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Article

Pediatric Trauma Trends Before and After Recreational Cannabis Legalization in Nevada: A Retrospective Repeated Cross-Sectional Study

by
Jenna Serr
1,
Vidhani Goel
2,3,
Roberto Sagaribay
2,
Kavita Batra
2,4,* and
Ami P. Shah
1,5,*
1
Pediatric Emergency Medicine, Kirk Kerkorian School of Medicine at UNLV, Las Vegas, NV 89102, USA
2
Office of Research, Kirk Kerkorian School of Medicine at UNLV, Las Vegas, NV 89106, USA
3
School of Public Health, University of Nevada, Las Vegas, NV 89154, USA
4
Department of Medical Education, Kirk Kerkorian School of Medicine at UNLV, Las Vegas, NV 89154, USA
5
Pediatric Emergency Medicine, University Medical Center of Southern Nevada, Las Vegas, NV 89102, USA
*
Authors to whom correspondence should be addressed.
Children 2026, 13(5), 681; https://doi.org/10.3390/children13050681 (registering DOI)
Submission received: 22 April 2026 / Revised: 14 May 2026 / Accepted: 14 May 2026 / Published: 15 May 2026
(This article belongs to the Special Issue Pediatric Emergency Department Visits: Challenges, Innovation and Best Practices in the Care of Children)
Versions Notes

Highlights

What are the main findings?
  • Overall pediatric trauma incidence remained stable, with post-legalization shifts toward more motor vehicle-related injuries and fewer pedestrian injuries.
  • ICU utilization patterns changed, with fewer admissions but longer ICU lengths of stay, alongside shifts in socioeconomic and insurance profiles.
What are the implications of the main findings?
  • Cannabis legalization was not associated with increased pediatric trauma rates, but may be linked to changes in injury patterns and severity.
  • Ongoing surveillance and targeted, equity-focused injury prevention strategies are needed, particularly for motor vehicle-related injuries.

Abstract

Background: Cannabis legalization has raised concerns regarding its potential influence on injury patterns, particularly among children. However, evidence on pediatric trauma remains limited. Objective: To examine trends in pediatric trauma incidence, injury mechanisms, healthcare utilization, and socioeconomic characteristics before and after recreational cannabis legalization in Nevada. Methods: A retrospective repeated cross-sectional study of trauma registry data was conducted using pediatric trauma activations recorded between 2013 and 2023. Incidence rates per 100,000 population were calculated using census data. Pre-legalization (2013–2016) and post-legalization (2017–2023) periods were compared using incidence rate ratios (IRRs) and bivariate tests. Socioeconomic status was assessed using the Distressed Communities Index (DCI). Results: Among 1772 pediatric trauma activations, overall incidence remained stable (21.6 vs. 21.4 per 100,000; IRR = 0.99, 95% CI: 0.90–1.09). Post-legalization, motor vehicle collision-related injuries increased (49.3% vs. 41.3%, p = 0.002), while pedestrian injuries declined (25.5% vs. 32.4%). ICU admissions decreased (19.5% vs. 27.3%, p < 0.001), although ICU length of stay increased (5.9 vs. 4.0 days, p = 0.005). A higher proportion of patients originated from less distressed communities post-legalization (p = 0.021), alongside shifts in insurance coverage (p < 0.001). Conclusions: Pediatric trauma incidence remained stable following cannabis legalization in Nevada; however, shifts in injury mechanisms, healthcare utilization, and socioeconomic patterns were observed. Because cannabis legalization was assessed at the population level and individual cannabis exposure was not directly measured, findings should be interpreted as temporal associations rather than causal effects. These findings highlight the need for ongoing surveillance and targeted, equity-focused injury prevention strategies.

