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Editors
Ghassan Soleiman Abu-Sittah Jamal J. Hoballah
Department of Plastic and Department of Surgery
Reconstructive Surgery American University of Beirut
American University of Beirut Medical Center
Beirut, Lebanon Beirut, Lebanon

ISBN 978-3-031-28612-4    ISBN 978-3-031-28613-1 (eBook)

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© Springer Nature Switzerland AG 2023

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To the war injured child…tomorrow is a
better day
Acknowledgments

This book represents an attempt to capture the wealth of expertise that has devel-
oped over the years within the American University of Beirut Medical Center in the
treatment of children with war related and weapons inflicted injuries. My thanks go
to everyone within that institution, which is the Middle East’s primary academic
medical institution and the world’s leading civilian academic institution with such
unique experience and expertise.
I would like to acknowledge the support given to this project by the Global
Health Institute at the American University of Beirut, which is leading the way in
undertaking and disseminating research on the clinical burden of war injuries. My
gratitude also goes to the Center for Blast Injury Studies at Imperial College which
supports collaborative research on war injuries through the ProTect project consor-
tium and to the National Institute for Health Research (UK) which has been funding
these international research partnerships looking at the complex relationship
between protracted conflict and health. I am grateful to the UK charity Save The
Children which was the first to highlight the need for more clinical data on pediatric
war injuries and launched the Pediatric Blast Injury Network that continues to work
on improving outcome in pediatric war injuries.
The partnership forged between the Department of Surgery at the AUBMC and
the charity the International Network for Aid Relief and Assistance (INARA) and
the United Nations Children’s Fund (UNICEF) to set up the Pediatric War Injuries
Program at the Division of Plastic and Reconstructive Surgery was a critical step
towards developing a multidisciplinary approach to the treatment of these injuries.
My personal gratitude goes to Dean Mohammed Sayegh (Raja N. Khuri Dean
of the Faculty of Medicine and Executive Vice President of Medicine and Global
Strategy at the American University of Beirut (AUB) from 2009 to 2020) for his
support and encouragement in developing the field of Conflict Medicine at the
AUBMC and to my friend and colleague Dr. Imad Kaddoura who was my strongest
supporter and ally in developing these projects and partnerships. Most of all my
heartfelt thanks and enduring gratitude to Professor Jamal Hoballah, Head of the
Department of Surgery at the AUBMC for agreeing to co-edit this book but most
importantly for spearheading the initiative to develop the AUBMC into an aca-
demic center of excellence in the management of war injuries and in particular in
children.

vii
viii Acknowledgments

My deep appreciation goes out to all the books’ contributors for their hard work
and patience. It also goes out to Dr. Ismael Soboh and Dr. Theresa Farahat who
helped me edit this book.
But most of all, I will be forever grateful to and in awe of the children whom I
have treated over the past 25 years in wars not only in Lebanon, but also in Palestine
(Gaza Strip), Iraq, Syria, and Yemen. They continue to inspire me in both my work
and my daily life.
Ghassan Soleiman Abu-Sittah MBcHB FRCS(Plast)
Associate Professor of Surgery
Plastic, Reconstructive and Aesthetic Surgeon
Honorary Senior Lecturer, Center for Blast Injury Studies, Imperial College
London University
Visiting Senior Lecturer, Conflict & Health Research Group, Faculty of Life
Sciences and Medicine, King’s College London University
Director, Conflict Medicine Program, Global Health Institute, American
University of Beirut
Clinical Lead, Trauma Advisory & Operational Team, WHO-EMRO
Contents

Part I Introduction
1 
The Epidemiology of the Pediatric War Injuries������������������������������������   3
Ismail Soboh and Ghassan Soleiman Abu-Sittah
2 
Biodynamics of Blast Injury �������������������������������������������������������������������� 17
Seif Emseih and Ghassan Soleiman Abu-Sittah
3 
Physiologic Considerations in Pediatric Population ������������������������������ 45
Ahmad Zaghal and Rebecca Andraos

