Injury 52 (2021) 1748–1756 Contents lists available at ScienceDirect Injury journal homepage: www.elsevier.com/locate/injury Pediatric casualties in contemporary armed conﬂict: A systematic review to inform standardized reporting ✩ Hannah Wild a,* , Barclay T. Stewart a,b , Christopher LeBoa c , Christopher D. Stave d , Sherry M. Wren e a Department of Surgery, University of Washington, Seattle, WA USA b Global Injury Control Section, Harborview Injury Prevention and Research Center, Seattle, WA, USA c Department of Epidemiology, Stanford University, Stanford, CA, USA d Lane Medical Library, Stanford University School of Medicine, Stanford, CA, USA e Stanford University School of Medicine, Stanford, CA, USA a r t i c l e i n f o Article history: Accepted 23 April 2021 Keywords: Pediatrics Mortality Conﬂict War Trauma Humanitarian response a b s t r a c t Background: Children represent a signiﬁcant percentage of casualties in modern conﬂict. Yet, the epi- demiology of conﬂict-related injury among children is poorly understood. A comprehensive analysis of injuries sustained by children in 21 st -century armed conﬂict is necessary to inform planning of local, military, and humanitarian health responses. Methods: We conducted a systematic search of databases including PubMed, Embase, Web of Science, World Health Organization Catalog, and Google Scholar to identify records that described conﬂict-related injuries sustained by children since 2001. Results: The search returned 5,264 records. 9 eligible reports without potentially duplicative data were included in analysis, representing 5,100 pediatric patients injured in 5 conﬂicts. Blast injury was the most frequent mechanism (57%), compared to 24.8% in adults. Mortality was only slightly higher among chil- dren (11.0% compared to 9.8% among adults; p <0.05). Non-uniform reporting prevented pooled analysis and limited the conclusions that could be drawn. Conclusions: Children sustain a higher proportion of blast injury than adults in conﬂict. Existing data do support the conclusion that child casualties have higher mortality than adults overall; however, this dif- ference is slighter than has been previously reported. Speciﬁc subpopulations of children appear to have worse outcomes. Overall, non-uniform reporting renders currently available data insuﬃcient to under- stand the needs of children injured in modern conﬂict. © 2021 Elsevier Ltd. All rights reserved. Introduction Children are one of the most vulnerable populations in mod- ern armed conﬂict and constitute an increasing percentage of casu- alties during protracted insecurity, particularly in the Middle East and Africa [1,2]. Thus, they represent a signiﬁcant proportion of in- jured patients cared for by local, military, and nongovernmental or- ganization (NGO) health facilities [3–5]. For example, in the conﬂict in Syria, children accounted for 27% of deaths due to barrel bombs ✩ Type of Study: Systematic Review. * Corresponding auhtor: 1959 NE Paciﬁc St., Seattle, WA 98195, USA. E-mail address: hbwild@uw.edu (H. Wild). between 2011-2016 [2]. Similarly, in U.S. military treatment facili- ties in Iraq and Afghanistan, 25% of all civilian patients admitted for blast injury between 2002-2010 were under the age of 15 [6]. The epidemiology of pediatric injury in modern conﬂicts must be evaluated to inform humanitarian healthcare capacity needs, de- velopment of standardized reporting guidelines, and advocacy ini- tiatives. Unfortunately, the epidemiology of conﬂict-related injuries sus- tained by children is poorly understood due to a lack of data. In the absence of organized and cooperative trauma registries, spo- radic reports on the nature and frequency of pediatric injuries may not provide the true scope and nature of injury burden. Reports from Afghanistan and Iraq suggest that blast injuries cause the ma- jority of conﬂict-related injuries among children [7–9]. This is in https://doi.org/10.1016/j.injury.2021.04.055 0020-1383/© 2021 Elsevier Ltd. All rights reserved.