Historically, the focus of blast injury research has been on how an explosive weapon effects the body of a fit male adult combatant. Today, there seems little justification for this focus given that over the last decade, explosive weapons have overwhelmingly killed and injured civilians, not combatants. Many of the dead and injured were older-men women and children. Indeed AOAV data shows that when explosive weapons were used in populated areas, over 90% of those killed and injured were civilians. The ‘huge knowledge gap’ in paediatric blast injury and the lack of paediatric medical equipment has contributed to the higher in-hospital mortality rates of children in conflict.

The Paediatric Blast Injury Partnership has done much to fill this vacuum. In 2019, the Partnership’s Blast Injury Field Manual was published to provide medical staff in conflict settings with little or no previous experience or training, guidance on the treatment of severely injured children. However, gaps still remain with regard to gender and the longitudinal outcomes of child blast patients. Outlined in this report are AOAV’s findings on how children are uniquely affected by explosive weapons and how the aftercare that children receive is frequently inadequate or non-existent.

Between 2011 and 2019 at least 15,248 children were killed and injured by explosive violence, according to AOAV’s explosive violence data set. This is just a fraction of the true number as many child injuries and deaths would go unreported in English language media. An additional 610 children were also reported as having been casualties of unexploded ordinance (UXO).

It is worth stressing again that, in recording casualties of explosive weapons, monitoring and observation groups often do not distinguish between adults and children in their reporting.

Analysis carried out by Save the Children in 2019 found that, across five of the deadliest global conflicts for children (Afghanistan, Yemen, Syria, Nigeria, Iraq), an average of 72% of child casualties were because of explosive weapons.

Taking a closer look at Syria, Debarati Guha-Sapir, a Professor at University of Louvain School of Public Health, led a 2018 study examining patterns of harm in the Syrian conflict between 2011 and 2016. The study found that 83% of all child deaths were caused by explosive weapons in comparison to 11% which were the result of shooting. The trend was the opposite for adult combatants: 84% of adult male combatants were killed by shooting and only 13% by explosive weapons. Guha-Sapir’s study provided incontrovertible evidence that explosive weapons disproportionately killed and injured children in Syria, while having a relatively minimal effect on adult combatants.

Data extracted from AOAV’s Explosive Violence Monitor shows that between 2011 and 2019 airstrikes were, proportionally, the most harmful explosive weapon for children. Air-launched explosive weapons accounted for 35% of all child casualties, followed by shelling (including rockets, missiles, mortar, and tank shells) which represented 28% of all child casualties from explosive violence (see Figure 2). AOAV’s data has been corroborated with the findings of other studies; Guha-Sapir’s study of Syria found that air bombardments were responsible for as many as 53% of all child deaths.

The fact that airstrikes were the primary cause of child casualties is deeply concerning given that non-state actors very rarely have access to air-launched explosive weapons. Indeed, AOAV data shows that state actors were the perpetrators of at least 53% of all child casualties from explosive violence (see Figure 3). This means that state actors, all of which have ratified the four Geneva Conventions and signed the UN Conventions on the Rights of the Child, have been responsible for the majority of child casualties from explosive violence globally over the last decade.

Children are seven times more likely to die from blast injuries than adults. This higher mortality rate is not only explained by children’s inherent physiological vulnerability, but also the quality and cost of paediatric care provided in conflict zones.

In an explosion children (in about 65-70% of cases) are most likely to suffer injuries to multiple regions of the body. In AOAV’s interview with Guha-Sapir, she described how barrel bombs “perforate a child’s body in multiple places with shrapnel.”

While an adult body may be able to withstand this, a body of a three or four year old cannot. Barrel bombs are unguided and cause immense harm – especially in populated areas. The proportion of children killed by barrel bombs in Syria was nearly twice that of civilian men.

Children are much more likely to suffer head and facial wounds from explosive weapons than adults are; injuries to the face, neck, head, upper limb and trunk affect 31% of adult patients in comparison to 80% of child patients. Injuries in these parts of the body are also more likely to kill than explosive harm to extremities and lower limbs. For this reason, explosive weapons that may have been designed to maim adult male combatants – kill children. Toe poppers and butterfly mines contain a small amount of explosive materials and are designed to slow down advancing forces. The mini explosions caused by these weapons may blow up a soldier’s foot or part of their foot, but they can kill a child.

A 2017 study that profiled IED and mine injuries in Afghanistan observed the disturbing frequency with which children suffered the severest injuries from IEDs. In the entire cohort of adults and children, 70% of victims underwent multiple amputations from IED injures. Within the cohort of children this rose to 89% suffering multiple amputations. 33% of children lost three limbs. In AOAV’s interview with one of the authors of the report, Dr Vivian McAlister, he described how IEDs were being deployed “to cause maximum injury to the individual”.

Sadly, even when the fighting has stopped children are still at great risk. In fact, children are 50% more likely to be victims of blast injury after conflicts are over than during conflicts. UXOs and explosive remnants of war (ERW) disproportionately effect children as they are prone to playing in mined fields and picking up these sometimes colourful, toy-like devices.

A child’s age, gender and socio-economic background are all variables which will determine their recovery from explosive violence. For example, while blast injuries are more likely to kill younger children, older children have similar injury patterns to adults.

A review of paediatric blast literature found that, following the use of explosive weaponry by non-state actors against civilians, the most commonly injured paediatric cohort are 10–18 year olds, while children involved in with ERW blast injuries were generally aged between 4 and 10 years old.

