pain and neurological sequelae of cluster munitions on children and adolescents in south lebanon
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ORIGINAL ARTICLE
Pain and neurological sequelae of cluster munitions on childrenand adolescents in South Lebanon
Youssef Fares • Fouad Ayoub • Jawad Fares •
Rabi Khazim • Mahmoud Khazim •
Souheil Gebeily
Received: 23 February 2013 / Accepted: 26 March 2013 / Published online: 7 April 2013
� Springer-Verlag Italia 2013
Abstract This paper aims at evaluating the neurological
repercussions arising from injuries sustained due to cluster
munitions in children up to 18 years in South Lebanon
following the 2006 conflict. Data on neurological and pain
symptoms suffered during and after treatment because of
sub-munitions in South Lebanon from August 2006 till late
2011 were prospectively recorded. Patients were divided
into subcategories; children aged 12 and under and ado-
lescents aged between 13 and 18. During the study period,
there were 407 casualties, 122 (30 %) of which were aged
18 years or younger. There were 116 (95 %) males and six
(5 %) females. Average age was 14 years. 10 (8.2 %), all
males, died as a result of their injuries. 42 (34.4 %) were
children and 80 (65.6 %) were adolescents. 112 had sur-
gical treatments for their injuries. 83 out of 112 patients
(74 %) with non-lethal injuries had amputations, 67 %
children and 78 % adolescents. Among those who had
amputations, 31 (37.4 %) suffered from phantom limb pain
and 71 % suffered from stump/residual limb pain. 88 % of
patients were diagnosed with post-traumatic stress disorder
(44 % children and 77 % adolescents) and 41 % were
diagnosed with post-concussion syndrome. Four patients
(3.6 %) suffered from traumatic brain injuries, both pene-
trating and closed. Pain syndromes were found in all
patients who had amputation. The injury related comor-
bidities together with many post-concussion syndrome
cases, and fewer traumatic brain injuries lead into a high
level of physical, psychosocial and economic burdens on
the community.
Keywords Cluster bombs � Cluster munitions �Neurological effects � Psychological effects � Pain
Introduction
During the Israeli–Lebanese conflict from 12 July to 14
August 2006, upto four million sub-munitions were
reported to have been dropped on South Lebanon; one
million of which remained unexploded according to the
United Nations Mine Action Service [1]. Most of these
munitions were dropped on rural villages in the south of
Lebanon, where most of the hostilities were waged. The
environment and nature of the affected areas, the attractive
shapes and forms of the munitions, and the curiosity of
children who may mistake them for toys increase the sus-
ceptibility of children and adolescents to getting victimized
by cluster munitions [2] (Fig. 1).
Y. Fares (&)
Neurosurgery Division, Faculty of Medical Sciences, Lebanese
University, Beirut, Lebanon
e-mail: yfares@ul.edu.lb
F. Ayoub
Department of Basic Sciences, Faculty of Dental Medicine,
Lebanese University, Beirut, Lebanon
J. Fares
Faculty of Medicine, American University of Beirut,
Beirut, Lebanon
e-mail: jyf04@mail.aub.edu
R. Khazim
Orthopaedics, Southend University Hospital, Westcliff on Sea,
Essex, UK
M. Khazim
Institute of Human Genetics,
Newcastle University, Newcastle, UK
S. Gebeily
Neurology Division, Faculty of Medical Sciences,
Lebanese University, Beirut, Lebanon
123
Neurol Sci (2013) 34:1971–1976
DOI 10.1007/s10072-013-1427-4
While civilians constitute roughly 70 % of all causalities
caused by cluster munitions; Landmine & Cluster Muni-
tions Monitor reports that children make up one-third of
causalities worldwide [2, 3]. UNICEF reported that from
2008 till 2010, children accounted for half of all civilian
casualties [4].
Cluster munitions-related neurological injuries include
phantom limb pain, stump/residual limb pain (SP/RLP),
post-traumatic stress disorder (PTSD), post-concussion
syndrome (PCS), penetrating traumatic brain injury (pTBI)
and closed traumatic brain injury (cTBI).
