Background & Aims
Children are frequently injured as a result of war. Approximately, 468 million children worldwide live in areas affected by armed conflict (Save the Children, 2022), with these rates expected to increase since the escalation of conflict in Gaza where 6000 children were predicted to have been injured during the first 3 weeks of conflict in October 2023 (Save the Children, 2023).
Major physical trauma inflicted because of war can result in major burns, amputation and other painful events requiring analgesics and rehabilitation. Often these injuries can result in complex pain presentations, including nociceptive and neuropathic pain, and headaches (Clark et al., 2009). However, there is no guidance on how to manage pain in children with major trauma, despite a critical need internationally (Bertani et al., 2015; Bullman et al., 2018). This review aims to identify key findings from the scarce existing literature and highlight the many research gaps within this field.
Methods
We conducted a series of mini literature reviews that focus on two aspects of the research; 1) To identify established factors that need to be considered when treating paediatric pain associated with major trauma; 2) To determine which of these factors have been researched in the context of war.
9 reviews were conducted on communication, the role of the caregiver, paediatric pain assessment, PICU pain management, rehabilitation, amputation, burns management, dignity and culture, respectively. Experts in the field agreed these factors to be pertinent to treating paediatric pain following a major accident.
A base level literature search was conducted using key terms relevant to the review topic. Information was extracted based on agreement among experts of its relevance to the review aims. Each review was conducted over just a few days due to a limited research timeframe, a result of escalation of conflict globally, as well as a call from clinicians for guidance in the area.
Results
We summarise factors key to treating children injured in war zones including assessment, communication and the role of the caregiver. Most research had been conducted within high income, conflict free countries, with few studies conducted in countries experiencing war. However, the content of these reviews suggests the following should be considered by those treating children injured in war.
Language and pain assessment methods used needs to be age and culture appropriate due to differences in cognitive development and social norms for the individual. The role of the caregiver can be complicated as they can influence a child’s self-report, however, they are more accurate at assessing children’s pain than clinicians and play a significant role in the comfort and communication of the child so should not be overlooked.
However, crucially, there is the apparent lack of literature that looks at any aspect of pain management in children who have sustained an injury due to war.
Conclusions
Limited research explores pain management of children injured in war. To combat this, we plan to do three things; research, collaborate and promote intervention.
Firstly, we will conduct research in novel areas identified by the review to gain a better understanding of factors that will aid paediatric pain management in war zones.
Secondly, we aim to find likeminded experts who can contribute to research and intervention development. We believe the bigger community of researchers, the bigger the difference we can make.
Lastly, we plan to develop a Paediatric Major Trauma Pain Manual in collaboration with the Paediatric Blast Injury Partnership. The pain manual, guided by the Lancet transformative goals for paediatric pain (Eccleston et al.,2021) will provide guidance on how to best treat the pain of children injured in war ethically and effectively from first contact, through ward care to ongoing rehabilitation with the aim of preventing the development of chronic pain.
References
Bertani, A., Mathieu, L., Dahan, J. L., Launay, F., Rongiéras, F., & Rigal, S. (2015). War-related extremity injuries in children: 89 cases managed in a combat support hospital in Afghanistan. Orthopaedics & Traumatology: Surgery & Research, 101(3), 365-368. https://doi.org/10.1016/j.otsr.2015.02.003
Bulman, R. J., & Wortman, C. B. (1977). Attributions of blame and coping in the” real world”: severe accident victims react to their lot. Journal of personality and social psychology, 35(5), 351.
Eccleston, C., Fisher, E., Howard, R. F., Slater, R., Forgeron, P., Palermo, T. M., … & Wood, C. (2021). Delivering transformative action in paediatric pain: a Lancet Child & Adolescent Health Commission. The Lancet Child & Adolescent Health, 5(1), 47-87.
Worst Crimes Against Children In Conflict Reach Highest Level Since Records Began (14.12.2023), Save the Children, https://www.savethechildren.org.uk/news/media-centre/press-releases/crimes-against-children-in-conflict-reach-highest-level#:~:text=The%20report%20also%20reveals%20that,2.8%25%20increase%20compared%20to%202021.
Gaza: 3,195 Children Killed In Three Weeks Surpasses Annual Number of Children Killed In Conflict Zones Since 2019,(29/10/2023), Save the Children, https://www.savethechildren.org.uk/news/media-centre/press-releases/gaza-childrens-deaths-in-last-three-weeks-surpasses-total-child-