1. Introduction

Trauma continues to be the leading cause of morbidity and mortality in the pediatric population after one year of age, and particularly in the teenage years [1,2,3]. Research has established that the use of psychoactive substances decreases sensory perception, increases reaction times, and affects coordination, thus increasing the risk of injury and motor vehicle collisions [4,5,6,7,8,9]. From a motor vehicle collision (MVC) perspective, a positive correlation between alcohol use and impairment in driving has been well documented. Accordingly, various safety laws are in place regarding Driving Under the Influence (DUI) [10]. After alcohol, cannabis is the most commonly detected substance in MVCs.
Among pediatric trauma mechanisms, MVCs, pedestrian injuries, and bicycle-related incidents remain major contributors to morbidity and mortality, particularly among school-aged children and adolescents [1,2,3]. Prior literature has demonstrated that impaired driving and risky transportation behaviors substantially increase the risk of MVC-related injuries [4,5,6,7,8,9,10]. Given the established association between psychoactive substance use and impaired driving performance, the present study primarily focuses on motor vehicle-related pediatric trauma patterns in the context of cannabis legalization.
As of November 2025, apart from the legalization of medical use of cannabis, its use for recreational purposes has been legalized by 24 states and District of Columbia (DC) [11]. The state of Nevada legalized cannabis for medical use on 1 July 2010, while recreational cannabis legalization, including implementation of legal retail sales, began on 1 January 2017 [12]. Accordingly, the present study defined the post-legalization period as 1 January 2017, through 31 December 2023. From a public health and safety perspective, DUI laws need to address driving under the influence of cannabis (DUIC). From a public health and safety perspective, DUI laws need to address driving under the influence of cannabis (DUIC).
The impact of cannabis use and legalization remains unclear and controversial. Research on the subject is challenging for various reasons, including differences in state laws and a lack of reliable testing that correlates with cannabis intoxication, given the varied effects based on the mode and duration of consumption by the individual [4,5,6,7]. A further confounding factor includes the effect of cannabis when combined with other psychoactive substances [10,11,12,13,14,15].
While research in the adult population is limited, most studies have focused on fatal MVC outcomes and have yielded mixed results [16,17]. Initial research indicated that medical marijuana laws may be somewhat protective and translate into fewer, or at least no significant change in the rate of fatal MVCs [2,18,19]. However, this has not consistently held true over time [20,21]. Prior studies have shown that cannabis use increases the risk of fatal MVCs [21,22,23,24] and non-traffic-related injuries in the adult population [25] without a significant change in pedestrian-related fatal MVCs [2]. Reports also indicate that cannabis use is associated with higher rates of healthcare utilization [24,26,27], although some studies have not observed statistically significant increases over longer follow-up periods [28].
In contrast, research evaluating pediatric populations remains limited. In the pediatric age range, younger children may be affected due to driver impairment, while adolescents are more likely to experiment with substances and engage in risky behaviors [16,19,20,21,22,23,24,25,26,27,28,29,30,31,32]. The majority of existing research in the United States involves fatal crash data and focuses on alcohol-related impairment [33,34,35], with limited evaluation of non-fatal crashes [36] or cannabis-specific effects [14,25,37]. To date, alcohol use by drivers transporting children has been identified as a major risk factor for child endangerment [13,36,38], but comparable evidence for cannabis remains sparse [14]. Evidence regarding non-fatal trauma, injury mechanisms, and healthcare utilization in pediatric populations is particularly lacking. Accordingly, the present findings provide additional observational evidence regarding pediatric trauma patterns in a real-world policy environment following cannabis legalization.
Given these gaps, evaluating real-world pediatric trauma trends in the context of cannabis legalization is critical for informing injury prevention strategies and public health policy. The purpose of this study was to (1) evaluate the incidence of pediatric trauma activations at a Level I trauma center and teaching hospital in the Southwestern United States before and after legalization of cannabis; (2) analyze healthcare resource utilization, including hospital length of stay, ICU admission, ICU length of stay, ventilator use, ventilator days, and hospital disposition; (3) examine in-hospital mortality; and (4) assess socioeconomic factors at both individual and community levels. The study hypothesis proposed that there would be no change in MVC-related pediatric trauma activations before and after recreational cannabis legalization at the study site.

2. Methods

2.1. Study Design and Setting

A retrospective repeated cross-sectional study of trauma registry data from a Level I trauma center at a teaching hospital in the Southwestern United States was conducted. The study period spanned 1 January 2013 to 31 December 2023, encompassing pre-legalization (2013–2016) and post-legalization (2017–2023) periods relative to recreational cannabis legalization in Nevada, with the post-legalization period beginning 1 January 2017, corresponding to implementation of legal recreational cannabis retail sales. Throughout the study period, the institution consistently functioned as the primary Level I trauma center in the region, and trauma registry data were collected using standardized institutional trauma registry coding and trauma activation practices.

2.2. Study Population

The study included pediatric patients aged 0–18 years who presented with trauma activations related to motor vehicle collisions (MVCs), including pedestrian and bicycle incidents involving a motor vehicle, during the study period. Patients were identified using the institutional trauma registry database. Patients were included if they met trauma activation criteria and had a diagnosis code consistent with MVC-related injury. Patients with non-MVC-related mechanisms of injury or those who did not meet trauma activation criteria were excluded.