Although child injuries from cluster munitions are a
public health concern in Lebanon, as they result in dev-
astating neurological, psychological and socio-economic
consequences, the extent of neurologic and pain syndromes
has never been investigated in this population. The aim of
this study is to determine and evaluate the neurological and
pain syndromes in children and adolescent casualties
because of cluster munitions following the end of war
hostilities on 14 August 2006.
Materials and methods
This prospective study was conducted at the Neurosurgery
Division at the Lebanese University and its affiliated hos-
pitals. The study reported all the cases reported between 14
August 2006 and 31 December 2011, with injuries related
to cluster bombs. Age, sex, type of injury, location of
incident, organ loss, post-treatment and post-traumatic
neurological and social circumstances of the patients were
evaluated. The DN4 questionnaire was used as a tool to
identify the subtypes experienced by the patients [5].
Neuropsychiatric injuries studies included post-ampu-
tation pain symptoms, PTSD, PCS, and post-traumatic
brain injury (pTBI).
Post-amputation pain syndromes were categorized into
phantom limb pain (PLP) and SP/RLP. PLP is identified as
a chronic neuropathic pain, perceived stressfully by the
individual as originating from the amputated part of the
body. SP is identified as an evoked pain whenever it was
localized in the distal residual limb and usually made worse
by the pressure of wearing an artificial limb (prosthesis).
RLP was included as an SP subtype in this study. The
Faculty of Medical Sciences of the Lebanese University
granted ethical approval.
Results
During the study period, there were 407 casualties as a
result of cluster munitions, 122 (30 %) of which were aged
18 years or younger, who are the subjects of this study.
34.4 % were children and 65.6 % adolescents. Table 1
summarizes the study population with regard of the dis-
tribution of deaths and non-lethal injuries by age and sex
(Table 1). 116 (95 %) were males and 6 (5 %) females. 10
patients (8.2 %), all males, died as a result of their injuries.
112 had non-lethal injuries. The average age was 14 years.
Fig. 1 A Lebanese child passing near an unexploded sub-munition
Table 1 Distribution of deaths and non-lethal injuries as a result of
cluster munitions explosions by age and sex
Age Deaths
(% of all
males)
Injuries
(%males)
Injuries
(%females)
Injuries
(%all)
Total (%)
Children
(0–12 years)
3 (7.1) 36 (29.5) 3 (7.1) 39 (92.9) 42 (34.4)
Adolescents
(13-18 years)
7 (8.75) 70 (87.5) 3 (3.75) 73 (91.25) 80 (65.6)
Total 10 (8.2) 106 (86.88) 6 (4.92) 112 (91.8) 122 (100)
Table 2 Distribution of amputations and post-amputation pain
syndromes as a result of cluster munitions explosions by age
Injuries Children
(%)
Adolescents
(%)
Total (% of
amputations)
Amputations 26 (66.7) 57 (78.1) 83 (100)
Phantom limb pain (PLP) 8 (20.5) 23 (31.5) 31 (37.3)
Stump/residual limb pain
(SP/RLP)
17 (43.6) 42 (57.5) 59 (71.1)
Total number of surviving or non-lethal injuries: children 39, ado-
lescents 73
1972 Neurol Sci (2013) 34:1971–1976
123
112 had surgical treatments for their injuries that included
injuries to the head, upper and lower limbs, abdomen,
genital areas, skin and muscular lesions, and infections.
83 out of 112 patients with non-lethal injuries (74 %) of
patients had amputations. The incidence of post-amputa-
tion pain syndromes by age is presented in (Table 2). The
incidence of neuropsychiatric syndromes by age is pre-
sented in (Table 3).
Discussion
Children’s vulnerability
The vast majority of the distribution of unexploded cluster
munitions in South Lebanon is in rural areas. As such,
various land activities such as farming, grazing, hunting
and fruit gathering, and simply walking or wandering in
affected areas can often bring innocent civilians in contact
with cluster munitions. In South Lebanon, tobacco planting
and olive picking is common in rural areas and villages,
and traditionally this is considered a family business that is
shared by all family members, including children, putting
them in danger of getting in direct contact and injuries as a
result of undetonated cluster munitions.
