA).9 The most dangerous types of fireworks are banned for sale and use by consumers under the FHSA. These fireworks include M-80s, large reloadable mortar shells, cherry bombs, aerial bombs, and large firecrackers containing more than 50 mg of powder.8 Under the FHSA, reloadable shells are limited to 1.75 inches in diameter, and shells in prefused tubes are limited to 2 inches in diameter.8 Any fireworks that exceed these limits are not considered consumer fireworks and require a license issued by the Bureau of Alcohol, Tobacco, Firearms, and Explosives for purchase. “Safe and sane” is a slogan used in some states to indicate which fireworks can be sold in that state but it is not a true indication of any inherent safety. Sales of fireworks in the US increased from 29 million pounds in 1976 to 268 million pounds in 2016, for a total revenue of nearly $900 million.10

The relationship between type of firework and risk and severity of injury has not been well studied in the past. Sandvall et al.11 explored this question using data from a level I trauma center. The study was limited to people with injuries severe enough to require operative intervention and/or admission to an inpatient unit, so the results cannot be generalized to those with more minor injuries. Of the 294 patients included, the most common type of firework causing injury was legal shells and mortars, which were associated with 39% of all injuries. The next most common type of device was homemade fireworks, accounting for 25% of all injuries.11 The investigators found that shells/mortars resulted in more permanent impairment than other injuries, largely as a result of more eye (visual loss) and hand (amputation) injuries than other devices.11 In this study, 69% of eye injuries resulted in partial or complete visual loss and 18% required enucleation.11 Sparklers are particularly hazardous to small children because they may be considered “safe” by parents who allow children to handle them despite the fact they burn at temperatures of approximately 2,000°F.12 Even after sparklers have finished burning they remain hot and can cause serious burns from handling or stepping on them.

In addition to age and gender, misuse of fireworks is a major cause of injuries. Each year, the CPSC conducts in-depth investigations of incidents occurring from mid-June to mid-July, the time of greatest use and, therefore, risk. Circumstances of the injuries are investigated and hazard patterns are described. In 2016, the two major categories were (1) malfunction (67%), such as tip overs, short fuses, and errant flight paths; and (2) misuse (30%), such as holding fireworks in hands, setting off fireworks improperly, and “mischief.”1

Prevention

Like any other potentially injury-causing product, the best approach to fireworks injury prevention involves separating the hazard (that which causes injury) from the person who may potentially be injured. Fireworks injury prevention has traditionally taken two approaches: legal regulation and education.

Laws regulating the sale and use of fireworks are a key component of injury prevention because they reduce exposure. Federal statues are fairly narrow in scope, so most regulation occurs at the state or local level. State and local laws vary widely on the sale and use of fireworks. Regulations vary on selling season, age of purchase, sale to non-state residents, and type of firework allowed for sale. In the US, laws also vary greatly from state to state and even county to county. Two states (Delaware and Massachusetts) ban the sale and use of all consumer fireworks, including novelties and sparklers.13 Evidence suggests that states with restricted sales have significantly lower rates of firework injuries.14

The American Academy of Pediatrics15 (AAP) and SAFE Kids Worldwide16 recommend leaving fireworks to the professionals as the best way to prevent injuries in both children and adults. A great number of communities both large and small have public displays of fireworks on the Fourth of July and other major holidays. If families do make the choice to use fireworks, it is highly advisable that they use those that are legal in their area. Small children should not be allowed to handle any fireworks, including sparklers. Safe behavior while handling fireworks is essential. Other pieces of advice include never trying to re-light a “dud” (ie, a firework that did not explode), and not using old fireworks or those that are obviously damaged. When using fireworks, it is advisable to not wear loose clothing, and to not light fireworks near dry brush/leaves or flammable substances. It is also important to have a bucket of water or hose and a fire extinguisher nearby. Other safety precautions include lighting only one firework at a time, never lighting them indoors, constant adult supervision, reading all directions, and never throwing or shooting fireworks into metal or glass containers.16

The AAP's policy statement on fireworks injury prevention concludes with five key recommendations: (1) pediatricians should counsel the families they serve to choose public displays and not use fireworks at home; (2) prohibition of sales of fireworks to the general public; (3) banning private use of fireworks; (4) surveillance and reporting of fireworks-related injuries; and (5) additional research in the factors related to injury by fireworks.15