Part II Acute Management

4 
Resuscitation and Critical Care of the Injured Child���������������������������� 59
Ghadi Abou Daher, Nidale Darjani, and Marianne Majdalani
5 
Nursing Management for War Injured Child ���������������������������������������� 71
Nour Nahhas
6 
Airway Management in the War-Injured Child�������������������������������������� 79
Wissam Maroun and Roland Kaddoum
7 Abdominal Injuries������������������������������������������������������������������������������������ 89
Samir Akel and Arwa El Rifai
8 
Management of Pediatric Vascular Injuries in Blasts���������������������������� 101
Jamal J. Hobballah
9 
Acute Pediatric Burn Management���������������������������������������������������������� 115
Bachar F. Chaya, Dunia Hatabah, and Amir E. Ibrahim
10 
Head Trauma in the Pediatric Population ���������������������������������������������� 133
Elias Elias and Marwan W. Najjar

Part III Reconstruction and Rehabilitation

11 
Management of Soft Tissue Defects in the Limbs ���������������������������������� 147
Salim Saba and Ahmad Oneisi

ix
x Contents

12 
The Role of Microsurgery in Pediatric War Injuries������������������������������ 157
Reem A. Karami and Amir E. Ibrahim
13 
Management and Reconstruction of Long Bone Fractures ������������������ 173
Said Sodki Saghieh, Serge Jean Sultanem, and Ahmad
Salaheddine Naja
14 
Reconstruction of Pediatric Craniomaxillofacial Injuries �������������������� 183
Rawad Chalhoub and Ghassan Soleiman Abu-Sittah
15 War-Related Amputations and Prostheses in the Pediatric
Population �������������������������������������������������������������������������������������������������� 191
Paul Beaineh, Seif Emseih, and Ghassan Soleiman Abu-Sittah
16 
Rehabilitation of the War Injured Child ������������������������������������������������ 203
Natasha Habr and Ghassan Soleiman Abu-Sittah
17 The Microbiology of War Wounds����������������������������������������������������������� 209
Fadi M. Ghieh, Ismail Soboh, and Abdul Rahman Bizri
18 The Invisible Wounds: Mental Health Support for the War
Injured Children���������������������������������������������������������������������������������������� 219
Evelyne Baroud and Leila Akoury Dirani
Index�������������������������������������������������������������������������������������������������������������������� 239
 Part I
Introduction
The Epidemiology of the Pediatric War
Injuries 1
Ismail Soboh and Ghassan Soleiman Abu-Sittah

1.1 Introduction

“Every war is a war against children,” said Eglantynne Jebb over 100 years ago [1].
According to the “Save the Children” reports, more than 357 million children live
in conflict zones and are at risk of grave violations [1].
It is significantly important to know that children injured in a war setting need
special treatment considerations that differ from adults. Even trained medical staff
such as surgeons, nurses, and therapists may lack the expertise and training they
need to treat injured children in conflict zones [1]. Such experts are supposed to
make complex decisions in the terrible situations of war, like whether to amputate a
child’s leg or how best to help a child with a life-changing injury reintegrate back
into society [1].
This book was written to address the necessity of having a backbone for the treat-
ment and management of pediatric war injuries especially due to the very little
information available in this regard. In fact, pediatric war injuries require specific
considerations of early and late management that are way different from adults.
Readers of this manual are going to be mainly surgeons who are not really
exposed to the practice of pediatric war injuries and its literature. Even general
pediatricians can benefit from the information provided. This chapter on the epide-
miology of pediatric war wounds introduces a specific approach to the factors influ-
encing war injured child treatments and outcomes.