Some children, particularly in poor rural areas may lack
the ability to read and heed warning signs [6, 7], which
increases children’s susceptibility to cluster munitions and
landmines. In this study, among child casualties, boys
constituted the highest percentage (95 %). It is possible
that this male predominance may reflect some specific
cultural attitudes to South Lebanon. For example, tradi-
tionally in South Lebanon, only boys do certain jobs, such
as shepherding that include walking in non-inhabited areas;
boys are allowed more freedom to go outdoors without
being accompanied by adults and are more likely to take
risks.
Cluster munitions have serious detrimental economic
and communal effects. The presence of these sub-muni-
tions and risk of exploding would either force inhabitants
out of their lands, leading to land degradation and or loss of
agricultural lands’ productivity [8]. Alternatively, similar
to previous experience in Cambodia and Vietnam [9], we
noticed that some, particularly poor and rural families
chose to take risks to earn their living, increasing the
vulnerability of their children in the process (Fig. 2).
There are some differences between cluster munitions
and landmines. Cluster munitions are usually visible and
located on the surface of the ground, unlike buried land-
mines. Cluster munitions’ explosions also have a wider
diameter and are more powerful than those of landmines
and, as such, can injure nearby children [10–12], and in
addition can cause various injuries in the body and not
mostly limited to lower limb injuries associated with
landmines. As previously reported in Cambodia [12], we
found that the injuries were more severe when the muni-
tions exploded onto the upper part of the body. For
example, in one child’s case, while picking grapes, a sub-
munition was settled on the grape vine, without noticing he
Table 3 Distribution of neuropsychiatric syndromes as a result of cluster munitions explosions by age
Neurologic syndromes Children (%) Adolescents (%) Total number of syndromes
(% of patients)
Total number of
patients (%)
Post-traumatic stress disorder (s 17 (43.6) 56 (76.7) 73 (65.2) 112 (100)
Post-concussion syndrome (PCS) 13 (33) 21 (28.8) 34 (30.4) 112 (100)
Penetrating traumatic brain injury (pTBI) 1 (2.6) 2 (2.7) 3 (2.7) 112 (100)
Closed traumatic brain injury (cTBI) 0 (0) 1 (0.9) 1 (0.9) 112 (100)
Total number of surviving or non-lethal injuries: children 39, adolescents 73
Fig. 2 Lebanese children standing beside an undetonated cluster
bomb that fell in their house
Neurol Sci (2013) 34:1971–1976 1973
123
collected the munition, which exploded instantly. In
another case, the munition fell from an orange tree into an
adolescent’s chest and exploded instantly. Several opera-
tions and prolonged rehabilitation were required.
Cluster bombs are distributed remotely from land or air
by rockets and artillery, enabling extensive and wide dis-
tribution of those munitions. In one attack alone, thousands
of sub-munitions can be scattered from a plane, whilst
planting landmines requires laborious human efforts. It
takes a huge effort, manpower, and financial resources as
well as time and risks to clear these munitions. Despite
concerted efforts by national and international organiza-
tions over more than 6 years, there are still a lot of areas
that have not yet been decontaminated or cleared of these
munitions. We observed that some farmers, aware of the
threats, cannot afford waiting for clearance of contami-
nated areas and choose to enter dangerous fields assuming
that, by visual inspection alone, the cluster munitions can
be detected and avoided. In addition, unexploded muni-
tions are often brightly colored and attractive to children
(Fig. 3). This increases the risk of children being exposed
to unexploded sub-munitions. We believe that the use of
cluster munitions pose a greater threat than landmines for
civilians and particularly children.
Neurological effects
Children and adolescent victims of sub-munitions suffered
from neurological and craniofacial tribulations (Fig. 4).
Neuropsychological effects were evident and highly
noticeable as well.
Pain syndromes
All of our 83 cases with amputations suffered from painful
symptoms associated with PLP and SP/RLP. PLP is typical
a neuropathic pain, defined as pain initiated or caused by a
primary lesion or dysfunction in the nervous system and
considered to be associated with alterations in structure of
the nervous system. Some authors have reported that most
patients who undergo amputation experience the sensation
that the absent body part is still present with this sensation
usually presenting as a chronic and distressing pain to the
patient [13–16]. The prevalence of PLP differs based on the
location of the amputation. The prevalence of PLP in upper
limb amputees is nearly 82 %, while the prevalence of pain
in lower limb amputees is only 54 % [16]. The rate of PLP
in our study is lower (37.3 %) than that reported in other
studies.