2.3. Variables and Measures

Study variables included exposure, outcomes, and covariates related to demographic, clinical, and socioeconomic characteristics. The primary exposure was the time period relative to recreational cannabis legalization in Nevada, categorized as the pre-legalization period (2013–2016) and post-legalization period (2017–2023). The post-legalization period corresponded to implementation of legal recreational cannabis retail sales beginning 1 January 2017. The primary outcome was the annual incidence rate of pediatric trauma activations per 100,000 pediatric population. Secondary outcomes included injury characteristics (mechanism, location, severity, and probability of survival), healthcare utilization measures (hospital admission, ICU admission, ICU length of stay, ventilator use, ventilator days, and hospital disposition), and mortality outcomes (emergency department and inpatient mortality). Demographic variables included age, sex, race, and ethnicity. Injury severity was assessed using the Abbreviated Injury Scale (AIS) and Injury Severity Score (ISS), as recorded in the trauma registry. Socioeconomic characteristics were evaluated using the Distressed Communities Index (DCI), a validated zip code-level composite socioeconomic measure incorporating indicators of educational attainment, employment, poverty, median income, housing vacancy, and business establishment growth. Patients were assigned DCI categories based on residential zip code information available in the trauma registry and classified as prosperous, comfortable, mid-tier, at-risk, or distressed communities according to established DCI criteria [39]. Insurance payer type was also assessed. Detailed definitions and measurements of all variables are summarized in Table 1.

2.4. Ethical Considerations

This study was conducted in accordance with institutional guidelines and was reviewed by the Institutional Review Board. Given the retrospective nature of the study and use of de-identified data, informed consent was waived.

2.5. Statistical Analysis

Annual incidence rates were calculated by dividing the number of pediatric trauma activations each year by the corresponding pediatric population and expressed per 100,000 population. Because the pre- and post-legalization periods differed in duration, annualized population-adjusted incidence rates and incidence rate ratios (IRRs) were used to facilitate time-adjusted comparisons between periods rather than relying on cumulative case counts alone. Incidence rate ratios (IRRs) with 95% confidence intervals (CIs) were used to compare pre-legalization (2013–2016) and post-legalization (2017–2023) periods.
Descriptive statistics were used to summarize patient characteristics and outcomes. Categorical variables were reported as frequencies and percentages and compared using chi-square tests. Continuous variables were summarized as means with standard deviations and compared using independent-sample t-tests or analysis of variance (ANOVA), as appropriate.
Assumptions for statistical tests were evaluated prior to analysis. Normality of continuous variables was assessed using graphical methods and the Shapiro–Wilk test, and homogeneity of variances was evaluated using Levene’s test. Where assumptions were not met, appropriate alternative methods or transformations were considered. A two-sided p-value of <0.05 was considered statistically significant. All analyses were conducted using IBM SPSS Statistics version 29.0 (IBM Corp., Armonk, NY, USA). This study was reported in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines for observational studies [40].

3. Results

3.1. Study Population Characteristics

A total of 1772 pediatric trauma activations were included in the analysis, with 629 cases during the 4-year pre-legalization period and 1143 cases during the 7-year post-legalization period. To account for unequal observation periods, incidence comparisons were based on annualized population-adjusted rates and incidence rate ratios. There were no statistically significant differences in age, sex, or ethnicity between the two periods. However, the distribution of race differed significantly (p = 0.002), with a higher proportion of Black or African American patients in the post-legalization period (Table 2).

3.2. Incidence of Pediatric Trauma

Annual incidence rates of pediatric trauma activations remained relatively stable over the study period. The incidence rate was 21.6 per 100,000 in the pre-legalization period and 21.4 per 100,000 in the post-legalization period, with no statistically significant difference (IRR = 0.99, 95% CI: 0.90–1.09) (Table 3 and Table 4).

3.3. Injury Characteristics

Significant changes in injury mechanisms were observed between periods (p = 0.002). The proportion of motor vehicle collision-related injuries increased from 41.3% pre-legalization to 49.3% post-legalization, while pedestrian injuries decreased from 32.4% to 25.5% (Table 5). No statistically significant differences were observed in injury location or mean Injury Severity Score (ISS). However, a higher proportion of patients in the post-legalization period had a greater predicted probability of survival (p < 0.001).

3.4. Healthcare Utilization

Hospital admission from the emergency department decreased in the post-legalization period (75.5% vs. 70.2%, p = 0.016). ICU admissions also declined significantly (27.3% vs. 19.5%, p < 0.001). Despite fewer ICU admissions, the mean ICU length of stay increased from 4.0 to 5.9 days (p = 0.005). No significant differences were observed in ventilator use or ventilator days (Table 6).