I. Soboh
Division of Plastic Surgery, Department of Surgery, American University of Beirut Medical
Center, Beirut, Lebanon
G. S. Abu-Sittah (*)
Conflict Medicine Program, Global Health Institute, American University of Beirut,
Beirut, Lebanon
e-mail: [email protected]

© Springer Nature Switzerland AG 2023 3

G. S. Abu-Sittah, J. J. Hoballah (eds.), The War Injured Child,
https://doi.org/10.1007/978-3-031-28613-1_1
4 I. Soboh and G. S. Abu-Sittah

1.2 Public Health Consequences of Armed Conflict

on Children

More than 1 in every 6 children is affected by armed conflicts globally in 2016 [2].
This number has increased by 30 million to reach 420 million in 2017 [3]. Children
living in conflict zones are subjected to several forms of not only physical injuries
but also physiological and mental health problems. During the past several decades,
health facilities, health workers, and schools have become direct targets, increasing
the impact of war on children [4]. The pediatric population that is affected whether
directly or indirectly from war conflicts suffers from mild to severe effects that
might persist throughout the life course.
The direct effects of war on children range from physical injury, medical illness,
and psychological trauma to death [3]. In addition, a complex set of political, eco-
nomic, environmental, and social factors have an indirect impact on child health in
areas of combat [4]. Therefore, it is extremely challenging for the medical and pub-
lic health systems to function normally after the destruction of their infrastructure,
limiting both the access and the quality of care provided.

1.2.1 Geographical Spread of Children Living in Conflict Zones

During the period 1946–2016, there were 280 distinct armed conflicts around the
world [5]. Of these conflicts, 165 took place in the last 30 years [4]. Although there
is a lack of data regarding child health in most of the past conflicts, the number of
children living in conflict zones has increased drastically. It has increased by 75
percent from the early 1990s when it was about 200 million to reach around 357
million in 2016 and 420 million in 2017 according to “Save the Children” reports
[1, 3] (Fig. 1.1).

1995: 200
400 Million children 2016: 357
in conflict areas million
350
children
300
250
200
150 66 countries in conflict 52
countries
100
50
0
1990 2016

Fig. 1.1 The Chart shows the number of children living in conflict zones and the number of coun-
tries in conflict between 1990 and 2016 [1]. Source: War on Children
1 The Epidemiology of the Pediatric War Injuries 5

Fig. 1.2 Map showing the 10 worst conflict-affected countries for children to live in. Source: Stop
the war on Children

According to the UN’s provided Data and PRIO’s Research, the “Save the chil-
dren” institute identified the 10 worst conflict-affected countries for children in their
report referring to several indicators such as conflict intensity, number of grave
violations, prevalence of children living in conflict zones, etc. [3]. The worst 10
countries can be identified in Fig. 1.2.

1.2.2 Historical Overview

It is commonly known that war conflict leads to a greater percentage of civilian vic-
tims rather than military and that children have a big share in this. In all main combats
over the last 100 years, with some exceptions, civilians have become a direct target
and accounted for around two-thirds of the casualties [6]. Therefore, the heavy burden
on the public health of children in contemporary conflicts is not new and children had,
throughout history, paid the cost of wars that others start and end. Indeed, in certain
conflicts, the destabilization of political, social, and economic infrastructures, the
destruction of cultural institutions, and the psychological terrorizing of civilians, espe-
cially children, have led to 2–15 times more civilian deaths than direct injuries [6].

1.2.3 The Public Health Effects of Social Disruption

One of the most dangerous effects of war conflicts is social disruption. This includes
the displacement of the population whether internally or externally from their home-
land, the breakdown of nutrition and Sanitary conditions, pauperization, polluted
drinking water, and the disruption of the whole medical system [6]. Nevertheless,
there is no doubt regarding the tremendous effects—whether direct or indirect—of
political violence on health services and the health system in general (Table 1.1).
6 I. Soboh and G. S. Abu-Sittah

