Pediatric casualties in war zones are a devastating consequence of armed conflicts, causing significant physical, emotional, and cognitive challenges for affected children (1). War zones expose children to various forms of violence, such as being caught in crossfire or becoming victims of deliberate attacks, leading to head injuries that can result in severe head traumas such as traumatic brain injury (TBI). The consequences of pediatric TBIs in war zones are extensive, impacting not only the individual child but also their families and the community at large (2, 3).

War amplifies injuries due to the use of heavy artillery, explosive devices, and other weapons that cause substantial damage. The developing brains of children are particularly vulnerable, making them more susceptible to long-term cognitive and neurological impairments. The immediate effects of pediatric TBI in war zones can be life-threatening. Children may suffer from loss of consciousness, seizures, and respiratory difficulties, requiring urgent medical attention (4, 5).

Access to quality healthcare is often limited in war zones due to medical infrastructure destruction, lack of resources, and restricted movement. These challenges further exacerbate the difficulties in providing timely and appropriate care for children with TBIs. However, even when children with TBI receive initial medical care, the long-term consequences can be profound. Cognitive impairments, including memory deficits, attention problems, and executive functioning difficulties, are common. Emotional and behavioral changes, such as depression, anxiety, aggression, and impulsivity, may also arise due to the injury (1–3, 6).

These impairments can significantly affect a child's ability to learn, concentrate, and perform daily activities and their integration into society, leading to economic and public health burdens. Therefore, it is crucial that appropriate resources and research efforts are focused on comprehending the underlying mechanisms of TBIs in children in war zones. This understanding is essential for making accommodations considering the limited availability of specialized medical personnel, a shortage of rehabilitation facilities, and socioeconomic barriers that hinder comprehensive care (7). Our study aimed to clarify this topic, promoting awareness and prompting actions on this matter.

We carried out a systematic review using the PRISMA protocol. Figure 1 shows the results of the study using this protocol.

We found 14 clinical trials that specifically discussed pediatric traumatic brain injuries in war zones, along with other pediatric casualties in this context.

Table 1 presents the demographics of each study. Our findings show that 50% (7/14) of the studies report pediatric TBIs that occurred in Afghanistan. The total sum of all pediatric samples found in these studies is 14,624. The mean age falls between 8 and 10 years. The most prevalent mechanism of injury is blast related to explosive devices (57%), followed by ballistic injuries caused by gunshots (29%) and fragment injuries (14%). TBI accounts for one of the most commonly reported injuries in war zones.

Table 2 shows the outcomes and conclusions of the studies included in this systematic review. Our findings show that 64% (9/14) of the studies used the New Injury Severity Score or the Injury Severity Score (NISS or ISS) to report injuries. The range of mortality lies between 3.4 and 47%. Cuenca et al. report that most TBIs generate an unspecific pattern but suggest that neurosurgeons should be prepared for intracranial hemorrhages (18). Naaman et al. support this idea (19). On a different note, Cingoz et al. report that intraparenchymal bone fragments caused most TBIs in their study and suggest that surgical treatment should be established in all patients using a Glasgow Coma Scale (GCS) higher than 3 and a radiological indication (20). Finally, Klimo et al. and Maitland et al. emphasize that male patients die less than female patients, possibly due to the inequality of healthcare access for female patients in these regions (17, 21).

Table 3 shows the quality assessment of the studies included in this systematic review.

Multiple studies have demonstrated the vast consequences of war on children, from physical trauma to mental health problems (1, 6, 9, 11). Our study shows that TBIs in war zones have many mechanisms of injury that vary depending on the location and historical time. It is difficult to detail the characteristics of TBIs in every study, given that the scale used to represent the trauma is inconsistent and varies depending on the study. Additionally, most studies include “head trauma” or “head injury” as part of their TBI reports, even when the injuries range from minor bruises to injuries requiring neurosurgical consultation, making a detailed analysis of the TBIs difficult (5).

Our study focuses on all characteristics of TBIs; some data are provided by articles that failed to distinguish between pediatric and adult patient injuries but are good for understanding the background and characterization of TBIs in war. The most prevalent mechanism of injury is blast. Blast injuries usually cause more damage to the body than an isolated brain injury, which directly worsens the prognosis of the patients, increases the mortality of these cases, and raises concerns for bias in the collected data by making the reports unspecific information.

Blast injuries are linked directly to neurological effects due to the physical science behind them. Technically, explosive devices create shock waves with high-speed pressure changes that travel faster than sound. However, war explosions are more chaotic because they may involve multiple shock waves and reflections from surfaces. This causes various injuries from direct pressure effects on organs, flying objects that get thrown and hit people, and thermal effects. Electromagnetic disturbances may also be present, but their physiological impact is unclear (12).

Researchers are pivotal in advancing pediatric TBI understanding and treatment in war zones. Studies examining TBI's long-term outcomes, rehabilitation strategies, and psychosocial impact can guide evidence-based interventions.

We found a lack of evidence-based information concerning the approach and management of children with TBIs in conflict zones, primarily due to the absence of a clear consensus on their characteristics. Our findings reveal that head injuries were the most frequently identified type of injury, often caused by blasts. The majority of affected children were reported to be from Afghanistan, with both male and female children impacted, and their average age falling between 8 and 10 years. Mortality rates varied significantly from 4 to 47%, depending on the conflict, indicating substantial diversity. In light of these findings, it is evident that as the world seeks pathways to global peace, there is an urgent need to conduct research, provide training, and deploy specialists to these regions if governments are genuinely committed to enhancing outcomes for this vulnerable population. These conclusions should serve as a catalyst for potential recommendations aimed at medical professionals, legislators, and stakeholders, urging them to ensure timely treatment and rehabilitation services for pediatric patients based on this compelling evidence.

The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.

AA: Data curation, Formal analysis, Investigation, Methodology, Resources, Visualization, Writing—original draft, Writing—review and editing. KR: Formal analysis, Validation, Visualization, Writing—review and editing. AT: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Resources, Validation, Visualization, Writing—original draft, Writing—review and editing.