3.5. Mortality Outcomes

Mortality remained low across both periods. There were no statistically significant differences in emergency department mortality or inpatient mortality between pre- and post-legalization periods (Table 7).

3.6. Socioeconomic Characteristics

Significant differences in socioeconomic characteristics were observed. The distribution of the Distressed Communities Index (DCI) shifted post-legalization (p = 0.021), with a higher proportion of patients from more prosperous communities and fewer from distressed communities (Table 8). Insurance coverage also changed significantly, with increases in both Medicaid/government and private insurance coverage and a marked decrease in uninsured or self-pay patients (p < 0.001).

4. Discussion

This study evaluated population-level trends in pediatric trauma following recreational cannabis legalization in Nevada and found that overall incidence remained stable over time. This finding remained consistent even after accounting for changes in the pediatric population, suggesting that legalization was not associated with a measurable increase in pediatric trauma activations or life-threatening injuries. However, important shifts were observed in injury mechanisms, healthcare utilization, and socioeconomic characteristics. These findings contribute to the evolving literature examining pediatric injury epidemiology in the context of changing cannabis policies and broader societal shifts.
The finding of stable pediatric trauma incidence aligns with several prior studies in adult populations that reported no statistically significant changes in emergency department visits or fatal crash rates following cannabis legalization [2,13,20,21]. However, the existing literature remains mixed and continues to evolve, particularly regarding pediatric and non-fatal trauma outcomes. Some studies have demonstrated increased prevalence of cannabis use among drivers involved in fatal motor vehicle collisions [23], while others have reported increased odds of motor vehicle collisions associated with driving under the influence of cannabis [20,41], although not consistently across all analyses [42,43]. These inconsistencies likely reflect differences in study design, measurement of exposure, and confounding factors.
Despite stable incidence, significant shifts in injury mechanisms and healthcare utilization patterns were observed during the post-legalization period. Several factors may explain these findings beyond cannabis legalization alone. Importantly, a substantial portion of the post-legalization study period (2020–2023) overlapped with the COVID-19 pandemic, which significantly altered mobility patterns, traffic density, pedestrian activity, healthcare-seeking behavior, and injury exposure among pediatric populations. During the COVID-19 pandemic, changes in school attendance, recreational activities, mobility patterns, transportation behaviors, and healthcare-seeking practices were widely reported and may have contributed to shifts in pediatric trauma exposure and healthcare utilization [44,45,46,47,48,49]. Several studies have additionally demonstrated substantial reductions in pediatric emergency department visits and emergency hospital admissions during the COVID-19 pandemic, likely reflecting both reduced injury exposure and avoidance of healthcare services for minor and even serious conditions [45,46,47,48,49]. Travel restrictions, lockdown measures, school closures, and implementation of remote learning may also have contributed to the observed decline in pediatric injuries and changes in healthcare utilization patterns during this period [45,46,47,48,49]. Prior studies have similarly demonstrated substantial changes in pediatric trauma epidemiology during the COVID-19 era, including altered injury mechanisms, reduced trauma activations, shifts in injury severity, and changes in healthcare utilization patterns [45,46,47,48,49]. Because the COVID-19 pandemic overlapped substantially with the post-legalization study period, pandemic-related behavioral and healthcare system disruptions may represent an important source of temporal confounding when interpreting observed trends.
These pandemic-related societal and healthcare disruptions may partially explain several patterns identified in this study. These include stable overall trauma incidence, increased MVC-related injuries, fewer pedestrian injuries, reduced hospital and ICU admissions, and higher predicted probabilities of survival during the post-legalization period. Additionally, evolving trauma triage practices and healthcare system adaptations during the pandemic may have influenced admission thresholds and trauma activation patterns. Additional environmental and urban design factors may also have contributed to changes in injury mechanisms. These factors include pedestrian infrastructure, roadway configuration, traffic density, transportation patterns, driving behaviors, and traffic safety enforcement. Because the post-legalization period included a longer observation window than the pre-legalization period, cumulative injury counts should be interpreted cautiously. However, comparisons of injury mechanisms in this study were based primarily on proportional distributions within each period rather than raw counts alone, thereby reducing the influence of unequal observation duration on prevalence estimates. These contextual variables were not directly measured in the current study and should be explored in future research. Because these contextual factors, including the COVID-19 pandemic, occurred concurrently with recreational cannabis legalization, and individual-level cannabis exposure or intoxication data were not available, the findings should be interpreted cautiously as temporal associations rather than direct causal effects attributable solely to legalization. Future longitudinal and multicenter studies are needed to better disentangle the independent effects of cannabis legalization from broader societal and pandemic-related influences on pediatric trauma trends.
Changes in healthcare utilization were also identified. Both hospital and ICU admissions decreased in the post-legalization period, while ICU length of stay increased. This pattern is consistent with national trends [49] and may reflect evolving triage practices, including updates to national field triage guidelines and American College of Surgeons (ACS) criteria [50,51], which have raised concerns regarding potential under-triage of pediatric patients [52]. Longer ICU stays during the post-legalization period may reflect multiple factors, including evolving clinical practices, operational factors, or changes in ICU admission and discharge patterns over time. Notably, ventilator use and mortality remained stable, suggesting no substantial change in overall injury severity.
Significant shifts were also identified in socioeconomic characteristics. A higher proportion of patients originated from more prosperous communities, while fewer were from distressed areas, and insurance coverage patterns shifted toward increased Medicaid/government and private insurance utilization. These findings may reflect broader demographic and policy changes, including population shifts and healthcare coverage expansion associated with the Affordable Care Act [53]. Given the well-established relationship between socioeconomic disadvantage and childhood injury risk [54], these changes highlight the need for continued attention to equity in injury prevention and trauma care.
Cannabis use has been well documented to impair neurocognitive function, including attention, reaction time, and executive functioning, all of which are critical for safe driving [6,7,15,38,55]. Meta-analyses have demonstrated increased risk of motor vehicle collisions among cannabis-impaired drivers, with pooled odds ratios ranging from modest to moderate increases depending on study design and adjustment for confounding factors [56,57,58,59]. However, the present study did not include individual-level data on cannabis use or driver impairment. Therefore, findings should be interpreted as temporal associations rather than causal effects of cannabis legalization, as multiple factors, including polysubstance use, behavioral changes, and policy shifts may influence observed outcomes.
Recent pediatric injury epidemiology studies have emphasized the importance of monitoring evolving injury mechanisms and healthcare utilization trends among children and adolescents in response to changing societal and policy environments [46,47,49]. From a public health perspective, these findings underscore the importance of continued surveillance of pediatric trauma patterns in the context of evolving recreational cannabis policies. Prevention strategies should focus on high-risk mechanisms, particularly MVC-related injuries, and incorporate education for adolescents and caregivers regarding impaired driving. Additionally, addressing socioeconomic disparities remains critical for reducing the burden of pediatric injury.

