This multicentre epidemiologic study provides extensive information on the epidemiology and demographics of the paediatric weapon-wounded patient population treated at eight different ICRC-supported medical treatment facilities. As opposed to many previous reports on weapon-wounded children, this study includes patients from multiple conflict zones over time.
This study shows that children make up a significant part of the patient population (15.3%) in ICRC-supported hospitals, have considerable surgery needs and often require multiple surgeries per individual. When compared with adult patients, children are more frequently seen with fragment injuries, burns and mine injuries. Sadly, our data reveal that children, more often than adults, are injured in multiple body regions and have higher in-hospital mortality rates.
The surgical workload for paediatric patients of 15.7% that was found in this study is closer to that in military hospitals (16%) [13, 14], than in other humanitarian efforts (30%) [15,16,17,18,19].This is expected since the ICRC mainly treats weapon-wounded patients. The unequal distribution of sex among children treated in hospitals in conflict areas, with the vast majority being male (overall male to female ratio of 4:1), is widely described in the literature [8, 11, 12, 16, 21, 24, 30, 31]. It has often been speculated that females are less likely to become injured in armed conflicts. However, over the years, females seem to be participating more actively in conflicts  and to be markedly affected by armed conflicts , which could be reflected in the decrease in the male/female ratio in the most recent time period of our study (Goma).
In the studied areas, paediatric patients often reached the hospital faster than adults. Generally, children are probably less likely to go outside on their own and will often have a supervising adult in close proximity who could take them to the hospital. With limited prehospital medical services and poor infrastructure in conflict areas, there might be more societal support to arrange transport to the hospital for injured children because of the emotional impact this has on witnesses.
Although paediatric patients had significantly shorter hospital stays than adult patients, the median length of hospital stay for children in this study (13 days IQR 6–31) was much longer than those reported in the literature concerning military hospitals (median ranging from 3 to 4 days) [7, 8, 10, 24]. Due to the difference in mandates between military hospitals and the humanitarian ICRC treatment facilities, children are likely to be transferred from a military hospital to a civilian medical facility after emergency care , whereas the ICRC treats patients until they are in no further need of in-hospital care.
The difference in the mechanism of injury seen between adults (gunshot wounds) and children (fragments, mines, burns) is also seen in casualties of the ongoing Syrian civil war  and could be because adults are more likely to be actively involved in the conflict. A previous study concerning ICRC data stated that during war, mines and fragmenting munitions are more likely than bullets to injure civilians .
Significantly more mine injuries were reported among paediatric casualties in Quetta and Peshawar (located in Pakistan close to the Afghan border) during 1990–1993 and Kandahar (Afghanistan) when compared with mine injuries from other locations. Our data from Peshawar 2009–2012 reveal a significant decline in mine injuries compared to those injuries from the early 1990s. We have reported on this previously, and other papers corroborate this finding [11, 32]. This decline in mine injuries was anticipated in Afghanistan, as large areas have been cleared of mines and unexploded ordnance since 1999; the same year, the Mine Ban Treaty came into force [34, 35]. A further decline in mine injuries should, hopefully, be expected from current conflicts in areas around participating states.
Very few paediatric patients had burns reported as the mechanism of injury, which is much less than reported in the literature [8, 10, 21, 24]. This underrepresentation is probably attributable to the high pre-hospital mortality rate of patients who sustained extensive burn injuries. Additionally, in the ICRC’s data, there could be an overlap between fragment, mine and burn injuries due to constraints in the classification of injury mechanisms. For example, a burn could be the most significant injury, but the injury could still be classified as fragments or mine if that was what caused the burn. The prevalence of burns could therefore be underestimated in this material.
Concerning the anatomical site of injury, our study results are in line with those of more recent epidemiological studies on paediatric injuries in Iraq and Afghanistan; the extremities were most frequently injured followed by the head and neck [12, 21, 24].