Not only is age particularly difficult to identify, but within the field of blast injury research the varying definitions of a child, ranging from less than 15 to less that 19 years poses a challenge when making comparisons.

AOAV’s Explosive Violence Monitor data shows when the gender is known, there are 7% more male child casualties than female. However, it must be emphasised that gender of a child is rarely specified, so these results provide only an impression, rather than an exact reflection. Often adolescent boys are counted as adults or on some occasions, combatants. The real number of male child casualties is much higher. For instance, in Guha-Sapir’s study boys represent 64% of deaths in Syria. In paediatric blast injury research, over 70% of studies three-quarters of the victims are boys.

The predominance of boys among casualties of explosive violence is largely due to cultural norms in low-and medium-income countries (LIMCs) in which boys are present in social areas targeted by IEDs or are working in fields laden with ERW and landmines.

Data collected from Afghanistan’s Directorate of Mine Action Coordination (DMAC) shows that, since 1979, 15,278 male child casualties compared to 2,404 female child casualties. While the fatality rate was almost identical (30% and 31% respectively), boys were found to be six times more likely to suffer injuries from mines and ERW.

How children experience pain remains poorly understood. In adults pain is present in the entire blast injury continuum, from point of injury to the fitting of prosthesis. But according to the Paediatric Blast Injury Partnership treatment, and the management of pain in that treatment, has yet to be adapted to meet the specific needs of child who has been injured by a blast.

Undertreated, unrecognised, or poorly managed pain in childhood leads to and long-lasting negative consequences that continue into adulthood, including continued chronic pain, disability, and distress.

Pain is invisible and so treatment of pain often relies on communication with the patient. In a 2017 study girls were found to be more likely to report chronic pain than boys during adolescence, however, their chronic pain concerns were dismissed more often by physicians (35% of cases) compared with boys (17% of cases).

From the emergency surgical procedures in field hospitals to the years of aftercare appointments – paediatric care is expensive. According to a 2019 review of paediatric blast care: “paediatric victims affected by blasts constitute a disproportionately large resource burden on operative workload, as well as intensive care and hospital beds.” Studies of US military medical treatment facilities in Afghanistan found that, while children comprised only 3%–6% of their total admissions, they required approximately double the total bed spaces (7%–11%). On average a child’s length of stay was three times that of coalition troops admitted.

Children also often require multiple operative procedures. One multi-paper review found that blast injury patients aged between 9-14 years old were found to need an average of five procedures per patient. The financial burden of rehabilitation and prosthesis on the children and host country’s health system is considerable, in the US on average equating to $116,000 until the age of 18 for a single lower limb amputation.

Such paediatric care can be prohibitively expensive. If treatments are provided by public health services and parents cannot afford them, life-saving procedures will be denied to children. In 2020, AOAV conducted interviews among the refugee population in Lebanon. Parents told AOAV that they could not afford treatments and operations for their children, including severely disabled children unable to access care or assistance. AOAV met with one mother whose child had passed away four months before the researchers’ visit; she claimed that she could not afford the surgery her daughter needed. The operation, it was stated, would have been curative.

In an interview with AOAV, Dr Michael von Bertele, the former Director General of the Army Medical Services, identified the long-term outcomes of survivors as the largest knowledge gap in the field of paediatric blast research. Follow up rarely exists, where there is monitoring of the long-term effects of paediatric blast injury, it is patchy. Geographical displacement, especially when driven by conflict, increases the likelihood of children not receiving follow-up care and rehabilitation.

Paediatric patients confront unique challenges in managing prosthesis. Unlike an adult, when a child undergoes an amputation the amputated bone will “continue to outgrow the surrounding tissue”. This not only means they will need repeated visits to the hospital to resize their prosthesis, but that they may also need “repeated surgical amputations” in order to manage the bone length. It is difficult to overstate the psychological impact of an amputation, let alone having to undergo the procedure multiple times.

The long-term social implications for children with blast injuries are little known and country dependent. For example, in Afghanistan so-called ‘villages of the handicapped’ have been erected to serve as communities for people with a disabled family member. Most of the disabled living in these villages have been injured over the past four decades of war. This approach is incompatible with UN policies of inclusion and integration, yet one resident remarked: “I think we’ve made the best out of it. There is war everywhere around us, but our village – our home – is quiet and peaceful.”

Such community, though, is sparse on the ground, and the absence of social care is often gendered. Despite girls comprising a minority of those effected by explosive weapons, they are likely to be disproportionally disadvantaged and suffer gender-specific discrimination as survivors. Examples of this is are in marriage and education. According to a 2020 Human Rights Watch report, in Afghanistan, “Women with disabilities are generally seen as unfit for marriage and a burden on their families.”. The report details how “girls with disabilities often lose out entirely on education” – as many as 80% of disabled Afghan girls do not go to school.

Save the Children’s Paediatric Blast Injuries Partnership has made enormous progress in advancing professional and public understanding of child blast injuries and on how to provide effective treatment for children caught up in the violence of war. However, the long-term outcomes of children, especially girls, who suffer blast injuries remains largely unknown and their experiences are all too often untold.

At a time when civilians are shown to be the most likely to be harmed by explosive violence in populated areas, the urgency of more research into and more funding provided in relation to paediatric blast injuries cannot be under-estimated.