Strengths and Limitations

This study has several strengths. It utilizes a large trauma registry dataset spanning a decade, allowing for longitudinal assessment of pediatric trauma trends before and after cannabis legalization. The inclusion of detailed clinical variables, injury characteristics, and healthcare utilization measures provides a comprehensive evaluation of trauma patterns. Additionally, the integration of community-level socioeconomic indicators, such as the Distressed Communities Index, offers important context for understanding disparities in pediatric injury.
However, several limitations should be considered. As a retrospective repeated cross-sectional study, causal relationships between cannabis legalization and observed outcomes cannot be established. The absence of individual-level data on cannabis use, intoxication status, driving under the influence of cannabis (DUIC), or polysubstance exposure limits the ability to directly attribute observed changes to cannabis-related impairment or establish causal relationships between recreational cannabis legalization and pediatric trauma outcomes. Residual confounding may persist due to unmeasured or incompletely measured factors, including behavioral, environmental, and policy-related variables. In addition, contextual confounding is likely, as the post-legalization period coincided with major external influences, including the COVID-19 pandemic, changes in mobility patterns, and updates to trauma triage guidelines. The overlap between the post-legalization period and the COVID-19 pandemic may have substantially influenced observed temporal trends through changes in traffic patterns, mobility, healthcare utilization, school attendance, recreational activity, and trauma exposure independent of cannabis legalization. Broader societal and environmental factors, including changes in transportation patterns, traffic density, healthcare-seeking behaviors, healthcare utilization, urban mobility, school closures, and post-pandemic behavioral shifts, may also have contributed to temporal changes in pediatric trauma patterns independent of cannabis legalization. These concurrent influences should be considered when interpreting the observed associations. These factors may have independently affected injury mechanisms, healthcare utilization, and trauma activation practices. Future studies using interrupted time-series analyses or sensitivity analyses excluding pandemic years may help better isolate the independent association between recreational cannabis legalization and pediatric trauma trends. Although the study institution consistently functioned as the primary Level I trauma center in the region throughout the study period, overall hospital referral patterns remained relatively stable. However, evolving trauma triage recommendations, potential operational shifts in trauma activation practices over time, regional population growth, and demographic changes in Southern Nevada may also have contributed to temporal variations in pediatric trauma incidence and healthcare utilization.
Socioeconomic status was assessed at the community level using zip code–based measures, which may not fully capture individual-level variability and could introduce ecological bias. Finally, as a single-center study conducted at a Level I trauma center, the findings may have limited generalizability to other regions with different demographic, policy, or healthcare system characteristics.