Table 1.1 Effects of political violence on health and health systems [7]
Direct effects Indirect effects
Death Reduced food distribution and production
Disability Economic pressures and disruption
Injury Environmental disruption
Destruction of health system Internal displacement and refugees
Disruption of the health programs Family disruption
Psychological stress Impact on housing, water supply, and sewage
disposal
Source: Toward an epidemiology of political violence in the third world

Thousands of children have been dying all over the globe because of violence at
war every year [8]. They become direct targets whether citizens or recruited worri-
ers on the battlefield or die for ethnic reasons [8]. Preventable diseases are epidemic
during the war due to the lack of proper vaccination in addition to a significant
increase in infant mortality when compared to peacetime or in comparison with
peaceful parts of the same country [4]. Furthermore, children in conflict zones suf-
fer from various types of injuries and mutilation. There is a wide range of injuries
affecting all organs of the body and they are broadly classified as crush injuries,
blunt trauma, penetrating injuries, and burns [4]. They are all attributed to gunshots,
explosions, Motor Vehicle Accidents (MVAs), buildings destruction, and shelling
[4]. The most important heritage of war is the fact that children are mainly affected
by landmines. Mine explosions have a higher incidence of injury and a greater mor-
tality rate among children than adults leading to foot and lower limb injuries, genital
injuries, blindness, and deafness [8].
Nevertheless, damage to the health system in the areas of conflict extremely
affects children’s health. They will be exposed to several types of infectious dis-
eases that are easily transmitted in camps and refugee gatherings. This is the result
of the lack of proper health facilities, lack of immunizations, contaminated water,
malnutrition, and exposure to vectors. Moreover, the adverse effects of population
displacement, destruction of social infrastructure, economic sanctions, and environ-
mental damage may compromise children’s access to basic needs such as food,
health care, and education, for decades [9]. Similarly, schools have been direct tar-
gets in any raising armed conflict, and children are being targeted in their way
whether to or back from school. What is worst is the fact that schools in many con-
flicts are being used as shields and bases for combatants or governments in the
recruitment of children into war [9]. Therefore, children living in areas of conflict
suffer from various terrible consequences—direct or indirect—on public health as
the result of social disruption ranging from injury and malnutrition to death.

1.2.4 The Burden of War Wounded Children

Pediatric war injuries have been always a major cause of morbidity, mortality, and
disability all over the globe; especially in Low and Middle-Income Countries
(LMICs) [10]. These injuries are a growing global concern, which falls
1 The Epidemiology of the Pediatric War Injuries 7

disproportionately on developing countries where the public health system and the
health facilities are initially not well prepared [11]. That is also because the conse-
quences of injury do not fall only on the injured child but also place a substantial
burden on family members, institutions, and society in general provoking poverty
and social disability. According to the World Health Organization (WHO), around
15% of the burden of diseases worldwide in the 1990s was due to war injuries [12].

1.2.5 Six Grave Violations

Since the official council of the Special Representative for Children and Armed
Conflicts was established in 1996, the United Nations (UN) general assembly has
been trying to promote data gathering in terms of children, who are the victims of
armed conflicts, in order to raise awareness globally and ensure international coop-
eration to strengthen protection of these children [13]. As a result, a Monitoring and
Reporting Mechanism (MRM) was created to track grave violations against chil-
dren in 2005 by UN Security Council [3]. These criteria serve as the basis to report
and gather information on violations affecting children all over the globe [13].
Killing and maiming are one of these violations that are being practiced against
children in conflict zones. According to the “save the children” report, around
73,000 children have been killed or maimed across 25 conflicts between 2005 and
2016 [1] (Fig. 1.3). In some reports of Children and Armed Conflicts (CAAC), it
was stated that children are being directly targeted in order to create maximum

2014: 12393
14000
39% in Occupied
Palestinian
12000 Territory
2011: 11458
68% in Somalia
10000

