Post-crisis health reality and wellbeing of children within Syria: a scoping review of research from 2012 to 2024 | Conflict and Health

This scoping review identified 51 studies published after the onset of the Syrian conflict that focused on the health of children residing within Syria. Of these, 30 studies were directly or indirectly related to the impact of the conflict. The findings indicate a growing body of health research in Syria in the post-conflict period; however, substantial gaps persist in the literature, particularly concerning medical conditions associated with the Syrian conflict [43].

Burden of physical trauma and injuries

The protracted conflict in Syria has inflicted a severe toll on children’s physical health, particularly in war-affected regions such as Northern Syria. Although numerous children have sustained injuries as a direct result of the violence, only 13.7% of child health research conducted during the conflict has focused on physical trauma among children residing within Syria. This highlights a significant gap in the literature, particularly in capturing the realities faced by those living in active conflict zones [44]. Most available data come from hospitals in neighboring Turkey, especially facilities in border towns like Hatay and Kilis, which have served as key referral centers for injured Syrian children [45,46,47,48]. For instance, Çelikkaya et al. reported that over half of the children treated for war-related injuries at a major hospital in Hatay presented with severe trauma, and many died due to delayed intervention and injury severity [48]. Widespread shelling and aerial bombardments have been identified as the leading causes of pediatric mortality, accounting for over 70% of deaths in conflict zones [45, 49]. In 2016, child deaths from war-related injuries reached 23.3%, with the highest numbers reported in Aleppo, Idlib, and Daraa [50]. Moreover, forced displacement has significantly increased the risk of injury among children in Northern Syria. Adolescents aged 12–17 years were especially vulnerable, with markedly higher odds of trauma-related disorders compared to younger age groups [13]. Within Syria, particularly in GC regions, war-related injuries have also been reported; however, clinical response has been hampered by shortages of medical equipment, economic instability, and a lack of trained personnel [51,52,53]. A study from Al-Mouwasat Hospital found that one-third of burn patients died from their injuries, with children making up over half of the sample and showing the highest rates of leaving the hospital against medical advice [53]. Data collection within Syria remains limited due to security concerns and fear of government retaliation, particularly in underserved or besieged areas. These findings underscore the urgent need for improved documentation, coordinated trauma care, and child protection efforts within conflict settings.

Burden of mental disorders

The existing body of literature predominantly concentrates on the psychological well-being of Syrian children refugees residing in neighboring countries [54, 55]. In contrast, there is a notable paucity of research addressing the mental health of children remaining within Syria. However, indictors of higher prevalence of conflict-related mental disorders between Syrians living within Syria compared to Syrian refugees were reported [56]. Based on our results, mental health was number one on the list of discussed subjects on conflict related child health research. The toll of war on mental health has become increasingly acknowledged, with conditions such as: post-traumatic stress disorder (PTSD), depression, anxiety, obstructive sleep apnoea syndrome and increasing suicidal behaviors gaining recognition, which are largely attributed to worsening economic conditions and harsh living circumstances [34, 35, 54, 55]. Moreover, internal displacement, exposure to violence, and lack of basic resources in NGC areas have significantly contributed to the increased prevalence of mental disorders [13, 29, 49]. Adolescent boys, who were tragically drawn into armed conflicts and labor [29], and teenage girls, who were frequently subjected to early marriage [17, 42], are particularly affected. In GC areas, more than 50% of school-aged children demonstrated symptoms of PTSD as a result of prolonged exposure to armed conflict and internal displacement [32, 34]. Adolescent males, in particular, were subjected to forced labor, which was associated with deteriorating physical health, exacerbated anger issues, and a higher incidence of smoking [32]. These adverse psychosocial and physical factors have had a profound impact on students’ cognitive and emotional well-being, leading to a marked decline in academic performance across the affected student population. Furthermore, behavioral difficulties prevalence was notably high among children affected by the Syrian conflict, with 74.67% of children aged 2–4 years and 61.29% of children aged 5–17 years exhibiting such challenges. These behavioral issues were significantly associated with war-related factors, including the loss of family members, disruptions in school attendance, and ongoing economic hardships (p < 0.05) [30]. Although intervention studies were limited, supportive strategies demonstrated effectiveness [29]. For instance, art therapy significantly reduced PTSD symptoms among war-affected and internally displaced children (P < 0.01) [31]. Additionally, community-based social support programs for pregnant teenagers were found to enhance self-confidence and promote self-care behaviors [42]. Providing adequate mental health care faces notable challenges, including cultural barriers and a shortage of trained professionals [57, 58]. Expanding the psychiatric knowledge of medical staff and enhancing the availability of mental health services in public sectors, including medical centers and schools, are critical steps to alleviate the burden of conflict-related mental disorders [59].