71 % of our patients had SP/RLP, which is often due to
underlying disease process, surgical trauma, bone abnor-
mality, local scar, neuroma, or central neuropathic phe-
nomenon as a result of autonomic nervous system
abnormalities involving the sympathetic post-ganglion
neurons after peripheral nerve injury.
Post-traumatic stress disorder (PTSD)
According to the Diagnostic and Statistical Manual of
Mental Disorders (DSM-IV), PTSD is a severe anxiety
disorder that can develop after exposure to any event that
can result in psychological trauma [17].
Post-traumatic stress disorder was diagnosed in 73
(65 %) children. The incidence was higher in adolescents
than children (76.7 % compared to 43.6 %). We docu-
mented that children suffered from typical symptoms of
flashbacks and nightmares. We also noted hysterical
aphonia and neurological symptoms unrelated to a neuro-
logical cause, in some of the victimized children, especially
in the first six hours post trauma. Emotional numbing and
Fig. 3 A sub-munition that looks like a ball Fig. 4 A craniofacial lesion affecting both eyes, more severe in the
left eye, in a patient suffering from closed Traumatic Brain Injury
(cTBI)
1974 Neurol Sci (2013) 34:1971–1976
123
memory loss of the incident were also noted, especially in
adolescents. Furthermore, we observed that many of the
child survivors of cluster munitions detonations were also
affected by their family’s response after the traumatic
incident. We noticed that in the majority of cases, espe-
cially in rural families, families were unable to cope well
with the resulting disabilities of their victimized children.
We observed that this led the children to feel significant
responsibility for the traumatic incident. Moreover, simi-
larly to other authors [18], we observed that community
rejection or the rejection of one’s family could lead child
survivors to feelings of depression.
Post-concussion syndrome (PCS)
Post-concussion syndrome was diagnosed and recorded in
30.4 % of cases, with no significant difference in incidence
between children and adolescents. Patients complained
from headache, dizziness and vomiting as well as lack of
concentration, noise/light intolerance and a blurred vision.
Traumatic brain injuries (TBI)
Two forms of TBI are encountered in children with
explosive blast trauma: penetrating traumatic brain injury
(pTBI) and closed traumatic brain injury (cTBI) [19]. We
had a total of four TBI injuries.
We had three pTBI cases (2.7 %) with contusion and
hemorrhage due to the penetration of an object or foreign
body into their brain parenchyma. They had an impaired
level of consciousness, PTSD symptoms, PCS symptoms
and some other neurological deficits.
We had only one patient with cTBI, who in addition to a
localized neurological lesion had also PCS. cTBI is caused
from the motion and deformation of the brain within the
cranium causing disruption of the brain [20].
Conclusion
Cluster munitions pose serious detrimental humanitarian
and societal hazards. The nature of these munitions and the
large areas they affect tend to increase exposure to children
and adolescents who account for 30 % of all cluster
munitions-related casualties. Pain syndromes were found in
all cases of amputation. This, together with a high instance
of PTSD, feelings of guilt by the child for the family’s
inability to cope with the disability due to injury, as well as
many cases of post-concussion syndrome and few cases of
traumatic brain injuries all add to high levels of physical,
psychosocial and economic disability and burden on those
injured, their family and community.
It is the opinion of the authors that more should be done
to mark out areas contaminated by unexploded ordnances.
Likewise, awareness campaigns should be launched to
inform high-risk communities, such as those in South
Lebanon, of the dangers posed by these munitions. Most
importantly, there needs to be greater effort undertaken to
clear contaminated areas to prevent civilian and particu-
larly children injuries. Furthermore, rehabilitation centers
should be established to give support to affected families
and communities.
Currently, the convention on cluster munitions has been
ratified by 77 countries and signed by another 34. Countries
ratifying the convention are obliged not to use or be
involved in actions that encourage cluster munitions use.