Regarding the different contexts studied, it is important to consider the possibility of pre-hospital patient selection, meaning that more severely injured children cannot gain access to medical care in time and die in the field. This is reflected by a lower percentage of paediatric patients with fewer critical injuries and a lower in-hospital mortality rate in Lokichogio, which was located further away from the conflict. Although in-hospital mortality rates were therefore generally low, paediatric patients showed a slightly higher mortality rate than adults, which could be explained by various reasons. Mainly, paediatric patients often reach the hospital faster than adults, which reduces the number of patients that deceases in the field. Furthermore, a higher mortality rate might indicate that more skills and expertise are required for this patient category; younger and more severely injured paediatric patients have shown to benefit from a higher level of paediatric expertise at the treatment facility . However, the difference in mortality rate could just as well be caused by differences in body physiology and anatomy, mechanism of injury, and higher in-hospital prevalence of critical (head and neck) injuries in children. It has also been suggested that young children with conflict-related injuries may have an independent increased risk for death .
This study analysed differences in the epidemiology and demographics of paediatric patients between hospital locations and their contexts. The main findings may be mostly attributable to the differences in hospital location in relation to the conflict. However, any of the differences between hospital locations found in this study could also be attributed to differences in hospital logistics and the compliance of each individual employee with ICRC treatment protocols.
This study is not without limitations. Foremost, data acquisition can be impeded under field conditions in austere environments, and therefore, the accuracy of these data somewhat relies on the ability of ICRC medical personnel to keep a record of every patient and to thoroughly record every variable for each patient. This difficulty is reflected by the missing data for some variables and could have resulted in missing cases (patients) in our database. Additionally, the paper data were manually transferred into an electronic database, which poses the risk of coding mistakes.
Our data largely corroborate more recent data from military hospitals in conflict zones, but it would be preferable to compare our data with those of other humanitarian organizations located in conflict zones. The varying definitions of a child, ranging from < 15 years to < 19 years, also pose difficulties for comparisons with existing literature; hence, these comparisons should be interpreted with appropriate caution. An age of less than 15 years was used in this study as the definition of a child to ensure that a strictly paediatric population was studied. Additionally, this definition has been used in several previous studies [15, 23, 37, 38].
Although some of the patient data analysed in this study are somewhat dated, they provide a unique opportunity to study the evolution of paediatric injury epidemiology from conflicts over time.
The majority of our study subjects were victims of protracted conflicts in South Sudan (ICRC facility in Lokichogio) and Afghanistan (ICRC facilities in Kabul, Kandahar, Peshawar and Quetta), countries that face ongoing armed violence. During our study period, Afghanistan has been affected by rocket attacks and aerial bombings , strategies that are largely still used in modern conflicts . Although the nature of these conflicts is subject to change, recent developments in modern warfare could increasingly affect civilians, including children. First, modern conflicts more often occur in densely populated urban areas . Second, the nature of conflicts has shifted from confrontations between professional armies to one-sided violence, intrastate confrontations between the military and civilians or hostile groups of armed civilians . Last, new technologies in weaponry design are increasing the distance between the user and the victim, which might cause the user to feel less responsible for his or her actions; this, together with the fact that these weapons can easily injure multiple people, could both contribute to the ongoing increase in the proportion of civilian casualties of armed conflict, as previously stated by Coupland et al. .
Due to the continued high prevalence of paediatric injuries in conflicts, the ICRC and other humanitarian organizations should deploy medical personnel who are skilled in treating paediatric trauma. This applies not only to surgeons but also to the whole scope of medical professions. The ideal situation would encompass deployment of highly skilled medical professionals with many years of experience in the (surgical) treatment of both paediatric and adult trauma patients. Considering the highly specialized medical professions nowadays, this is generally not feasible. Organizations could consider deployment of medical personnel primarily trained for paediatric trauma patients, but it is just as important to ensure greater participation of non-paediatrically trained personnel in basic courses or master classes focusing on paediatric casualties or to provide them with theoretical learning materials on this topic. Medical equipment on deployment should be suitable for paediatric populations, and deployed personnel should be provided the chance to become familiar with the equipment they will have at their disposal to treat paediatric patients during deployment.