Burden of communicable diseases cds

CDs ranked second among medical concerns post- conflict, following mental disorders, in the context of children affected by the conflict. The majority of studies on CD in children have primarily focused on Northern Syria and IDP camps, reflecting the high prevalence of these conditions in regions severely affected by conflict and displacement [19, 60]. The deteriorating living conditions within IDP camps, coupled with widespread poverty and a severe lack of medical services, exacerbated the vulnerability of children to infections [17, 19, 20]. These risks peaked during the winter months, when overcrowded conditions and limited access to sanitation and healthcare facilities heightened the transmission of infectious diseases [13, 21]. Furthermore, vaccine-preventable infections emerged as a significant concern due to disruptions in routine immunization programs, which were compounded by the mass displacement and the associated breakdown in healthcare infrastructure [18, 20, 21]. Children under the age of five were particularly vulnerable to infections, a susceptibility often compounded by malnutrition, leading to elevated rates of morbidity and mortality [18, 21]. Syria was classified as one of the fragile countries in the face of the COVID-19 epidemic leading to destructive effects on women and child health [16, 61, 62]. More than two thirds of the children in Northern Syria suffer from infections, mainly of respiratory, neurological, digestive and dermatological origin [19, 63]. Children respiratory infection cases contributed to 73% of respiratory infection cases in Northern Syria prior to the COVID-19 epidemic [63]. Children and neonates’ mortality of infection has increased with the critical lack of medical services and hard access to medical points [64, 65]. Moreover, vaccine-preventable diseases such as tuberculosis (TB), measles, and polio were reported in both GC and NGC areas [14, 66, 67]. The implementation of vaccination program helped successfully supplant the vaccines related diseases [22]. The lack of appropriate maintenance and destroyed understructure contributed to insufficient clean water supplies and increase the chance of contamination which is the main cause of outbreaks like Cholera [68, 69]. Despite the lack of sufficient COVID pandemic related research in Syria, it’s very clear that COVID epidemic imposed a pressure on the Syrian socioeconomic situation and exacerbated the mental stress for the community which is already devasted by the war [70]. The negative impact of the COVID-19 pandemic on food insecurity and the nutritional status of children is also critical [16, 71]. Further detrimental impact was on the social, psychological, and economic well-being of children with health problems [72]. Furthermore, the COVID-19 crisis has escalated into a children’s crisis in IDP camps. The lack of child protection services, minimal preventive measures, and inadequate sanitation have left children, already suffering from weakened immune systems or underlying health conditions due to living in desperate conditions, particularly vulnerable to this vicious virus [65, 73].

Burden of oral diseases

Prior to the conflict, Syria has suffered from the burden of poor oral health between children and the heavy years of conflict had certainly worsen the children oral health in many aspects with limited studies in this field [74, 75]. Oral health is very important health indicator, which could be assessed easily and with affordable costs. In our search, 19 studies were detected examining the children oral health inside Syria after the conflict, 7 of them were included based on our criteria, with age ranged between 8 and 17 years old, the geographic distribution of these studies was in GC areas of Damascus governance, no studies related to oral health was detected in NGC areas. Notably, children with pre-existing medical conditions [76, 77], particularly those undergoing chemotherapy in Syria [36], exhibited a significantly higher incidence of poor oral health. The ongoing war has created numerous barriers to healthcare access and continuity of treatment, further exacerbating the oral health challenges faced by these children.

Additionally, a significant association between poor oral health and war-related mental health disorders was observed among school students in Damascus [26,27,28]. In addition to the high prevalence of smoking among adolescents, passive smoking among children also contributes to worsening oral health [78, 79]. The role of the conflict in the deteriorated oral health was expanding, with the collapse of families’ financial situation, decline the educational level and health awareness which contribute to the failure of the application of minimal health guidelines. In addition, high carbohydrates and sugar intake was related to early dental caries and linked to poor socioeconomic and knowledge background [74, 80].

