The heart-rending image of a little girl trying to stop her infant sister from falling to her death in the rubble of a bomb-ruined building encapsulated the plight of children caught up in Syria’s war. Foreign Editor David Pratt examines the suffering of the innocents in a conflict the world seems to have largely forgotten about.

Last year while in Syria I made some photographs in the backstreets of Raqqa city.

The images showed some volunteer emergency workers retrieving the body parts of people who had been killed and dumped in mass graves or discovered in bombed out buildings.

Coming across the pictures again the other day and examining them more closely, I realised that in almost all of them, children were often standing nearby watching this grisly spectacle. Indeed many of the victims being unearthed were children too.

On closer scrutiny of those in the pictures, the looks on each of their faces spoke volumes of the horrors the children doubtless had witnessed many times before.

In one picture a row of young boys looks on as body bags are loaded into an ambulance. Some cover their faces with the neck of their T-shirts, trying to ward of the cloying stench from the corpses, while others stare impassively or seem fixated.

Looking at each of the boys in turn, I couldn’t help wondering about their thoughts and how such scenes must play out or are etched indelibly in their minds.

Children especially so often bear the brunt of war. There was another powerful photographic reminder of that last week in the heart-breaking image of a five-year-old Syrian girl’s desperate attempt to save her seven-month-old sister in the rubble of a building hit by an air strike.

Syrian photographer Bashar al-Sheik, captured the scene last Wednesday in the town of Ariha in the country’s northwest Idlib province,

The girl, whose name was Riham al-Abdullah, is seen buried up to the neck in slabs of concrete but still trying to reach out to her baby sister Touka, who dangles precariously by her shirt caught on rubble, in an effort to stop her falling to the ground several storeys below.

Above them their father cries in anguish unable to reach either of them. Syrian media later reported that Riham and her mother died in hospital from their injuries while Touka remains in intensive care. Their other sister, Dalia, barely visible in the photo, is also recovering after a chest surgery.

Why are Syrian children like these continuing to suffer and die while the world looks on seemingly unable or unwilling to prevent it?

That was the question posed on Friday by the United Nations High Commissioner for Human Rights Michelle Bachelet, who described the intensifying campaign of air strikes killing civilians in Syria as having been meet with a “collective shrug” internationally.

“Several hundreds of thousands of children, women and men have been killed in Syria since 2011,” the High Commissioner said.

“So many that it is no longer even possible to give a credible estimate. During the early years of this murderous conflict, when the casualties were in the tens, then hundreds, then thousands, the world showed considerable concern about what was happening,” Bachelet added, expressing concern that the continued carnage in Syria “is no longer on the international radar”.

In the midst of this relentless bloodletting, children are the most vulnerable and among many of the victims. In the area of Idlib alone where tiny Riham al-Abdullah struggled to save her sister, the number of children killed in the last four weeks has exceeded the total for 2018, according to humanitarian agency Save the Children and its partner organisation Hurras Network.

That the area is technically one of four so-called “de-escalation zones” – truce areas brokered by Turkey, Russia and Iran in May 2017 – only adds to the accusations of international indifference.

The escalation in violence, which started at the end of April, has now resulted in the deaths of at least 400 people, including 90 children, and displaced 440,000 people.

Save the Children confirmed that at least 33 children have been killed since June 24, compared to 31 children killed during all of 2018.

“The current situation in Idlib is a nightmare. The injuries we are seeing are horrific. It’s clear that once again children have been killed and injured in indiscriminate attacks,” said Sonia Khush, Save the Children Syria response director. Civilians in the area also described how they felt they were being deliberately targeted.

“The bombardment is relentless. It seems as though the different sides have stopped fighting each other and are fighting us, civilians, now. It’s just senseless brutality. I saw dozens of people killed in the marketplace, torn to pieces, including many young children who were playing on the street. They should have been safe,” Ahmad, an eyewitness, told Save the Children using a pseudonym.

If 2018 was the deadliest year for children since the start of the war in Syria then this year is shaping up no better. After eight years of war 13.1 million people require humanitarian assistance, including 5.6 million children. A staggering 2.5 million Syrian children are now living as refugees in Egypt, Iraq, Jordan, Lebanon and Turkey.

During visits to these countries I’ve seen for myself the often-terrible conditions in which many of them live and the war’s impact on their physical and mental wellbeing. I recall once in the Turkish port city of Izmir coming across Syrian refugee families living in disused shop fronts and tumbledown outhouses, many ruthlessly exploited by Turkish landlords, who in some instances have charged rent for premises that were scheduled for demolition.

Among the families I met was one with four children who had been living in a shop front in the city’s rundown Mevlana neighbourhood for over a year. The mother of the family, a woman called Emira, told me how since the outbreak of the war her eldest daughter Istaa, who is 10 years old, has only had one year of schooling and the others no tuition at all since becoming refugees.

As we talked in the rundown shop front that the family had tried to make into a home I noticed that one of the children has drawn a crayon picture of a man and woman surrounded by the shape of a heart.

