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

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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.

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