Burden of malnutrition and non-communicable diseases NCDs

The nutritional status of children in Syria remains critically under-documented, particularly concerning micronutrient deficiencies such as iron deficiency anemia and vitamin D deficiency. This data gap limits the ability to implement targeted interventions. Nonetheless, existing evidence suggests severe levels of undernutrition among children, especially those living in IDP camps, due to widespread poverty, food insecurity, and inadequate healthcare access [81]. According to the WHO and Ministry of Health’s Nutrition Surveillance System (2018), the prevalence of Global Acute Malnutrition (GAM) among children under five was 12%, with 30% of those affected identified as stunted [82]. Recent studies further highlight a dual burden of malnutrition and obesity. In 2021, Syria recorded one of the highest global rates of concurrent stunting and overweight in children (12.3%) [83]. A national growth reference study found overweight and obesity rates of approximately 20% and 4% respectively, linked to increased consumption of low-cost, carbohydrate-rich diets amid economic decline [84]. Anemia remains widespread; for example, in Damascus, prevalence rates for anemia, iron deficiency, and iron deficiency anemia reached 57%, 71.85%, and 55.55%, respectively [37]. In NGC regions, malnutrition and severe acute malnutrition were notably higher among IDP children, particularly infants and toddlers [17, 18, 21]. One study reported nutritional deficiencies in 8% of the child population, with significantly higher rates of chronic anemia, malnutrition, and severe acute malnutrition observed among IDP children [17]. Additionally, girls had significantly higher odds of receiving nutrition consultation (AOR: 1.52, p < 0.001) [13].

Regarding non-communicable diseases, only nine studies addressed pediatric NCDs, five of which were conflict-related. These focused on conditions such as asthma, epilepsy, and cancer, primarily in GC areas [38, 39, 72, 85]. Post-conflict evidence points to increased asthma prevalence, likely linked to war-related stress and environmental exposure [39, 86, 87]. While data from non-government-controlled regions remain limited [17], findings suggest that displacement increases the likelihood of developing NCDs among children in northern Syria [13].

Challenges and gaps in child health research within Syria

During the past fourteen years, the IDP crisis in Syria has worsened both in quantity and quality, as IDPs often receive less recognition and protection and face greater barriers to accessing humanitarian interventions compared to refugee populations [6, 88, 89]. Despite the escalating needs and increased attention, funding remains critically insufficient, with a 62% shortfall reported in 2023 [90]. The socio-economic situation in Syria continues to deteriorate as sanctions persist and humanitarian funding decreases, resulting in a further breakdown in access to services and livelihoods [91]. This situation has been further exacerbated by the COVID-19 pandemic in 2020 and the earthquakes in 2023, which have intensified vulnerabilities, increased medical needs, displaced families once again, and heightened the suffering of children [92, 93].

Post-conflict health research has seen a notable increase in publication rates. However, research within Syria is subject to significant limitations [9, 10, 89]. Within Syria, researchers in GC areas encounter significant barriers, including inadequate funding, limited institutional support, and restricted access to essential tools and resources. Moreover, the ability to conduct conflict-related research in these regions is further constrained by political sensitivities, lack of data transparency, and concerns over researcher safety, all of which have impeded the production of independent and systematic studies in these areas despite the occurrence of significant conflict. Students at both government and non-government institutions face considerable challenges in securing financial support to pursue advanced research, compounded by the lack of reliable data due to the extensive damage and underdevelopment of the country’s infrastructure. The analysis revealed that only 27.5% of the total child health research conducted within Syria received funding, and 80% of conflict related research received no funds. This underscores a significant gap in financial support for critical research focused on the health of children in the region, highlighting the need for increased investment and resources to address the pressing health challenges faced by Syrian children. The lack of funding likely impacts both the reliability and comprehensiveness of the research, as limited financial resources constrain study design, sample size, data collection methods, and analytical rigor. Unfunded studies may also face challenges in ensuring adequate quality control, leading to increased risks of bias, incomplete data, and reduced generalizability of findings. In NGC areas, local institutions and international organizations are further restricted by difficult access and the dangers posed by ongoing conflict [9, 10, 81]. However, research in NGC regions has been more heavily supported by NGOs and funded by foreign organizations [18, 63, 81].