8000
7000
6000
5000
4000
3000
2000
1000
0

2005 2016

Fig. 1.3 Killing and maiming of children. Source: War on children

8 I. Soboh and G. S. Abu-Sittah

emotional damage or to get rid of the next generations of certain ethnic or religious
groups [14].
Recruitment of children into conflicts is also one of the major grave violations
breaching children’s rights. Around 49,650 verified cases of both sexes were
recruited by armed forces between 2005 and 2016, according to the UN CAAC
annual report [1]. Being used or recruited by combatants in armed groups may leave
behind a significant negative life-long impact on the recruited or used children, for
those who survived the experience [1]. The traumatic aspect of the brutality they
have witnessed and experienced can have tremendous psychological effects that
will accompany them into adulthood [1].
Nevertheless, sexual violence is a hugely under-reported facet of conflicts and
outside the conflicts too [1]. The Sexual Violence in Armed Conflict (SVAC) data-
base, which includes “sexual slavery, forced prostitution, rape, forced pregnancy,
forced sterilization/abortion, sexual mutilation, and sexual torture shows that glob-
ally 35% of conflicts involved some sort of sexual violence against children between
1998 and 2009” [1]. Moreover, Children can also be abducted or seized during
conflicts which can take many forms ranging from conscription to kidnapping.
Other Violations include attacks on hospitals and schools along with humanitar-
ian access denial which is also considered of major importance in reflecting the
present and future of children in conflict.

1.3 Global Epidemiology of War Injured Children

Children are resilient and they represent a high-risk population for injuries world-
wide. One of the major direct ramifications of wars and combats on children is
being—whether intentionally or unintentionally—targeted and injured. Injuries in
this case can take several forms and each requires special considerations regarding
the treatment options. However, these injuries fluctuate between blunt injuries,
which the child might face in a collapsed building, for example, to penetrating
wounds, landmine injuries, and explosive blast injuries.

1.3.1 Blunt Injuries and Penetrating GSWs

Blunt trauma represents a separate category of injury that has several characteristics
that overlap with blast injury [15]. This is because sometimes, and due to blast
explosion, the victims might be thrown over hard solid objects or be under the threat
of a collapsed building resulting in blunt injury.
Penetrating wounds of pediatric populations mainly due to gunshot wounds
(GSWs), in war settings, are under-reported in most of the studies done. This is
because GSWs in the pediatric population occur mainly in high-income countries
and places where weapons are easily accessible as per law. In the USA, for example,
guns are ubiquitous and it is estimated that over 90 million firearms are present in
civilian homes [16]. That is why firearm-related deaths are the third leading cause
1 The Epidemiology of the Pediatric War Injuries 9

of death among US children aged 1–17 years and it is the second leading cause of
death-related injuries after car crashes [17]. Although relatively rare compared to
adolescents and adults, deaths occurring in young children represent a particularly
tragic subcategory of firearms-related fatalities [18]. Nearly 33,636 firearm-related
deaths were reported in the USA in 2013 [18]. According to the NVSS and NEISS*,
1300 children died and 5790 were injured and treated in the USA each year as a
result of firearm-related injury [19]. Fifty-three percent of those who died were
homicides, 38% were suicides, and 6% were unintentional firearm deaths; the
remaining 3% were due to legal intervention and deaths of undetermined intent [19].

1.3.2 Blast and Landmine Injuries

Although explosions might be the result of civilian actions such as industrial acci-
dents or fireworks, most of them globally stem from terror or conflict-related attacks
[20]. More than 90% of death-related injuries occur in LMICs, where these coun-
tries are under-resourced in terms of treatment and prevention [21]. It is worth men-
tioning that the pathophysiology of blast injuries differs significantly from other
forms of injuries and traumas resulting in a multiple and scattered numbers of dis-
tinctly patterned injuries [22]. That is why, blast and landmine injuries resulted in
three-quarters of all child casualties in the five deadliest conflicts (Afghanistan,
Yemen, Syria, Nigeria, and Iraq) for children in 2017, according to the Save the
Children analysis of the UN data [23] (Table 1.2). It is estimated that 7364 children
were killed or maimed in conflicts in 2017 through which 5322 were linked to blast
explosions [23]. Nevertheless, the unexploded ordnance along with landmines inju-
ries constitutes a major risk for injury to children living in conflict areas. A review
of surveillance data done between 1997 and 2002 in Afghanistan showed that 6114
injuries were due to unexploded ordnance and landmines, in which 54% of those
injured were children under the age of 18 years [24]. It also indicated that children
who were mostly affected by unexploded ordnance were playing or tampering with
these explosives because of its higher visibility, whereas the adults sustained their