The drawing was the work of Istaa, who said it was a picture of her mum and dad. When I asked if I could take a photograph of it and raised my camera, the little girl ran to hide behind a curtain, tears in her eyes, afraid of being in the picture for fear that it might get into the hands of “Bashar” – Syrian President Bashar al-Assad.

Only the gentle persuasion of her mother Emira enabled her to pose with her wonderful drawing.

“She has nightmares and cries whenever she sees images on the news from Syria,” explained Emira. This, too, is another of the terrible tragedies of Syria’s war on children, its ability to cling to the psyche and corrode the lives of the youngest and most vulnerable.

In countries neighbouring Syria where many refugees with children now find themselves, psychosocial support and psychiatric care are predominantly privatised. The situation is also compounded by a severe shortage of psychiatrists, psychologists and social workers.

Inside Syria itself, of course, there is little in the way of clinical help. Those doctors who are treating child survivors of the violence say the devastation and lasting mental health implications far exceed any symptoms they have seen before, eclipsing all existing notions of Post Traumatic Stress Disorder or PTSD.

Dr Mohammed Hamza, a neuropsychologist with the Syrian-American Medical Society (SAMS), created the term "human devastation syndrome" because he thought anything else was simply not adequate to accurately describe the levels of horror experienced by the child survivors.

Hamza chairs the mental health committee of SAMS, whose 1,000 or so Syrian-American members have volunteered to provide medical aid wherever survivors of the war can be found.

“We have talked to so many children, and their devastation is above and beyond what even soldiers are able to see in the war,” Hamza said in an interview with online US media company ATTN.

“They have seen dismantled human beings that used to be their parents, or their siblings. You get out of a family of five or six or 10 or whatever, you get one survivor, two survivors sometimes. A lot of them have physical impairments. Amputations. Severe injuries. And they’ve made it to the refugee camp somehow,” Hamza added.

For many youngsters trapped in Syria’s warzones the trauma often proves too much. According to Ana Moughrabieh, another Syrian-American critical care specialist who continues to help fellow colleagues in Syria’s Idlib province via telemedicine, last year medical workers witnessed a troubling pattern emerging among some women and teenagers.

For brief periods women and teenagers were admitted to local hospitals after suicide attempts by ingesting insecticides. The insecticide is known locally as “gas pill” and leads to multiple organ failures, causing a painful and slow death.

All of these are symptoms of a deeply traumatised community say doctors where ultimately the root of the problem need to be addressed,

“We try to fill the gaps, but all the relief organisations, we’re just putting a Band-Aid on the wound,” Iyad Alkhouri, a psychiatrist who volunteers with SAMS told ATTN.

“Instead of providing resources to treat this 10-year-old child who was hit by a missile,” he said, “We have to stop the missile before it hits them.”

As UN High Commissioner for Human Rights Michelle Bachelet expressed on Friday however, right now there appears precious little chance of the international community achieving that.

Humanitarian agencies are already struggling to respond to the displacement across northwest Syria around Idlib. Civilian infrastructure, including schools and hospitals, continues to be damaged or destroyed.

In the last two weeks at least four medical facilities have been impacted by the violence.

“For the local population, having a hospital around them is even more dangerous than living near a military base,” said Dr Khalid, a Syrian doctor living as a refugee in Turkey, who has been helping coordinating cross-border, life-saving medical relief in Idlib. He uses this pseudonym to protect his identity in a place where doctors are at risk.

“In many areas people have refused to have hospitals built around them because they’re scared of being targeted,” Dr Khalid added.

Doctors in Idlib are reported to be working for days on end without a break, some without pay. Primary health care services, maternity care, dialysis, nutrition, and other non-emergency forms of care are critically under-resourced, leaving the civilian population reeling.

“We are preparing our facilities for trauma and war injuries, and we’re moving primary care clinics up to the north for the displaced,” Dr Khalid explained.

“We have evacuated hospitals in areas that have been totally abandoned by people because of the shelling… with all of the materials we can bring in trucks. When we can, we move everything - drugs, neonatal clinics, incubators, whatever,” he told the humanitarian agency Refugees International.

It is almost a year ago now that Russian foreign minister Sergei Lavrov expressed his desire that the “abscess” of Syrian resistance in Idlib, be “liquidated.

As that process now gets underway yet again innocent civilians many of them children are paying the price for the political failure to stop the violence and do what is demanded under international law - to protect all civilians.

“The children of northwest Syria have been caught in violent conflict for 80 days with no lull. They have been denied education, food, and health care, and forced to sleep under the trees in open fields for months now,” says Save the Children Syria Response Director Sonia Khush.

Michelle Bachelet the UN High Commissioner for Human Rights Michelle is right when she says that what we are seeing in Syria is a failure of leadership by the world’s most powerful nations. She is right too that the resulting tragedy is on such a vast scale that we no longer seem to be able to relate to it at all.

A few days ago in the rubble of her home five-year-old Riham al-Abdullah died while reaching out a helping hand to her little sister. The time is now long overdue for the world to do the same for the sake of all Syria’s children.