International laws should take into account the huge burden
of these munitions on civilians and children, as this study
demonstrates. It is our opinion that the rest of world
countries should follow those 111 countries that have
already signed the convention and international humani-
tarian laws must prohibit the production and use of such
inhumane weapons.
References
1. BeehnerL (2006)Thecampaign to banclusterbombs. Backgrounder.
http://www.cfr.org/lebanon/campaign-ban-cluster-bombs/p12060.
Accessed 21 April 2012
2. Jaber H (2009) Cluster bombs leave ‘toys’ that kill children.
Halajaber.com. http://www.halajaber.com/news/2006/11_01.php.
Accessed 24 November 2012
3. (2010) International Campaign to Ban Landmines. Landmine
Monitor. http://www.themonitor.org/lm/2010/resources/Landmine_
Monitor_2010_lowres.pdf. Accessed 24 May 2012
4. (2011) Children and Landmines: A Deadly Legacy. Unicef.
http://www.unicef.org/french/protection/files/Landmines_Factsheet_
04_LTR_HD.pdf. Accessed 23 June 2012
5. Bouhassira D, Attal N, Alchaar H, Boureau F, Brochet B,
Bruxelle J, Cunin G, Fermanian J, Ginies P, Grun-Overdyking A,
Jafari-Schluep H, Lanteri-Minet M, Laurent B, Mick G, Serrie A,
Valade D, Vicaut E (2005) Comparison of pain syndromes
associated with nervous or somatic lesions and development of a
new neuropathic pain diagnostic questionnaire (DN4). Pain
114:29–36
6. Nixon R (2007) Of landmines and cluster bombs. Cult Crit
67:160–174
7. Walsh NE, Walsh WS (2003) Rehabilitation of landmine vic-
tims—the ultimate challenge. Bull World Health Organ 81:665–
670
8. Watts HG (2009) The consequences for children of explosive
remnants of war: land mines, unexploded ordnance, improvised
explosive devices and cluster bombs. J Pediatr Rehabil Med
2:217–227
9. Williamson B (2011) The impact of ERW on children. J ERW
Mine Action 15:29–32
10. Fares Y, Fares J (2013) Anatomical and neuropsychological
effects of cluster munitions. Neurol Sci. doi:10.1007/s10072-013-
1343-7
Neurol Sci (2013) 34:1971–1976 1975
123
11. Borrie J, Cave R (2006) The humanitarian effects of cluster
munitions: why should we worry. Clust Munitions 4:5–13
12. Bendinelli C (2009) Effects of land mines and unexploded ord-
nance on the pediatric population and comparison with adults in
rural Cambodia. World J Surg 33:1070–1074
13. Kalauokalani DAK, Loeser JD (1999) Phantom limb pain. In:
Crombie IK (ed) Epidemiology of Pain. IASP Press, Seattle,
pp 143–153
14. Kooijman CM, Dijkstra PU, Geertzen JHB, Elzinga A, Van der
Schans CP (2000) Phantom pain and phantom sensations in upper
limb amputees: an epidemiological study. Pain 87:33–41
15. Flor H, Elbert T, Muhlnickel W, Pantev C, Wienbruch C, Taub E
(1998) Cortical reorganization and phantom phenomena in con-
genital and traumatic upper-extremity amputees. Brain Res
119:205–212
16. Sherman RA, Sherman CJ, Parker L (1984) A survey of current
phantom limb treatment in the United States. Pain 8:85–99
17. American Psychiatric Association (1994) Diagnostic and statis-
tical manual of mental disorders: DSM-IV. American Psychiatric
Association, Washington, DC
18. Roth W, Briar-Lawson K (2011) Globalizations. State University
of New York Press, New York, Social Justice and the Helping
Professions
19. Ling G, Bandak F, Armonda R, Grant G, Ecklund J (2009)
Explosive blast neurotrauma. J Neurotrauma 26:815–825
20. Bandak FA, Eppinger R, Ommaya A (1996) Traumatic brain
injury: bioscience and mechanics. Mary Ann Liebert Publishers,
New York, pp 167–172
1976 Neurol Sci (2013) 34:1971–1976
123
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