5. Conclusions

Recreational cannabis legalization in Nevada was not associated with a significant change in the overall incidence of pediatric trauma activations. However, shifts in injury mechanisms, healthcare utilization, and socioeconomic patterns were observed. These results highlight the complex interplay between policy, behavioral factors, and social context and underscore the need for continued surveillance and targeted, equity-focused injury prevention strategies in pediatric populations.

Author Contributions

Conceptualization, J.S. and A.P.S.; methodology, J.S., V.G., R.S. and K.B.; software, R.S.; validation, J.S., V.G. and K.B.; formal analysis, R.S. and V.G.; investigation, J.S. and A.P.S.; resources, A.P.S.; data curation, R.S.; writing—original draft preparation, J.S.; writing—review and editing, V.G., R.S., K.B. and A.P.S.; visualization, R.S.; supervision, A.P.S. and K.B.; project administration, J.S., K.B. and A.P.S.; funding acquisition, not applicable. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding. However, the APC were funded by the Open Access Funds provided by the Office of Graduate Medical Education.

Institutional Review Board Statement

The study was conducted in accordance with the Declaration of Helsinki, and approved by the Institutional Review Board (or Ethics Committee) of University Medical Center (UMC-2024-569 dated 17 October 2024) for studies involving humans.

Informed Consent Statement

The requirement for informed consent was waived due to the retrospective nature of the study and use of de-identified data.

Data Availability Statement

The data used in this study are not publicly available due to institutional and ethical restrictions related to patient privacy and are not available for sharing.

Conflicts of Interest

The authors declare no conflict of interest.

Abbreviations

ACSAmerican College of Surgeons
AISAbbreviated Injury Scale
CIConfidence Interval
DCIDistressed Communities Index
DUIDriving Under the Influence
DUICDriving Under the Influence of Cannabis
EDEmergency Department
ICUIntensive Care Unit
IRRIncidence Rate Ratio
ISSInjury Severity Score
MVCMotor Vehicle Collision
THCTetrahydrocannabinol