Furthermore, the ability of Syrian researchers to conduct high-quality studies is significantly constrained. This limitation is evidenced by our findings, which reveal that the majority of existing studies are observational in nature, lacking experimental interventions, and with a minimal presence of RCTs. This underscores the need for methodological advancements and greater research capacity within the Syrian scientific community [89]. The overall quality of included studies is moderate, with cross-sectional and retrospective cohort studies dominating the review. While they provide valuable epidemiological insights, their inability to establish causality, susceptibility to bias, and limited statistical control over confounders reduce their reliability. The inclusion of prospective cohort studies, case-control studies, and a single RCT adds depth but is insufficient to significantly strengthen causal inferences. This lack of methodological rigor directly limits the development of effective evidence-based policies and interventions, as policymakers are forced to rely on descriptive data without robust causal insights needed for targeted, efficient, and context-specific health strategies.

The findings underscore the imperative for an enhanced geographical diversity in research pertaining to IDP. Predominantly, studies on IDPs have been confined to north-western Syria, a trend also observed in another scoping review [49]. Additionally, consistent with findings from a previous review [10], our analysis highlights a significant geographic disparity in child health research within Syria. The majority of studies have been conducted in GC areas, particularly within the Damascus Governorate, often in affiliation with Damascus University. In contrast, research from other regions (such as Daraa, Al-Hasakah, Deir ez-Zor, and Raqqa) remains extremely limited or entirely absent. This underrepresentation is likely due to a combination of factors, including security concerns, restricted access for researchers, limited institutional capacity, and the collapse of healthcare and academic infrastructures in conflict-affected and opposition-held areas. Such research is exceedingly rare in other governorates, a gap further compounded by the absence of involvement from other local higher education institutions. This geographical concentration may lead to findings that do not accurately represent the broader spectrum of child health issues across Syria especially for IDP. Such geographic bias poses critical challenges to the generalizability of findings, as studies concentrated in relatively more stable, government-controlled areas may fail to capture the full extent of health burdens faced by children in underserved or severely affected regions, particularly among IDPs. This skewed evidence base risks informing policies and interventions that are not fully aligned with the needs of vulnerable populations across Syria.

Recommendations for rebuilding child health and Well-being in Post-Conflict Syria

The rehabilitation of public infrastructure following the Syrian conflict is a national imperative, particularly in the health sector. Rebuilding the healthcare system requires coordinated efforts among all stakeholders, including the implementation of supportive legislation, strategic planning, and the integration of modern technologies to overcome structural and operational challenges.

To inform effective interventions, future research must gradually adopt more rigorous yet context-appropriate methodologies, such as prospective cohort studies, nested case-control designs, and implementation science approaches. Our review underscores the urgent need to invest in research capacity-building, particularly among local institutions and community organizations, to foster context-specific, community-driven research. Expanding methodological diversity and addressing geographic gaps will be critical to generating reliable, locally relevant evidence and ensuring that health policies are equitable, inclusive, and responsive to regional disparities.

Comprehensive and ongoing monitoring of children’s health is vital to understanding both the immediate and long-term consequences of conflict exposure. Reliable data collection will allow for the tailoring of health interventions to specific needs and vulnerabilities. In particular, systematic investigations into communicable diseases (CDs) and non-communicable diseases (NCDs) among children across all Syrian governorates should be prioritized. Such research should evaluate not only disease burden but also the capacity, resilience, and readiness of medical facilities. It must also identify systemic barriers, resource constraints, and infrastructural deficits that hinder effective healthcare delivery. These findings are critical for evidence-based policy formulation and resource allocation aimed at improving child health at both regional and national levels.

Mental health services must be urgently rehabilitated to address the psychological toll of protracted conflict, particularly among children. Expanding the psychiatric training of healthcare professionals and increasing the availability of mental health services—especially within public institutions such as schools and health centers—is essential to reduce the burden of post-traumatic stress, anxiety, and related disorders.

Emerging evidence suggests that psychological distress from conflict exposure is also linked to poor oral health in children. Consequently, oral health research should be broadened to encompass diverse age groups and regions. Schools, given their accessibility and trust within communities, are well-positioned to serve as research sites and platforms for implementing health promotion and preventive interventions.

