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British doctors launch world’s first handbook for child blast injuries

Save the Children, May 16th 2019 

LONDON —A coalition of British doctors, researchers and charities has launched a life-saving handbook for children severely injured by explosive weapons.

The Paediatric Blast Injury Field Manual – designed for medics in war zones who often lack specialist training – is the first comprehensive guide to injuries suffered by children from weapons like airstrikes, artillery and landmines.

It was developed by the Paediatric Blast Injury Partnership (PBIP), a coalition of doctors and experts founded by Save the Children and Imperial College London. [1]

Earlier this month Save the Children partner Syria Relief began distributing the manual for the first time to emergency units across northwest Syria, including Idlib and Aleppo. The guide will be deployed later in the year to other conflict zones including Yemen and Afghanistan.

Step-by-step instructions cover situations ranging from resuscitating children on the battlefield and saving limbs, to rehabilitation and psychological care. The handbook is durable, lightweight, and readable in low-light conditions.

Dr Paul Reavley, Consultant Paediatric Emergency Physician at Bristol Royal Hospital for Children, a former UK military doctor and the lead author of the Paediatric Blast Injury Field Manual, said:

“I’ve seen medics overcome with emotion when children come in with blast wounds. In a war zone, you’re mentally prepared for the adults. You expect to treat injured soldiers, and even civilian adults. But the sights and sounds of a young child torn apart by bombs are something else. 

“I remember in Afghanistan having to resuscitate an 8-year-old girl, who had three limbs blown off by an IED. She was about the same age as my own daughter. I’m a trained paediatrician, but that connection shook me hard. And it hits you just when your mind needs to be at its clearest. 

“Until this manual, there really hasn’t been anything to prepare doctors for dealing with the horror of children injured by blasts. For the first time it tackles psychological, as well as the physical, challenges. It’s not just a guide to practical procedures – it’s a crucial emotional crutch.”

Dr Malik, Paediatrician and Medical Manager at Syria Relief, currently leading distribution of the manual to Syrian doctors, said:

“For more than eight years we’ve seen children dying on the operating table from wounds that adults have survived. The tragedy is these deaths could have been prevented with basic training. This manual is designed for anyone with a medical degree and a scalpel. I’m excited this is going to doctors in Syria. It’s a simple solution that will undoubtedly save lives.

Most medical studies are based on injured military personnel, making definitive estimates for the scale of blast injury in children almost impossible.

But existing research, while limited, suggests children suffer unique patterns of injury and are far more likely to die from blast wounds than adult conflict casualties.

A study in 2017 by Imperial College London found children injured by explosive weapons are far more likely than adults to suffer penetrating injuries to the head, severe burns and complex injuries which require multiple surgeries. [2]

Research published in the Lancet on conflict fatalities in Syria between 2011 and 2016 also suggests children were disproportionately affected by explosive weapons. Shockingly, children were seven times more likely to die from blast injuries than adults involved in the fighting. [3]

And in Afghanistan, new analysis by Save the Children found explosive weapons were the primary cause of death for 84 per cent of 1,580 child conflict fatalities across a two-year period, compared to 56 per cent of civilian adult deaths. Compared with adult casualties, children were twice as likely to be killed by mortars, rockets and grenades. [4]

Major General Michael von Bertele CB OBE FRCP, former Director General of British Army Medical Services and a member of Paediatric Blast Injury Partnership (PBIP), said:

"The sad reality is most medics just haven’t been trained to treat children injured by blasts. Nearly all the textbooks and procedures we have are based on research on injured soldiers, who are usually fit adults. 

“We know children’s bodies are different. They aren’t just small adults. Their skulls are still not fully formed, and their undeveloped muscles offer less protection, so a blast is more likely to damage their brain and lungs or tear apart organs in their abdomen, even when there’s no visible damage.

“And when children suffer severe injuries to their legs and arms, it takes highly specialised knowledge to know where to amputate so that you can factor in future growth. Without that, children are left with even worse disabilities, and often intractable pain for life."

A century after Save the Children was founded to protect children affected by conflict, the charity is today launching a new campaign to #StopTheWarOnChildren, urging the UK to make children off limits in war.

Among its recommendations, the charity is calling for a new ‘strategy to protect children’ that lays out exactly how the Government will keep children safe from the horrors of modern conflict.

That would include measures to avoid the use of indiscriminate explosive weapons in populated areas; a commitment to suspend arms sales where there is a risk they may be used to kill or injure children; and support for a Global Paediatric Trauma Register to better track trends in harm to children from military action by the UK or its allies.

Kevin Watkins, CEO of Save the Children, said:

“This manual is a practical step that will save countless lives. But prevention is the best option. Even in war, children have a right to protection.

That’s why we are calling on governments to adhere to the humanitarian laws and norms and human rights provisions that are there to protect children. We have been underestimating the harm done to children by explosive weapons in densely populated urban areas. And attacks that cause disproportionate civilian harm are illegal under international law.

“The bottom line is that all governments and armed forces need to stop treating children as though they are adults in miniature. Evidence on blast injury shows they are more vulnerable, and this should be reflected in how those using explosive weapons assess risk – and how agencies responsible for investigating possible war crimes review evidence.

“It is now vital that countries like the UK lead the way in applying international law to protect children. That includes not just setting the highest standards for civilian protection in military training and engagement with allies, but also reviewing arms exports to countries that fail to meet those standards.

“We desperately need a new approach to modern conflict that puts children and their families first.”


1.     In December 2017, Save the Children and the Centre for Blast Injuries Studies based at Imperial College London convened a pioneering workshop to explore issues around paediatric blast injury. It was the first time experts from diverse fields – including surgery, paediatrics, rehabilitation, prosthetic design, and academia – were brought together to discuss blast injury in children. The workshop issued a communique that created the Paediatric Blast Injury Partnership (PBIP) to deliver practical resources and research. At the request of Syrian medics, the PBIP pooled expertise from British doctors, researchers at Imperial College London, and charities like Save the Children and Humanity & Inclusion, to develop the first comprehensive field manual for paediatric blast injury. Full production credits for the Paediatric Blast Injury Field Manual can be found here.

2.     See The Impact of Blast Injury on Children, a literature review conducted in 2017 by the Centre for Blast Injury Science (CBIS) at Imperial College London.

3.     Between March 18, 2011 and December 31, 2016, Save the Children calculates 83 per cent of 17,401 child battle deaths were due to blast injury, compared to 56 per cent of 84,052 adult civilian deaths, and just 12 per cent of 41,844 adult combatant deaths. See Guha Sapir et al (2018) ‘Patterns of civilian and child deaths due to war-related violence in Syria: a comparative analysis from the Violation Documentation Center dataset, 2011–16’, The Lancet Global Health, Volume 6, ISSUE 1, Pe103-e110.

4.     Save the Children’s analysis of United Nations Assistance Mission for Afghanistan (UNAMA) casualty logs for 2016 and 2017, the only years for which a full breakdown of causes of death is publicly available. Of 1,580 child fatalities where a cause of death was specified, 1,331 (84%) deaths could be attributed to blast-related causes, 202 (13%) to non-blast causes and 47 (3%) to mixed attacks involving both explosive and non-explosive weapons. Over the same period there were 3,460 adult deaths, of which 1,948 (56%) were attributable to blast-related causes, 556 (16%) to non-blast and 956 (28%) to mixed attacks where no distinction was specified. Indirect fire systems used in ground battles, such as mortars, rockets and grenades, caused 487 (31%) child and 540 (16%) adult deaths.

Join the campaign to make children off limits in war at action.savethechildren.org.uk/offlimits

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