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Table 1. Definitions and Measurement of Study Variables.
Table 1. Definitions and Measurement of Study Variables.
CategoryVariableDefinition/MeasurementType
ExposureLegalization periodCategorized based on timing of cannabis legalization: pre-legalization (2013–2016) and post-legalization (2017–2023)Categorical
Primary OutcomePediatric trauma incidenceAnnual number of trauma activations divided by pediatric population, expressed per 100,000 childrenContinuous (rate)
Injury CharacteristicsInjury mechanismCategorized as motor vehicle collision (MVC), pedestrian injury, or bicycle/motorized vehicle-related injuryCategorical
Injury locationClassified by anatomical region (e.g., head/neck, thorax, abdomen, musculoskeletal, multiple sites)Categorical
Injury severityAssessed using Abbreviated Injury Scale (AIS) and Injury Severity Score (ISS)Continuous/Ordinal
Probability of survivalDerived from trauma registry (categorized as higher probability, preventable death, non-preventable death)Categorical
Healthcare UtilizationHospital admissionAdmission from emergency department (yes/no)Binary
ICU admissionAdmission to intensive care unit (yes/no)Binary
ICU length of stayNumber of days in ICUContinuous
Ventilator useUse of mechanical ventilation (yes/no)Binary
Ventilator daysDuration of ventilator support in daysContinuous
Hospital dispositionDischarge outcome (home, morgue, other)Categorical
Mortality OutcomesED mortalityDeath occurring in the emergency department (yes/no)Binary
Inpatient mortalityDeath occurring during hospitalization (yes/no)Binary
Demographic VariablesAgeAge at time of injury (years)Continuous
SexMale or femaleCategorical
RaceSelf-reported race categoriesCategorical
EthnicityHispanic or non-HispanicCategorical
Socioeconomic VariablesDistressed Communities Index (DCI)Validated zip code–level composite socioeconomic index based on indicators of education, employment, poverty, income, housing vacancy, and business growth; categorized as prosperous, comfortable, mid-tier, at-risk, or distressedCategorical
Insurance payer typeClassified as Medicaid/government, private/commercial, or other (self-pay/unknown)Categorical
Table 2. Baseline Characteristics of the Sample During Pre- and Post-Legalization Periods (N = 1772).
Table 2. Baseline Characteristics of the Sample During Pre- and Post-Legalization Periods (N = 1772).
VariablesOverallPre-Legalization
1 January 2013–16 January 2017		Post-Legalization
17 January 2017–31 December 2023		p-ValueEffect SizeTest Statistic
n%95% CIn%n%
Gender
Female68438.636.3, 40.925640.742837.40.1780.0321.813
Male108861.459.1, 63.737359.371562.6
Race
White71640.438.1, 42.727543.744138.60.0020.09114.766
Black or African American41023.123.1, 25.211518.329525.8
Asian or Pacific Islander7143.1, 5.0314.9403.5
American Indian/Alaskan Native or Others *57532.430.3, 34.720833.136732.1
Ethnicity
Hispanic56932.129.9, 34.319231.637733.30.465−0.0180.535
Non-Hispanic117166.163.8, 68.341668.475566.7
MSD95% CIMSDMSDp-valuePoint Estimate95% CI
Age at Injury10.794.410.6, 1110.64.510.94.40.102−0.081−0.793, 0.071
Table 3. Annual Pediatric Trauma Activations and Incidence Rates per 100,000 Pediatric Population in Nevada, 2013–2023 (N = 1772).
Table 3. Annual Pediatric Trauma Activations and Incidence Rates per 100,000 Pediatric Population in Nevada, 2013–2023 (N = 1772).
YearTrauma Activations (n)Incidence Rate (Per 100,000 People)95% CI (LCL, UCL)
201316423.119.8, 26.9
201415922.219, 26
201515921.618.5, 25.2
201614719.716.7, 23.1
201713918.515.7, 21.8
201815620.417.5, 23.9
201913918.015.2, 21.1
202016320.917.9, 24.3
202117623.220, 26.9
202218023.720.5, 27.5
202319024.921.6, 28.7
Absolute annual trauma activation counts are presented to facilitate interpretation of year-to-year fluctuations alongside population-adjusted incidence rates. All rates are calculated per 100,000 people unless otherwise specified.
Table 4. Pediatric Trauma Activation Incidence Rates and Rate Ratios by Recreational Cannabis Legalization Period (N = 1772).
Table 4. Pediatric Trauma Activation Incidence Rates and Rate Ratios by Recreational Cannabis Legalization Period (N = 1772).
Legalization PeriodTotal Ped PopulationTrauma Activation Incidence Rate95% CI (LCL, UCL)Incidence Rate Ratio95% CI (LCL, UCL)
Pre2,912,66962921.620, 23.40.990.898, 1.091
Post5,349,520114321.420.1, 22.6
All rates are calculated per 100,000 people unless otherwise specified.
Table 5. Comparison of Injury Characteristics Among Pediatric Trauma Patients Before and After Recreational Cannabis Legalization (N = 1772).