References

  1. Tu YUS Consumer Product Safety Commission. 2016 Fireworks annual report: fireworks-related deaths and emergency department-treated injuries during 2016. https://www.cpsc.gov/s3fs-public/Fireworks_Report_2016.pdf?t.YHKjE9bFiabmirA.4NJJST.5SUWIQJ. Accessed May 22, 2018.
  2. Billock RM, Chounthirath T, Smith GA. Pediatric firework-related injuries presenting to United States emergency departments, 1990–2014. Clin Pediatr (Phila). 2017;l56(6):535–544. doi:. doi:10.1177/0009922816664063 [CrossRef]
  3. Witsaman RJ, Comstock RD, Smith GA. Pediatric fireworks related injuries in the United States: 1990–2003. Pediatrics. 2006;118:296–303. doi:. doi:10.1542/peds.2006-0790 [CrossRef]
  4. Canner JK, Haider AH, Selvarajah S, et al. US emergency department visits for fireworks injuries, 2006–2010. J Surg Res. 2014;190:305–311. doi:. doi:10.1016/j.jss.2014.03.066 [CrossRef]
  5. Ahrens MNational Fire Protection Association. Fireworks. https://www.nfpa.org/-/media/Files/News-and-Research/Fire-statistics/Major-Causes/osfireworks.ashx?la=en. Accessed May 22, 2018.
  6. Kuhn F, Morris R, Witherspoon CD, et al. Serious fireworks-related eye injuries. Ophthalmic Epidemiol. 2000;7:139–148. doi:10.1076/0928-6586(200006)721-ZFT139 [CrossRef]
  7. Wilson RS. Ocular fireworks injuries and blinds: an analysis of 154 cases and a three-state survey comparing the effectiveness of model law regulation. Ophthalmology. 1982;89:291–297. doi:10.1016/S0161-6420(82)34789-2 [CrossRef]
  8. Consumer Product Safety Commission. Fireworks. Publication #12. https://www.cpsc.gov/s3fs-public/2016%20Fireworks%20Fact%20Sheet_0.pdf. Accessed May 22, 2018.
  9. United States Consumer Product Safety Commission. Federal hazardous substances (FHSA) requirements. https://www.cpsc.gov/Business--Manufacturing/Business-Education/Business-Guidance/FHSA-Requirements. Accessed May 29, 2018.
  10. American Pyrotechnics Association. U.S. fireworks industry revenue figures breakdown by industry segment, 1998–2016. http://www.americanpyro.com/assets/docs/FactsandFigures/fireworks%20revenue%20by%20industry%20segment%201998-16.pdf. Accessed May 29, 2018.
  11. Sandvall BK, Jacobson BS, Miller EA, et al. Fireworks type, injury pattern, and permanent impairment following severe fireworks-related injuries. Am J Emerg Med. 2017;35:1469–1473. doi:. doi:10.1016/j.ajem.2017.04.053 [CrossRef]
  12. United States Consumer Product Safety Commission. Fireworks information center. https://www.cpsc.gov/Safety-Education/Safety-Education-Centers/Fireworks. Accessed May 29, 2018.
  13. American Pyrotechnics Association. Directory of state laws. http://www.americanpyro.com/state-law-directory. Accessed May 29, 2018.
  14. Berger LR, Kalishman S, Rivara FP. Injuries from fireworks. Pediatrics. 1985;75:877–882.
  15. American Academy of Pediatrics: Committee on Injury and Poison Prevention. Fireworks-related injuries to children. Pediatrics. 2001;108:190–191. doi:10.1542/peds.108.1.190 [CrossRef]
  16. SAFE Kids. Fireworks safety tips. https://www.safekids.org/tip/fireworks-safety-tips. Accessed May 22, 2018.
Authors

M. Denise Dowd, MD, MPH

M. Denise Dowd, MD, MPH, is the Associate Director, Office for Faculty Development, and the Medical Director, Community Programs, Department of Social Work, Children's Mercy Hospital; and a Professor of Pediatrics, University of Missouri-Kansas City School of Medicine.

Address correspondence to M. Denise Dowd, MD, MPH, via email: ddowd@cmh.edu.

Disclosure: The author has no relevant financial relationships to disclose.

10.3928/19382359-20180522-02

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