In the broader context of child protection and development, schools play a vital role beyond education. They serve as safe spaces that shield children from exploitation and child labor while facilitating access to psychological, nutritional, and healthcare services. Strengthening the education sector, through targeted financing, teacher training, and psychosocial support, is thus an urgent priority. The interdependence of the health and education sectors in post-conflict Syria underscores the need for collaborative planning and implementation of child-focused interventions.

Finally, while the debate over international sanctions on Syria remains politically complex, their humanitarian consequences cannot be overlooked. Easing or lifting sanctions could facilitate the delivery of essential medical supplies and aid, support economic recovery, and improve the broader social determinants of child health. Enhanced economic stability could reduce psychosocial stressors among children and provide a foundation for long-term improvements in well-being and opportunity.

Actionable next steps for rebuilding child health and well-being in post-conflict Syria

Short-term (Within 12 Months)

1. 1.

   Advocate for Humanitarian Adjustment or Lifting of Sanctions.

• Engage international stakeholders to ease or lift sanctions that restrict the importation of essential medical supplies, equipment, and humanitarian aid.

• Prioritize exemptions for child health services, medications, and food security programs to immediately improve health outcomes and reduce psychosocial stressors among children.

1. 2.

   Conduct a National Rapid Assessment.

• Map the availability and gaps in pediatric health services, mental health infrastructure, school-based health programs, and the implementation of nutrition support and child protection programs across all governorates.

• Use findings to prioritize high-need areas and guide the allocation of resources and programmatic support.

1. 3.

   Establish a Conflict-Aware Health Surveillance System.

• Launch sentinel surveillance in schools and clinics to monitor key child health indicators such as malnutrition, trauma symptoms, communicable and non-communicable diseases, and the treatment of war-related injuries.

• Ensure data collection systems are sensitive to conflict exposure and capable of informing targeted health interventions in high-risk areas.

1. 4.

   Initiate Capacity-Building Programs.

• Organize workshops and online training for local professionals on child-focused research, basic mental health care, and data collection.

1. 5.

   Support Local Research Networks.

Medium-term (1–3 Years)

1. 6.

   Expand Rigorous Epidemiological Studies.

• Implement multicenter prospective cohort studies and RCTs focusing on nutrition, NCDs, CDs, mental health, and oral health.

1. 7.

   Integrate School-Based Health Services.

• Pilot comprehensive school health programs offering screening, counseling, and preventive care in partnership with local health departments.

1. 8.

   Develop and Implement a National Oral Health Strategy.

1. 9.

   Rehabilitate Mental Health Infrastructure.

1. 10.

   Formalize Health-Education Collaboration.

Long-term (3–5 Years)

1. 11.

   Institutionalize Data-Driven Policy Development.

• Create a National Child Health Observatory to coordinate data collection, analysis, and policy translation at national and subnational levels.

1. 12.

   Rebuild Health Infrastructure with Modern Technologies.

• Integrate telemedicine, mobile health tools, and e-health platforms into post-conflict reconstruction to expand care delivery in hard-to-reach areas.

1. 13.

   Sustain Local Ownership and International Collaboration.

Limitations

This study acknowledges several important limitations that should be considered when interpreting the findings:

Due to significant geographic constraints and the moderate quality of available evidence within the child health literature in Syria, detailed analysis of specific child health parameters was not feasible. Additionally, regional classifications used in this study reflect territorial control and demographic conditions at the time of data collection, which have been highly dynamic throughout the Syrian conflict. Therefore, these classifications may not represent static or uniform entities over time.

The study reflects the inherent difficulties associated with research in conflict zones, including:

• Methodological challenges, such as reliance on observational studies and limited access to comprehensive data.

• Financial constraints, due to scarce funding opportunities for in-country research.

• Logistical barriers, including security concerns, displacement, and restricted access to certain regions.

While much of the existing health research has focused on Syrian refugees in neighboring countries, there is a noticeable gap in studies addressing the health and well-being of IDPs and children residing within Syria. This imbalance limits comprehensive understanding of child health realities for those remaining inside conflict-affected areas.

The fluid nature of territorial control, ongoing displacement, and demographic shifts throughout the conflict present additional challenges in ensuring that findings remain representative over time.

Despite these limitations, this study offers a valuable contribution to the literature on child health and child rights violations in conflict settings. To our knowledge, it represents the first review explicitly focusing on the post- conflict health realities of children within Syria, highlighting critical gaps and informing future research priorities.