Table 1.2 The number of total child casualties and those linked to blasts in the five deadliest
conflicts for children in 2017 [23]
Child casualties linked to blast
Country Total child casualties (2017)
n (%) (2017)

Afghanistan 3,179 (251 girls) 2,216 (70%)

Yemen 1,316 (369 girls) 814 (62%)

Syria 1,271 1,058 (83%)

Nigeria 881 672 (76%)

Iraq 717 (227 girls) 562 (78%)

Total 7,364 5,322 (72%)

Source: SAVE THE CHILDREN (BLAST INJURIES)

10 I. Soboh and G. S. Abu-Sittah

injuries mainly while traveling or performing activities of economic necessity by

landmines [24, 25]. This was also confirmed by another surveillance study, done in
the same country between 2002 and 2006, showing that 92% of the victims were
civilians through which children less than 18 years constitute 47% [25]. A higher
percentage of children sustained upper limb amputation as compared to adults,
whereas more adults sustained lower limb amputations when compared to children
[25]. Among Children, the study showed that 65% of the injuries were related to
unexploded ordnance whereas 56% of adults’ injuries were related to landmines
[25]. Therefore, any area contaminated with unexploded ordnance should be cleared
in order to decrease the incidence of injured children in areas of conflict. This should
also be associated with risk awareness training campaigns and programs for chil-
dren addressing the danger of unexploded ordnance and the risky behavior by chil-
dren such as tampering in these special circumstances [25].
Explosive charges can be divided into High-order explosives (HE) and low-order
explosives which will lead to either primary, secondary, tertiary, and/or quaternary
blast injuries [26] (Refer to Chap. 2).
Nearly 83% of children and only 12% of the combatants of the people killed in
Syria’s conflict were killed by blasts (Table 1.2) [23]. Indeed, children killed by
blast injuries are 7 times more likely to be the victims of blast injuries than combat-
ants involved in the fighting. Similarly in Afghanistan, approximately a third of all
casualties in 2017 were children (Table 1.2) [23]. According to the Action on Armed
Violence (AOAV), around 42,000 deaths and injuries in 2017 resulted from explo-
sive violence, which is 38% more than the year before [27]. The continuous use of
explosive blasts in areas inhabited by civilians will result in a greater number of
child casualties when compared to adults and combatants living in the same con-
flict zone.

1.4 Anatomic Distribution

The epidemiological study of the anatomic distribution of war-related pediatric

injuries facilitates the proper identification of the etiology related to the injury and
the expectations of the treatment plans and outcomes.
Approximately 70% of pediatric blast injury patients have multiple body regions
affected, with burns and penetrating injuries to the extremities present in around
70–80% of the injured pediatric population, according to the pediatric blast injury
review [28]. Penetrating injuries to the head, neck, upper limb, and trunk affect over
80% of the children injured by blast explosions when compared to adults in which
31% were affected [28].
Children are subjected to an extremely high-energy burden following exposure
to a blast, which is measured through a widely used consensus called Injury Severity
Score (ISS) [20]. However, the ideal scoring system for injury is still unknown [29].
According to a literature review done on the Impact of Blast Injuries on Children,
20–36% of children experience severe injury with an ISS score of more than 15,
while 8–16% are critically injured with an ISS of more than 25 [20]. This can also
be classified according to the age group affected by the injuries. Children older than