Table 5. Comparison of Injury Characteristics Among Pediatric Trauma Patients Before and After Recreational Cannabis Legalization (N = 1772).
Pre-Legalization (n, %)Post-Legalization (n, %)p-ValueOverall Effect SizeTest Statistic
Injury Mechanism
Bicycle, Motorcycle, or Motorized Scooter165 (26.2)288 (25.2)0.0020.08412.523
Motor Vehicle Collision260 (41.3)563 (49.3)
Pedestrian204 (32.4)292 (25.5)
Injury Location
Abdominopelvic41 (6.5)49 (4.3)0.3480.0565.588
External161 (25.6)274 (24)
Head/Neck124 (19.7)239 (20.9)
Multiple Sites151 (24)286 (25)
Musculoskeletal134 (21.3)265 (23.2)
Thorax18 (2.9)30 (2.6)
Highest AIS Score
Minor181 (28.8)350 (30.6)0.0320.08312.199
Moderate199 (31.6)366 (32)
Serious143 (22.7)283 (24.8)
Severe75 (11.9)82 (7.2)
Critical29 (4.6)60 (5.2)
Untreatable/Potentially Unsurvivable2 (0.3)2 (0.2)
Injury Severity Score
Very Minor Injury162 (25.8)298 (26.1)0.7460.0331.946
Mild Injury189 (30)364 (31.8)
Major Injury150 (23.8)276 (24.1)
Critical or Very Severe Injury126 (20)203 (17.8)
Fatal or Currently Untreatable Injury2 (0.3)2 (0.2)
Probability of Survival
Higher Probability594 (96.7)1010 (98.7)<0.0010.09815.859
Possibility of Preventable Death9 (1.5)0 (0)
Death May Be Non-Preventable11 (1.8)13 (1.3)
M (SD)M (SD)p-valueCohen’s dt
Injury Severity Score9.8 (11.2)9.2 (10.3)0.2000.0601.2
* p-values < 0.05 are considered statistically significant.
Table 6. Hospital Disposition and Critical Care Utilization by Legalization Period (N = 1772).
Table 6. Hospital Disposition and Critical Care Utilization by Legalization Period (N = 1772).
VariablePre-Legalization
n (%)		Post-Legalization
n (%)		p-ValueOverall Effect SizeTest Statistic
Final Disposition
Home581 (92.4)1052 (92)0.4290.0311.691
Morgue20 (3.2)28 (2.4)
Other28 (4.5)63 (5.5)
Admitted from ED
Yes475 (75.5)802 (70.2)0.0160.0575.770
No154 (24.5)341 (29.8)
Admitted to ICU
Yes172 (27.3)223 (19.5)<0.0010.09014.378
No457 (72.7)920 (80.5)
Ventilator
Yes67 (10.7)120 (10.5)0.9200.0020.010
No592 (89.3)1023 (89.5)
M (SD)M (SD)p-valueCohen’s dt
ICU Days4 (6.5)5.9 (7)0.005−0.281−2.793
Ventilator Days5.6 (8.5)7.1 (7.9)0.206−0.194−1.246
* p-values < 0.05 are considered statistically significant.
Table 7. Emergency Department and Inpatient Mortality by Legalization Period (N = 1772).
Table 7. Emergency Department and Inpatient Mortality by Legalization Period (N = 1772).
OutcomePre-Legalization n (%)Post-Legalization n (%)p-Value
Emergency Department Mortality
Yes8 (1.3)15 (1.3)0.943
No621 (98.7)1128 (98.7)
Inpatient Mortality
Yes12 (1.9)13 (1.1)0.188
No617 (98.1)1130 (98.9)
Table 8. Socioeconomic Indicators by Legalization Period (N = 1772).
Table 8. Socioeconomic Indicators by Legalization Period (N = 1772).
Pre-Legalization (n, %)Post-Legalization (n, %)p-ValueOverall Effect SizeTest Statistic
Distressed Communities Index (DCI)
Prosperous135 (22.3)301 (27.4)0.0210.08211.500
Comfortable71 (11.7)138 (12.5)
Mid-Tier62 (10.2)109 (9.9)
At Risk183 (30.2)340 (30.9)
Distressed155 (25.6)212 (19.3)
Payer Source
Medicaid and Other Government259 (41.2)632 (55.3)<0.0010.375248.882
Private/Commercial Insurance174 (27.7)463 (40.5)
Other (Self-Pay, Unknown)196 (31.2)48 (4.2)
* p-values < 0.05 are considered statistically significant. DCI: Validated zip code-level composite socioeconomic index based on indicators of education, employment, poverty, income, housing vacancy, and business growth; categorized as prosperous, comfortable, mid-tier, at-risk, or distressed.
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Serr, J.; Goel, V.; Sagaribay, R.; Batra, K.; Shah, A.P. Pediatric Trauma Trends Before and After Recreational Cannabis Legalization in Nevada: A Retrospective Repeated Cross-Sectional Study. Children 2026, 13, 681. https://doi.org/10.3390/children13050681

AMA Style

Serr J, Goel V, Sagaribay R, Batra K, Shah AP. Pediatric Trauma Trends Before and After Recreational Cannabis Legalization in Nevada: A Retrospective Repeated Cross-Sectional Study. Children. 2026; 13(5):681. https://doi.org/10.3390/children13050681

Chicago/Turabian Style

Serr, Jenna, Vidhani Goel, Roberto Sagaribay, Kavita Batra, and Ami P. Shah. 2026. "Pediatric Trauma Trends Before and After Recreational Cannabis Legalization in Nevada: A Retrospective Repeated Cross-Sectional Study" Children 13, no. 5: 681. https://doi.org/10.3390/children13050681

APA Style

Serr, J., Goel, V., Sagaribay, R., Batra, K., & Shah, A. P. (2026). Pediatric Trauma Trends Before and After Recreational Cannabis Legalization in Nevada: A Retrospective Repeated Cross-Sectional Study. Children, 13(5), 681. https://doi.org/10.3390/children13050681

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